Exam 2 MK Obj

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Objective 7

State and recognize by verbal description, drawing or radiograph the

following fracture types, and provide a radiographic reading using the

ABCS format: (I put in the ABCs from Nancys notes and the avulsion

fracture that she described to give us an idea of how she really like the

ABCs)

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Fracture type & verbaldescription

Drawing or radiograph Radiographic reading using ABCs

Greenstick= the bone is

incompletely fractured,

resulting in a plastic

deformity on the concave side

of the fracture. The fracture

may need to be completed to

obtain adequate reduction.

A = Alignment: general skeletal

architecture, bone contour and

alignment with adjacent bones

B = Bone density: General

density (overall), Local bone

density changes, texture

abnormalities

C = Cartilage spaces: Joint width,

epiphyseal plates, subchondral

boneS = Soft Tissues: muscles, fat

pads and fat lines, joint capsules,

periosteum and adjacent soft

tissue

Simple transverse=

Fracture line is perpendicular

to the long axis of a bone.

This injury type is usually due

to direct trauma and is

typically STABLE

Comminuted= Fracture in

which more than 2 (3)

fragments are present are

termed comminuted. Such

fractures are often associated

with significant soft tissue

injury and are UNSTABLE

Butterfly is a type ofcomminuted fracture with acharacteristic butterfly-shaped fragment.

Compression= Occurs in

cancellous bone, when an

excessive axial load

compresses the bone

(squishes) beyond its limits. It

typically occurs in vertebral

bodies, both surfaces of bone

are forced together.

Stress= Microfractures,

fatigue fractures, or

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Adult Medicine: Ortho Exam B Objectives

yhObjective 8State and describe the mechanism of injury, signs/symptoms, physicalexamination, associated injuries, radiographic presentation (with a

radiographic reading using the ABCs format), stability, management,complications, and prognosis of the following common upper extremityfractures:Clavicle (pg. 121) f. Scaphoid (pg. 237/243)

Proximal Humerus (pg. 165) g. Base of thumb (pg. 264)

Adult Supracondylar (elbow) (pg. 179) h. Fifth Metacarpal (Boxers) (pg.)

Forearm (Monteggia, Galeazzi, Nightstick) (pg. 216) i. Phalanx (all) (pg.)

Wrist (Colles and Smiths) (pg. 227)

Clavicle Fractures

Middle 3rd fractures Distal claviclefracture Normal ClavicleMechanism

of Injury Falls onto affected shoulder account for most (87%)

Direct impact only accounts for 7% and FOOSH only 6%

RARE - occur 2 to muscle contractions during seizures, atraumatically from

pathologic mechanisms, or as stress fractures

Occurs in young active adults and osteoporotic elderly

Signs

&Symptoms

Pts presents with:

Splinting of affected arm

Arm adducted across chest/supported by contralateral hand to unload injured

shoulder

Tachypnea may be present as result of pain with inspiration

The patient usually supports the arm with the other arm and the affected arm is held

adducted across the chest

Symptoms and signs are the same as for most other fractures

The injured shoulder is lower and more medial than the other if the fracture is

displaced

If there is no displacement then no deformity other than swelling should be noted

The proximal fracture end is usually prominent and may tent the skin

Be sure to assess for vascular and neurologic damage and auscultate the chest for a

pneumothorax if there is tachypnea ~ 9% of patients with clavicle fractures have additional fractures typically ribs

Brachial plexus injuries are associated with proximal third fractures

PhysicalExamination

Careful neurovascular exam necessary to assess integrity of neural/vascular elements

posterior to clavicle

Proximal fracture end usually prominent may tent skin

Assessment of skin integrity essential to rule out open fracture

Auscultate chest for symmetric breath sounds

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80% of clavicle fractures occur in the middle third

The fracture may be displaced by the sternocleidomastoid muscle pulling the

proximal portion up and back and the weight of the arm, pectoralis major anddeltoid pulling the distal portion down and forward

Middle 3rd lacks reinforcement by muscles or ligaments distal to subclaviusinsertion causing additional vulnerability

AssociatedInjuries

9% pts have additional fractures usually ribs Most brachial plexus injuries associated with proximal 3rd clavicle fractures

RadiographicPresentation

Standard AP x-rays are sufficient to confirm presence of clavicle fracture and degree

of displacement

30 cephalad tilt view allows image w/o overlap of thoracic anatomy

Apical oblique view helpful in dx minimally displaced fractures

CT may be useful, esp. in proximal 3rd fractures, to differentiate SC dislocation from

epiphyseal injury or distal 3rd fractures to identify articular involvementStability Group 1: fracture of middle third (80%) most common fracture in children/adults;

proximal and distal segments are secured by ligamentous and muscular attachmentsClassification

Neer classification is of fractures at the distal portion only (Group III)

Class I - Ligaments intact, without significant displacement and stable Class II - Displaced interligamentous fracture, usually large displacement and

unstable

Class III Intraarticular

Management Nonoperative

Most successfully tx nonoperatively w/ some form of immobilization

Comfort/pain relief are main goals

Sling for comfort (fewer skin problems than figure 8 bandage)

Goals of various methods of immobilization are as follows:

Support shoulder girdle, raising lateral fragment in upward, outward, and

backward direction

Depress medial fragment

Maintain some degree of fracture reduction Allow for pt to use ipsilateral hand/elbow

Some degree of shortening/deformity usually result

Immobilize for 4-6wks

During immobilization active ROM of elbow, wrist, and hand should be done

Operative (1st 2 bullets for operative TX only from fracture book)

Surgical indications for midshaft fracture controversial

Accepted indications for operative tx of acute clavicle fractures are:

Open fractures

Associated neurovascular compromise

Skin tenting w/ potential for progression to open fracture

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Complications

Neurovascular compromise

Uncommon

Can result from initial injury or 2 to compression of adjacent structures by

callus/residual deformity

Malunion

May cause unsightly prominence (operation = unsightly scar)

Effect on fxnl outcome controversial Nonunion

Severity of initial trauma

Extent of displacement of fracture fragments

Soft tissue interposition

Refracture

Inadequate immobilization

1 open reduction and internal fixation

Post-traumatic arthritis

May occur after intraarticular injuries to SC or AC joint

Prognosis Shortening/deformity

Proximal Humerus Fractures

Mechanism

of Injury

Most common FOOSH from standing height, typically in older, osteoporotic woman

Younger pts typically present following high-energy trauma (car accident) Usually represent more severe fractures/dislocations w/ significant assoc. soft tissue

disruption and multiple injuries

Less common mechanisms (excessive shoulder abduction, direct trauma, electrical

shock/seizure, pathologic processes)

Older, osteoporotic female fall from a standing height onto an outstretched arm or

excessive shoulder abduction

Younger patient direct high-energy trauma such as auto accident or blow (Usually

with multiple injuries)Signs

&Symptoms

Increase in older population thought to be due to osteoporosis

Most common humerus fracture (45%)

Pts present with upper extremity help closely to chest by contralateral hand

Present with: Pain

Swelling

Tenderness

Painful ROM

Variable crepitus

Chest wall/flank ecchymosis may be present differentiate from thoracic injury

Anatomy plays a key role in determining the fragment displacement in the fracture

and the fractures are extensively classified by fragment number (up to 4) and location

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The vascular system is extremely vulnerable to injury as is the axillary nerve

Patients present with the arm held closely to the chest with the unaffected arm

Fracture findings of pain, swelling, tenderness, variable crepitus

Hematoma which may extend to the chest and/or elbow

Assess neurovascular status carefully!

Physical

Examination

Careful neurovascular exam essential particular attention to nerve fxn

Assess by presence of sensation on lateral aspect of proximal arm overlying

deltoid

Motor testing no possible because of pain

Inferior translation may result from deltoid atony

Usually resolves 4wks after fracture

If persists after 4wks must differentiate from true axillary nerve injury

AssociatedInjuries

Glenohumeral dislocation usually posterior


Trauma series AP & Lateral views in scapular plane + axillary view

Axillary best view for eval of glenoid articular fractures/dislocations may be hard to

get bc of pain

Velpeau axillary pt left in sling, leaned obliquely backward 45 over cassette

CT helpful in eval of articular involvement, degree of fracture displacement,impression fractures, and glenoid rim fractures

MRI only used to assess rotator cuff integrity

Stability Stable no major fragment is displaced more than 1 cm and angulation is less than

30 degrees, + humeral head dislocation

Unstable 2 Part, 3 Part, 4 Part; Fracture dislocations

Management Minimally displaced fractures

85% of proximal humerus fractures

Sling immobilization or swathe for comfort

Frequent x-ray f/u to detect loss of fracture reduction

Early shoulder motion 7-10 days if pt has stable or impacted fracture

Pendulum exercises followed by passive ROM exercises

Active ROM start at 6wks

Resistive exercises at 12wks

2 part, 3 part, 4 part fractures usually require ORIF with pins, plates and/or screws

Stable fractures (~80%)

Sling then gradual pendulum exercises and careful mobilization of fingers, wrist

and elbow

Unstable fractures

Orthopedist management may require open-reduction and/or pins

Complications

Vascular injury (5-6%)

Axillary artery most common site w/ inc. incidence in elderly with atherosclerosis

Neural injury Brachial plexus injuries can occur, especially with dislocations

Brachial plexus injury - 6% Axillary nerve injury particularly vulnerable with anterior fracture-dislocation (if

there is not complete improvement in 2-3mos may need electromyographic evaland exploration)

Axillary nerve injury is more common

Chest injury - Intrathoracic dislocation, pneumothorax, and hemothorax

Myositis ossificans rare

Shoulder stiffness minimized with aggressive PT

Osteonecrosis especially with 3 or 4 part fractures

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Nonunion especially in osteoporosis or severe displacement

Malunion occurs after inadequate reduction or failed ORIF impingement and

restriction of shoulder motionPrognosis Looks bad but usually heals up nicely

Adult Supracondylar Fractures Flexion and Extension Type (Elbow or Distal Humerus)

Mechanism

of Injury Most low-energy distal humeral fractures result from simple fall in middle-aged/elderly

women in which elbow is either struck directly or axially loaded in a FOOSH

Motor vehicle/sporting accidents more common causes of injury in younger individuals

Relatively uncommon only 2% of all fractures

Extension-type Supracondylar fractures of distal humerus account for > 80% of all

Supracondylar fractures in adults Flexion-type fracture

Force directed against posterior aspect of flexed elbow

Uncommon injury frequently associated with open lesions as the sharp, proximal

fragment pierces the triceps tendon and overlying skin

Associated vascular injuries rare

Extension Fall on outstretched hand

Flexion (rare) fall on the point of the elbow

Signs&

Symptoms

Signs/sx vary with degree of swelling/displacement

Considerable swelling frequently occurs, rendering landmarks difficult to palpate

Normal relationship of olecranon, medial, and lateral condyles should be maintained

(equilateral triangle)

Crepitus w/ ROM & gross instability may be present do NOT attempt, neurovasculardamage may result

More common in children, in the adult usually the force will cause a dislocation

Typically seen in older adult unless it is a direct blow

A serious fracture due to the proximity of the brachial artery and radial/medial/ulnar

nerves

Variable with the degree of swelling and displacement

Crepitus with range of motion examination

Flexion type is often open because the proximal fragment has a sharp edge in the

direction of pullPhysical

Examination Careful neurovascular eval essential bc sharp, fractured end of proximal fragment

may impale/contuse brachial artery, median nerve, or radial nerve

Serial exams w/ compartment pressure monitoring necessary w/ massive swelling Be sure to examine the neurovascular structures

AssociatedInjuries

Intercondylar fracture

Dislocation


Standard AP and Lateral views of elbow should be obtained

Oblique x-ray useful for further fracture definition

Traction x-ray better delineates fracture pattern good for preop planning

Nondisplaced fractures

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Anterior or posterior fat pad sign may be present on lateral radiograph

represents displacement of adipose layer overlying joint capsule in presence ofeffusion or hemarthrosis

Minimally displaced

May result in decrease in normal condylar shaft angle of 40 seen on lateralradiograph

Intercondylar fractures more common than Supracondylar in adults so AP x-ray shouldbe scrutinized for evidence of vertical split in intercondylar region of distal humerus

CT used to delineate fracture fragments further

Extension type

Oblique and transverse fracture line, downward and forward, with the distal

fragment displaced posteriorly

Flexion type

Oblique and transverse fracture line, downward and backward, with the distal

fragment displaced anteriorlyManagement General TX Principles:

Anatomic articular reduction

Stable internal fixation of articular surface

Restoration of articular axial alignment Stable internal fixation of articular segment to metaphysis and diaphysis

Early ROM of elbow

Extension-type Supracondylar Fracture

Nonoperative

Indicated for nondisplaced/minimally displaced fractures and severely comminuted

fractures in elderly pts with ltd fxnl ability

Posterior long arm splint placed in at least 90 of elbow flexion if swelling and

neurovascular status permits forearm in neutral

Continue splinting for 1-2wks then ROM exercises begin

Discontinue splint after ~6wks when x-ray evidence of healing present

Frequent x-ray eval necessary to detect loss of fracture reduction Operative

Indications: displaced fracture, vascular injury, and open facture

ORIF or total elbow replacement in elderly pt

Start ROM exercises as soon as pt able to tolerate therapy

Flexion-type Supracondylar Fracture

Nonoperative

Nondisplaced/minimally displaced fractures may be immobilized in posterior elbow

splint in relative extension

Elbow flexion may result in fracture displacement

Operative

ORIF ROM started as soon as pt can tolerate therapy

Total elbow replacement in elderly pt with severly comminuted fracture

It is critical to document neurovascular status repeatedly!

Immediate Orthopedic referral for any patient with displacement, vascular injury or

neural injury

Extension type

Non-displaced fractures are placed in posterior long-arm splint with at least 90degrees of flexion and forearm in neutral for 1 -2 weeks, then range of motion

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exercises (continued splint out of therapy) for at least 6 weeks

Flexion type non-displaced fractures in posterior splint in relative extension

Complications

Cubital fossa swelling may result in vascular impairment of development of volar

compartment syndrome resulting in Volkmann ischemia

Extension Type (operative tx)

Volkmann Ischemic Contracture - from unrecognized compartment syndrome

Stiffness up to 20 decrease Heterotopic bone formation may occur

Compartment Syndrome - major problem to worry about further down below the

elbow

Cubitus Varus (Gunstock deformity)

Forearm Monteggia, Galeazzi, & Nightstick

Monteggia Galeazzi

Nightstick

Forearm fractures are more common in males and the ratio of open to closed fractures is higher than

for any bone other than the tibia

Forearm acts as ring fracture that shortens either the radius or ulna results in a fracture or dislocation

of other forearm bone at proximal or distal radioulnar joint (nightstick fracture is an exception)

The ring structure of the fracture means that a fracture which shortens one bone results in a fracture

of dislocation of the other bone X-ray the entire forearm elbow to wrist

Fat pad sign ALWAYS pathopneumonic or indicative of a fracture

Alternatively, a fracture of one bone is comminuted

Capillary compression from increased pressure and/or compartment syndrome is a serious problems

and leads to Volkmanns syndrome if not treated urgentlyMechanism

of InjuryRadius & Ulnar Shaft Fractures

Commonly associated with motor vehicle accidents

Also commonly caused by direct trauma (while protecting ones head), gunshot

wounds, and falls either from a height or during athletic competition

Pathologic fractures uncommon

Ulnar Shaft Fractures Include nightstick and Monteggia fractures + stress fractures in athletes

A Monteggia lesion denotes a fracture of the proximal ulna accompanied by radial

head dislocation

Ulna nightstick fractures result from direct trauma to ulna along SC border

classically as victim tries to protect their head from assault

Monteggia fractures produced by various mechanisms (Bado classification)

Forced pronation of forearm

Axial loading of forearm with a flexed elbow

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Forced abduction of elbow

Forced pronation of the forearm + failure of radial shaft

Nightstick fracture

Results from direct trauma to the ulna along its subcutaneous border (protective

response)

Monteggia Fracture (at the elbow)

Fracture of the ulnar shaft with a dislocation of the radial head Isolated dislocation of the radial head is uncommon in adults, but not in children

Direct blow to the forearm

Fall on outstretched hand with hyperpronation of the forearm

Radial Shaft Fractures

Fractures of proximal 2/3 of radius w/o assoc. injuries may be considered to be trulyisolated

Radial fractures involving distal 3rd involve distal radioulnar joint until provenotherwise

Galeazzi Fracture (fracture of necessity)

Fracture of radial diaphysis at junction of middle and distal 3rd with assoc.

disruption of distal radioulnar joint Requires ORIF to achieve good result

~3x as common as Monteggia fractures

Four major deforming forces contribute to loss of reduction (weight of hand,

pronator quadratus insertion, brachioradialis, and thumb extensors and abductors

Direct trauma to the wrist (dorsolateral aspect) or fall onto an outstretched hand

with forearm supination

Reverse Galeazzi fracture of distal ulna w/ assoc. disruption of distal radioulnar joint

Radial diaphyseal fractures may be caused by direct/indirect trauma like FOOSH

Radial shaft in proximal 2/3 is well padded by extensor muscles

Most injures severe enough to result in proximal radial shaft fractures typically result

in ulna fracture as well

Anatomic position of radius in most fxnl activities renders it less vulnerable to directtrauma than ulna

May also involve the carpoulnar joints

Galeazzi lesion looks innocuous and easy to treat, it is not!

Signs&

Symptoms

Radius & Ulnar Shaft Fractures

Pts typically present with gross deformity of involved forearm, pain, swelling, and loss

of hand/forearm fxn

Excruciating, unremitting pain, tense forearm compartments, or pain on passivestretch of fingers should raise suspicions of compartment syndrome

Ulnar Shaft Fractures

Nightstick fracture

Typically present with focal swelling, pain, tenderness, and variable abrasions atsite of trauma

Monteggia fractures

Present with elbow swelling, deformity, crepitus, and painful ROM, esp.pronation/supination


Variable pt presentation related to severity of injury and degree of fracture

displacement

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Pain, swelling, and point tenderness over fracture site are typical

Galeazzi Fractures

Typically present with wrist pain or midline forearm pain exacerbated by stressing

of distal radioulnar joint in addition to radial shaft fracture

Neurovascular injury rare

Physical

Examination


Careful neurovascular exam essential assess radial/ulnar pulses + median, radial,and ulnar nerve fxn

Assess open wounds bc ulna border is SC and even superficial wounds can expose

bone

Monitor compartment pressure


Careful neurovascular exam essential nerve injury, esp. radial or posterior

interosseous nerve is common

Anterior (flexor) and posterior (extensor) compartments must be checked for

tightness or pain on passive stretch of the digits

Radial Shaft Fractures Elbow ROM (supination/pronation) should be assessed

Rarely ltd forearm rotation may suggest radial head dislocation in addition to

diaphyseal fractureRadiographicPresentation


AP and Lateral views of forearm should be done

Oblique views for further fracture definition

Include ipsilateral wrist/elbow to rule out presence of associated fracture or

dislocation

Radial head must be aligned with capitellum on all views


AP and Lateral views of elbow and forearm (to include wrist) should be done

Oblique view may aid in fracture definition

Normal radiographic findings:

Line drawn thru radial head and shaft should always line up with the capitellum

Supinated lateral lines drawn tangential to radial head anteriorly and posteriorly

should enclose capitellum

Monteggia Fractures

Anterior dislocation of radial head with fracture of ulnar diaphysis with anterior

angulation (I)

Posterior/posterolateral dislocation of radial head with fracture of ulnar diaphysis

with posterior angulation (II)

Lateral/anterolateral dislocation of radial head with fracture of ulnar metaphysis

(III)

Anterior dislocation of radial head with fractures of both radius and ulna withinproximal 3rd at same level (IV)


AP and Lateral views of forearm, elbow, and wrist should be done

Radiographic signs of distal radioulnar joint injury

Fracture at base of ulnar styloid

Widened distal radioulnar joint on AP x-ray

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Subluxed ulna on lateral x-ray

>5mm radial shortening

Break is in the shaft in the distal 1/3 of radius

Lateral or oblique view will show the dislocation of the ulna

Stability Ulnar shaft fractures are unstable

Galeazzi fractures can be stable or unstable

Management Radius & Ulnar Shaft Fractures

Nonoperative

Rare, nondisplaced fracture of both radius and ulna may be tx with well-molded,

long arm cast in neutral rotation with elbow flexed to 90

Frequent f/u to eval for possible loss of fracture reduction

Operative

ORIF is procedure of choice for displaced forearm fractures involving radius and

ulna in adults

Debridement of open fractures followed by ORIF


Nightstick Fractures

Nondisplaced/minimally displaced ulna fractures May be tx with plaster immobilization in a sugar-tong splint for 7-10 days

May need to follow this with fxnl bracing for 8wks with active ROM

exercises for elbow, wrist, and hand

Can also use simple immobilization in a sling with a compression wrap

Displaced Fractures (>10 angulation in any plane or >50% displacement of shaft)

- Tx with ORIF

Monteggia Fractures

Closed reduction/casting should be reserved only for peds

Require operative tx

Closed reduction of radial head

ORIF of ulna shaft

After fixation radial head is usually stable Postop posterior elbow splint for 5-7 days

Start PT if fixation is stable

In Adults open reduction of the fracture is the norm because it is unstable

The radial head dislocation may be reduced in a closed or open procedure

If the annular ligament is severely disrupted, open repair is needed


Galeazzi Fracture

ORIF is tx of choice (closed reduction has high failure rate)

Postop management (regarding distal radioulnar joint)

Stable - early mobilization recommended

Unstable immobilize forearm in supination for 4-6wks in long arm splint orcast

Pins removed at 6-8wks if needed

Complications


Nonunion and malunion uncommon (infxn or surgical error)

Infection 3% incidence

Neurovascular injury uncommon

Volkmann ischemia follows compartment syndrome

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Posttraumatic radioulnar synostosis uncommon, risk inc w/ crush injuries


Nerve injuries (especially Types II and III)

Radial/median nerves and their terminal branches

Posterior and anterior interosseous nerves

Radial head instability uncommon unless redislocation occurs 2wks

Single incision for fixation of both bone forearm fractures

Penetration of interosseous membrane

Crush injury

Infection

Recurrent dislocation result of radial malreduction

Prognosis Galeazzi

Worst prognosis is with distal synostosis

Best is with diaphyseal synostosis

Wrist Colles and Smiths (Distal Radius)

Colles

SmithsMechanism

of Injury Among most common fractures of upper extremity

Incidence in elderly correlates with Osteopenia and rises with increasing age

Risk factors for fracture of distal radius in elderly:

Decreased bone mineral density

Female

White

FHx

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Early menopause

80% of axial load supported by distal radius and 20% by ulna

Reversal of normal palmar tilt results in load transfer into ulna and TFCC

Common mechanisms in younger people:

Falls from a height

Motor vehicle accident

Injuries sustained during athletic participation

Common mechanisms in elderly people:

Arise from low energy mechanisms like simple fall from standing height

Most common FOOSH with wrist in dorsiflexion

Fractures of distal radius produced when dorsiflexion of wrist varies b/w 40 and

90, with lesser degrees of force required at smaller angles

Radius initially fails in tension on volar aspect fracture propagates dorsally

Bending moment forces induce compression stresses resulting in dorsal

comminution

Cancellous impaction of metaphysis further comprises dorsal stability

Shearing forces influence injury pattern result in articular surface involvement

High-energy injuries (vehicular trauma) may result in significantly displaced or

highly comminuted unstable fractures to the distal radius

Among the most common fractures, these are ~ 18% of fractures seen in the ER.

Osteoporosis is a major risk factor

Fall onto outstretched hand with the wrist in various degrees of rotation and flexion

Colles

More than 90% of distal radius fractures are of this pattern

Fall onto hyperextended, radially deviated wrist with forearm in pronation

Hand is displaced posteriorly or dorsally

Occurs in the 2.5 cm zone distally in radius

Smiths (aka Reverse Colles)

Fall onto a flexed wrist with the forearm fixed in supination

Signs

&Symptoms

Typical presentation:

Variable wrist deformity and displacement of hand in relation to wrist

Dorsal in Colles

Volar in Smiths

Wrist typically swollen with ecchymosis, tenderness, and painful ROM

Colles

Includes both extraarticular and intraarticular distal radius fractures demonstrating

various combinations of dorsal angulation (apex volar), dorsal displacement, radialshift, and radial shortening

Described as a dinner fork deformity

Intraarticular fractures generally seen in younger age group 2 to high-energy forces

Smiths

Fracture with volar angulation (apex dorsal) of the distal radius with a garden spade

deformity or volar displacement of the hand and distal radiusPhysical

Examination Ipsilateral elbow and shoulder should be examined for associated injuries

Careful neurovascular exam pay attention to median nerve fxn

Carpal tunnel compression sx common

AssociatedInjuries

Colles

Injuries to nerve, carpus, and distal ulna are more frequent

Involvement of both the radiocarpal joint and DRUJ

Radiographic PA and Lateral views of wrist should be done

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Presentation Oblique views for further fracture definition

Should or elbow sx should be evaluated with x-rays

Contralateral wrist view may help to assess pts normal ulnar variance and

scaphoulnate angle

CT may help show extent of intraarticular involvement

Normal radiographic relationships:

Radial inclination averages 23 (range 13-30) Radial length averages 11mm (range 8-18mm)

Palmar (volar) tilt averages 11-12 (range 0-28)

Stability Smiths

Notoriously unstable fracture pattern

Management Factors affecting tx:

Fracture pattern

Local factors bone quality, soft tissue injury, comminution, displacement, &

energy of injury

Patient factors age, lifestyle, occupation, hand dominance, assoc. medical

conditions/injuries, & compliance

Acceptable radiographic parameters for a healed radius in an active healthy pt:

Radial length w/in 2-3mm of contralateral wrist

Neutral palmar tilt

Intraarticular step-off

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Secondary loss of reduction

Articular comminution, step-off, or gap

Metaphyseal comminution or bone loss

Loss of volar buttress with displacement

DRUJ incongruity

Colles

Closed reductionSmiths

Closed reduction and subsequent referral for open reduction

Reduction improves pain and swelling and relieves median nerve pressure

Splint until swelling reduced then cast ~ 6 weeks

Cast too soon will almost guarantee compartment syndrome

Complications

Colles & Smiths

Median nerve injury

Malunion or nonunion

Posttraumatic osteoarthritis

Rupture of the extensor pollicus longus

Scaphoid Fractures

Mechanism

of Injury

Wrist injuries common but true incidence unknown

Normal anatomic relationships: The 47-degree scaphoulnate angle (normal range 30-70 degrees)

Less than 2mm scaphoulnate space

Most common mechanism of carpal injury is FOOSH resulting in axial compressive

force with wrist in hyperextension

Volar ligaments placed under tension with compression and shear forces applied

dorsally (esp. when wrist is extended beyond its physiologic limits)

Excessive ulnar deviation and intercarpal supination result in predictable pattern of

injury

Progresses from radial side of carpus to mid carpus to ulnar carpus

Scaphoid Fractures

Common and account for 50-80% of carpal injuries

Anatomically, scaphoid divided into proximal and distal poles, a tubercle, and awaist

80% of scaphoid covered with articular cartilage

Ligamentous attachments include:

Radioscaphocapitate ligament that attaches to the ulnar aspect of scaphoid

waist

Dorsal intercarpal ligament provides 1 vascular supply to scaphoid

Major vascular supply is from scaphoid branches of radial artery (enter dorsal

ridge and supply 70-80%)

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Fractures at scaphoid waist or proximal 3rd depend on fracture union for

revascularization

Most common mechanism is a FOOSH that imposes a force of

dorsiflexion, ulnar deviation, and intercarpal supination

Carpal bone fractures are complex due to the irregularity of shape, multipleligamentous connections and limited vascular supply (only supplied by one blood

vessel) 50-80% of fractures of the carpal bones involve the scaphoid and the fracture with the

highest risk of missed diagnosis and poor outcome is the scaphoid

If patient has snuffbox tenderness then must treat as a fracture

Fall onto an outstretched hand that causes dorsiflexion, ulnar deviation andintercarpal supination

If you are young take at scaphoid and if you are old - take at radius

Signs&

Symptoms

Clinical presentation of individual carpal injuries is variable

Most consistent sign of carpal injury is well-localized tenderness

Gross deformity may be present ranges from displacement of carpus to prominence

of individual carpal bones

Scaphoid Fracture

Pts present with wrist pain and swelling w/ tenderness to palpation overlying thescaphoid in the anatomic snuffbox

Variable degrees of wrist pain and swelling with tenderness to palpation of the

proximal pole overlying the scaphoid in the anatomic snuffbox and/or the distal pole onthe volar surface

PhysicalExamination

Provocative tests may reproduce/exacerbate pain, crepitus, or displacement indicative

of individual carpal injuries

Scaphoid Fracture

Provocative tests:

Scaphoid lift test reproduction of pain with dorsal-volar shifting of

scaphoid

Watson test painful dorsal scaphoid displacement as wrist is moved from

ulnar to radial deviation with compression of the tuberosity Pain with thumb pinch

AssociatedInjuries

Injuries to other carpal bones

Dislocation


PA and Lateral x-rays are each taken in neutral position

Gilula Lines: 3 smooth radiographic arcs should be examined on PA view

Disruption of arcs = ligamentous instability

For further dx of carpal and mainly scaphoid fractures:

Scaphoid view (AP x-ray with wrist supinated 30 degrees and in ulnar deviation)

Pronated oblique view done

Clenched fist PA view if worried about ligament instability

Arthrography, MRI assist in dx of ligament injuries

CT scans helpful in eval carpal fractures, malunion, nonunion, and bone loss MRI scans sensitive to detect occult fractures and osteonecrosis of carpal bones + soft

tissue injury

Scaphoid Fracture

PA view with hand clenched in a fist to extend scaphoid, a lateral, a oblique

(supinated AP), and an ulnar oblique view

Initial films are nondx in up to 25% of cases

If exam suggests fracture but x-ray not dx then immobilize and f/u x-ray 1-2wks

after injury to see fracture

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Technetium bone scan, MRI, CT, and ultrasound eval may be used to dx occult

scaphoid fracture

Classification is based on fracture pattern, displacement, and location

Request a scaphoid view radiograph as the radiolucent line is not visible initially on

routine viewsStability Stable nondisplaced fractures with no step-off in any plane

Unstable displacement with 1mm+ of step-off scaphoulnate angulation > 60degrees or radioulnate angulation > 15 degrees

Management Nondisplaced distal third fractures and tubercle fractures can be placed in a long-arm

spica cast in slight flexion and slight radial deviation for 6 weeks.

All others open reduction and fixation with screws

Indications for nonoperative tx:

Nondisplaced distal 3rd fracture

Tuberosity fracture

Nonoperative tx:

Long arm thumb spica cast for 6wks

Immobilization in slight flexion and slight radial deviation

Replacement with short arm thumb spica cast at 6wks until united

Expected union time = distal 3rd is 6-8wks, middle 3rd is 8-12wks, and proximal 3rdis 12-24wks

Management of suspected scaphoid fractures:

Pts with injury and + exam findings but normal x-ray, immobilization for 1-2wks in

thumb spica

Repeat x-rays if pt is still sx

If pain still present but x-rays continue to be normal, consider MRI or bone scan

If acute dx necessary consider MRI or CT scan immediately

Operative tx:

Indications for surgery:

Fracture displacement > 1mm

Radioulnate angle > 15 degrees

Scaphoulnate angle > 60 degrees

Humpback deformity

nonunion

Complications

Osteonecrosis

The major vascular supply to the scaphoid is a branch of the radial artery which

supplies 70-80% of the proximal scaphoid

Fractures at the waist of the scaphoid depend on fracture union for

revascularization, 10% of fractures develop nonunion

Proximal pole fractures are the most likely

Delayed union (more frequent with short arm cast)

Prognosis Healing rates with nonoperative tx

Tuberosity and distal 3rd 100%

Waist = 80-90%

Proximal pole = 60-70%

Proximal fractures are prone to nonunion and osteonecrosis

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Base of Thumb Bennetts Fracture/Dislocation

Mechanismof Injury

Extraarticular fractures

Usually transverse or oblique

Bennett Fracture

Fracture line separates major part of metacarpal from volar lip fragment

Produces a disruption of 1st carpometacarpal (CMC) joint

1st metacarpal is pulled proximally by abductor pollicis longus

Functionally, the thumb is considered 50% of the hand, equal to the other digits

combined

Bennetts is the most common type of thumb fracture

Pure dislocation of the thumb is rare because the multiple ligaments create

competing pull in an injury situation, especially the very strong anterior obliqueligament

The fracture is unique

The fracture extends into the joint (intraarticular)

One third to one half of the palmar lip of the base is fractured off and remains

attached via the anterior oblique ligament

The other fragment dislocates from the CMC joint with a posterolateral and

proximal displacement due to pull of the abductors pollicis longus and withabduction of the base and adduction of the head due to the pull of the adductor

pollicis and is rotated by the abductors pollicis longus Often the result of a fist fight, with a longitudinal axial blow on a partially flexed

thumbSigns

&Symptoms

Swelling and tenderness at the base of the thumb (distal to the snuffbox)

Pain with opposition of the thumb


Classic vs. occult

Management Most can be held by closed reduction and casting

Some unstable fractures require closed reduction and percutaneous pinning

ORIF

Basal joint of thumb is quite forgiving and an anatomic reduction of an angulated

shaft fracture is not essential Trial of closed reduction is recommended by some, however because the fracture is

difficult to maintain, even with pins, it is usually referred to an Orthopedic surgeonComplication

s Malunion

Rotational deformities

Chronic arthritis and ligamentous laxity

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Fifth Metacarpal Boxers Fracture

Mechanismof Injury

Ring and small finger carpometacarpal articulation is flexible

Fracture of the neck of the fifth metacarpal in which the distal portion is pulled into

the palm by hand intrinsics

This angulates the apex posteriorly

The anterior cortex is typically comminuted due to shatter of the cortex with

ligamentous pulling

Fracture is instable exception Striking a solid object with the head of the metacarpal

Management Fight-bite injuries any short, curved laceration overlying a joint in hand, must be

suspected of having been caused by a tooth assume contamination w/ oral flora ABX

5 major tx alternatives:

Immediate motion

Temporary splinting

CRIF (Closed Reduction and Internal Fixation)

ORIF

Immediate reconstruction

Stability less assured with nonoperative fixation

Metacarpal Shaft;

Nondisplaced or minimally displaced fractures can be reduced and splinted inprotection position

Operative indications include:

Rotational deformity

Dorsal angulation > 40 degrees for fifth metacarpal

Ten degrees of malrotation should represent the upper tolerable limit

Operative fixation may be achieved with either closed reduction and percutaneous

pinning or open reduction and plate fixation

With successful alignment, 5-6 weeks in an ulnar gutter splint

Stable fractures with angulation < 40: Closed reduction

Unstable fractures with angulation > 40: Open reduction and internal fixation

Complication

s

Malrotation

Nonunion

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Phalanx Fractures

Mechanism

of Injury Border digits most commonly involved distal phalanx 45%, metacarpal 30%,

proximal phalanx 15%, and middle phalanx 10%

Most common in males

Proximal phalanx fractures usually angulate into extension (apex volar)

Proximal fragment flexed by interossei

Distal fragment extended by central slip

Middle phalanx fractures unpredictable

Distal phalanx fractures usually result from crush injuries and are comminuted tuft

fractures

High degree of variation in mechanism of injury accounts for broad spectrum of

patterns seen in skeletal trauma sustained in hand

Axial loading or jamming injuries frequently sustained during ball sports or sudden

reaches made during everyday activities like trying to catch a falling object

The border digits are the most commonly involved nearly half involve the distal

phalanx

Diaphyseal fractures and joint dislocations usually require a flexion position during the

injury and tendon pull often causes avulsion of the plate

Crush injuries are most common in industrial setting, and some home hobbies

These are often open dirty fractures

Crush Fracture

Usually the distal portion, also called tuft fracture

Typically comminuted

Often associated with open injury

This area has a glove of the tendon attachments which helps hold the fragments

confined

Phalanx Avulsion Fracture

Commonly occur at the distal and medial phalanx due to tendon attachment

Therefore also dislocate

The outcome depends on the degree of articular involvement.

Mechanism of injury

Hyperextension injury causes volar lip fracture

Tendon avulsion occurs with flexion during the trauma

Mallet Finger

Results from a fracture of the dorsal lip with a disruption of the extensor tendon

Jersey Finger

Seen in football/rugby players, most commonly involving the ring finger

Results from fracture with rupture of the flexor profundus digitorum

Usually the result of forced hyperextension of the DIP joint against anactively contracting flexor tendonSigns

&Symptoms

Careful hx essential

Age

Hand dominance

Occupation

Systemic illnesses

Mechanism of injury crush, direct trauma, twist, tear, laceration, etc.

Time of injury

Exposure to contamination

Tx provided

Physical

Examination

Digital viability

Neurologic status Rotational and angulatory deformity

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Objective 9State and describe the mechanism of injury, signs/symptoms, physicalexamination, associated injuries, radiographic presentation (withradiographic reading using ABCs), stability, management, complications,and prognosis of the following common upper extremity dislocations or

sprains:a) glenohumeral (anterior, posterior) b) acromioclavicular sprain (all types)c) gamekeepers thumb d) phalanx (MCP, PIP, and DIP)

Glenohumeral Dislocation: Anterior

Mechanism ofInjury

Most common shoulder dislocation

Trauma, secondary to direct or indirect forces

Indirect trauma to upper extremity with the shoulder in abduction, extension,

and external rotation (most common mechanism)

Direct, anteriorly directed impact to the posterior shoulder

Convulsive mechanisms and electrical shock sometimes produce anterior

dislocation

Recurrent instability due to congenital or acquired laxity may dislocateshoulder with minimal trauma

Signs/Symptoms

Typically presents with injured shoulder held in slight abduction and external

rotation

Acutely dislocated shoulder is painful with muscular spasm

Patient is unable to touch the opposite shoulder

PhysicalExamination

Squaring of the shoulder due to prominence of the acromion, hollowing beneath the

acromion posteriorly, and a palpable mass anteriorly

If patient presents after spontaneous reduction or reduction in the field, exam may

reveal a positive apprehension test:

Passive placement of the shoulder in the provocation position reproduces the

patients sense of instability and pain

AssociatedInjuries

Bankart fx: avulsion of the inferior aspect of the anterior labrum


Trauma series of the affected shoulder: AP scapular-Y, and axillary views taken in

the plane of the scapula

No description of findings in notes or book

Stability Unknown

Management Rule out neurovascular deficits

Prompt closed-reduction confirmed by x-ray

There are numerous reduction techniques but Nancy claims we dont need to

know them yet

Countertraction/traction away from humerus

Splinting and immobilization for 2-5 weeks

Pts over 40 may require shorter time due to stiffness Younger patients need longer periods of immobilization

Post-reduction neurovascular exam

Occupational therapy

Refer to ortho for follow-up

Complications Recurrent anterior dislocations due to ligament and capsular changes

Most recurrences are in men within first 2 yrs

Osseous lesions

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Hill-sachs lesion

Glenoid lip fractures (bony Bankart lesion)

Greater tuberosity fracture

Fracture of the acromion or coracoid

Posttraumatic degenerative changes

Soft tissue injuries

Rotator cuff tear (older patients)

Capsular or subcapsularis tendon tears

Vascular injuries

Typically elderly with atherosclerosis and usually involve the axillary artery

May occur at the time of reduction

Nerve injuries

Typically the musculocutaneous and axillary nerves in the elderly

Prognosis Affected by age at time of initial dislocation

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Acromioclavicular SprainMechanism ofInjury

Most commonly in 2nd decade of life associated with athletic activities

Direct: Most common mechanism

Fall onto shoulder with arm adducted, driving the acromion medial and

inferior

Blow to tip of the acromion

Fall on point of elbow

Indirect

Glenohumeral Dislocation: PosteriorMechanism ofInjury

Indirect trauma: most common mechanism

Typically in the position of adduction, flexion, and internal rotation

Electric shock or convulsive mechanisms may produce posterior dislocations

due to greater muscular force o the internal rotator muscles compared with

external rotator muscles Direct trauma

From force application to the anterior shoulder resulting in posterior

translation of the humeral headSigns/Symptoms

Does not present with striking deformity

Injured upper extremity is typically held in traditional sling position of shoulder

internal rotation and adduction

Pt resists external rotation and abduction and there is limited forward elevation

PhysicalExamination

Palpable mass posterior to the shoulder, beneath the acromion with flattening of

the anterior shoulder, and coracoid prominence may be observedAssociatedInjuries

See complications


AP view signs suggestive of posterior dislocation include:

Absence of normal elliptic overlap of humeral head on the glenoid

Vacant glenoid sign: glenoid appears partially vacant

Through sign: impaction fx of the anterior humeral head caused by posterior

rim of the glenoid

Loss of profile of neck of humerus; full internal rotation

Void in the superior/inferior glenoid fossa due to infero-superiordisplacment

of the dislocated humera head

Most are recognized on axillary view

Stability Unknown

Management Same as anterior but requires full muscle relaxation, sedation, and analgesia

Pain usually greater and may require general anesthesia

Complications Fractures

Posterior glenoid rim, humeral shaft, lesser and greater tuberosities, and

humeral head

Recurrent dislocation

Requires surgical stabilization to prevent recurrence

Neurovascular injury

Less common but may include axillary nerve or the nerve to the

infraspinatus

Anterior subluxation

May result from overtightening posterior structures

Prognosis Unknown

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Fall onto an outstretched hand with force transmission through the hume

head and into the AC articulation

Levering motion with humerus

Signs/Symptoms

Patient should be examined while standing or sitting with upper extremity in

dependent postion to stress AC joint and exaggerate deformity

Downward sag of the shoulder and arm

Sag of the scapulaPhysicalExamination

Visible step-off or bump with point tenderness over AC joint

Painful but full range of motion in the shoulder, may be impaired in grade 3

AssociatedInjuries

Fractures

Clavicle, acromion process, and coracoid process

Pnuemothorax or pulmonary contusion


Type 1:

Sprain of the ligaments without displacement of the clavicle

Stable injury

AC tenderness, minimal pain with arm movement and no pain in the

coracoclavicular interspace

No radiographic abnormality

Type 2:

Tear of the acromioclavicular ligament and coracoclavicular ligament is

sprained but intact

Distal clavicle slightly superior to the acromion and mobile to palpation,

tenderness in the coracoclavicular space

Stable injury

Radiographs show slight elevation of the distal end of the clavicle; AC join

widening

Type 3:

Disruption of all ligaments with complete dislocation with elevation of the

clavicle above the acromion and detachment of the deltoid and trapezius

Upper extremity and distal fragment are depressed and the distal end of

proximal fragment may tent the skin AC joint tender, widening of coracoclavicular joint is evident

Unstable in both saggital and coronal planes

Radiographs show distal clavicle superior to the medial border of the

acromion

Type 4-6

Increasing degrees of injury to supporting muscle

Extensive displacement, possibly thorough the trapezius, with more pain

than grade 3; involves joint capsule

Severely unstable: always go to surgery

Stability See grading above

Management Type 1: Rest for 7-10 days, ice pack, sling. Refrain from full activity and ROM for

weeks. Type 2: Sling 1-3 weeks, gentle ROM. Refrain from heavy activity for 6 weeks.

Type 3: Sling, early ROM, strengthening, and acceptance of injury. Surgical

stabilization an option.

Type 4-6: Surgery

Complications Coracoclavicualr ossification

Distal clavicle osteolysis

AC arthritis

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Prognosis Type 1 and 2 injuries remain symptomatic at long-term follow-up

Gamekeepers Thumb

Injury of the ulnar collateral ligament of the thumb ranging from sever stretch to complete tear

Complete tear most common form and often termed ski pole thumb

Less commonly the radial collateral ligament is injured

Mechanism ofInjury

Forceful abduction of the base of the thumb (Acute) Repetitive stressing actions on the ligaments (Chronic)

Signs/Symptoms

Swelling and tenderness on medial aspect of thumb over IP joint

Decreased ability to hold or pinch objects

Hematoma if acute

Laxity of the joint under stress (only do if there confirmation of no fx)

PhysicalExamination

AssociatedInjuries

Avulsion fx in acute injuries


Unknown

StabilityManagement Partial tears: immobilization in a splint or thumb spica cast

Heals very slow; rest and protect joint for several weeks Complete tears: open repair referral

Complications Chronic instability of the thumb

Prognosis Unknown

*** for the finger dislocations there is very little information in the book ornotes so I didnt divide the information out

Phalanx Dislocation: PIP

High rate of misdiagnosis and are passed off as sprains

Can be complete or incomplete

Complete disruptions of the collateral ligaments and volar plate are frequent (long and ring

fingers)

Recognized patterns of dislocation are:

Dorsal dislocation

Phalanx Dislocation: MCP

Dorsal dislocation most common

Simple dislocation

Subluxations because some contact remains between phalanx and metacarpal head Present with a hyperextension posture

Reduction achieved with simple flexion of the joint

Complex dislocation

Irreducible, most often the result of volar plate interposition

Most frequently in the index finger

Pathognomonic x-ray sign is appearance of a sesamoid in the joint space

Most dorsal dislocations are stable following reduction and do not need surgical repair

Volar dislocations are rare but unstable and should have repair of ligament

Open dislocations may be reducible or irriducible

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Pure volar dislocation

Rotary volar dislocation

Stiffness is the primary complication

Tx:

Reduction

Can begin immediate active range of motion with adjacent digit strapping

Splinting allowing for movement of the DIP joint

Phalanx Dislocation: DIP

Pure dislocations are rare

Mechanism ofInjury

Hx of hyperextension injury

Usually result from ball catching sports

Signs/Symptoms

Painful, swollen fingertip

Grossly deformed DIP jointPhysicalExaminationAssociatedInjuries

May occur in association with PIP joint dislocations


Dislocations are often dorsal

Stability Unknown

Management Reduction with hyperextension and longitudinal traction after digital nerve block

Splint in slight flexion for two weeks

Complications Transverse open wounds of the volar skin crease are common

Prognosis Unknown

Objective 10State and describe the mechanism of injury, signs/symptoms, physicalexamination, associated injuries, radiographic presentation (with aradiographic reading using the ABCs format), stability, management,complications and prognosis of the following common lower extremityfractures:NNBs notes are in this color, I call it navy blue.

Femoral Neck fracture

Common in athletes, old folks and those in high energy trauma

For athletes, the force acting on the joint is a proportion of body weight Strait leg raise = 1.5 x Body

Weigh, One legged stance = 2.5 x BW, Running = 5.0 x BW, Two legged stance = 0.5 x BW

Femoral neck fractures have 3 zones where they occur Subcapital (separating head from neck),

Cervical, Basicervical (through base of the neck)MOI

Low energy trauma; most common in older patients (falling)

-Direct: a fall onto greater trochanter (valgus impaction) or forced external rotation of the lowerextremity impinges an

osteoporotic neck onto the posterior lip of the acetabulum (results in posteriorcomminution)

-Indirect: muscle forces overwhelm the strength of the femoral neck

High energy trauma; younger and older patients, occurring from MVAs or falls from significant heights.

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Cyclical loading stress fractures: Seen in athletes, military, ballet dancers; patients with osteoporosis/-

penia are at particular riskSigns and Symptoms/Physical Exam

Pts with displaced femoral neck fractures are typically non-ambulatory on presentation, with shortening

and external rotation of the lower extremity.

Pts with impacted or stress fractures may have subtle findings anterior capsular tenderness, pain with

axial compression, lack of deformity, and they may be able to bear weight Acute onset of pain, inability to bear weight

A shortened and externally rotated leg

Pain is evident of range of hip motion, +/- pain on axial compression and tenderness to palpation of the

groin

Accurate Hx is key to the low-energy fractures that occur in older patients

-obtaining a Hx of LOC, prior syncope, PMH, prior hip pain (think pathologic fx) and pre-injuryambulation status is critical

determining optimal Tx and disposition.

Assess wrists/shoulders also because 10% of elderly have associated upper extremity issues

Associated InjuriesRadiograph

AP view of the pelvis and an AP and a cross-table lateral view of the involved proximal femur areindicated

Internal rotation view of the injured hip may be helpful to clarify the fracture pattern

Technetium bone or preferably MRI are indicated in delineating non-displaced or occult fractures when

not apparent on x-ray.

Impacted fractures appear as misalignment of the trabeculae with the acetabulum, bending of the

trabeculae on the medial side and sclerosis at the impaction site

In complete undisplaced fractures there is a radiolucent line, the trabeculae are well aligned with the

head with discontinuity of the trabeculae along the fracture

Displaced or comminuted fractures are categorized be the Garden system and trabeculae vary, along

with the position of the head.

Garden Classification is based on the degree of valgus displacement and is especially important in

predicting post traumatic osteonecrosis

Type I Incomplete/Valgus impacted Type III complete with partialdisplacement; trabecular pattern

of the femoral headdoes not line up with the acetabulumType II complete and non-displaced(on AP lateral view) Type IV completely displaced;trabecular pattern of the

head assumes a parallelorientation with that of the acetabulumStability doesnt say, I would assume impacted or stress is somewhat stable and displaced fractures areless likely to be stableManagement

Goals of Tx are to minimize patient discomfort, restore hip function, and allow rapid mobilization by

obtaining early anatomic reduction and stable internal fixation of prosthetic replacement

Non-operative Tx for traumatic fracture only for patients at extreme medical risk for surgery, or for

demented nonambulators with minimal hip pain

Early bed to chair mobilization is essential to avoid increased risks and complications or prolonged

recumbency

Fatigue/Stress fracture Tension-sided (seen at the superior lateral neck on an internally rotated AP

view), not at risk for displacement. In situ screw fixation is recommended.-Compression sided (seen as haze of callus on superior neck) protective crutch

ambulation until symptomatic

Impacted/Non-displaced fracture In situ fixation with 3 cancellous screws; exceptions are

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pathologic fractures

Displaced fracture Young Pt urgent closed/open reduction with internal fixation. Old Pt depends

on bone density

Fracture reduction should be achieved in a timely manner to avoid osteonecrosis

Treatment, in regard to the Garden classification:Type I or II can be plated or pinned Type III and IV may need femoral head

replacementType I can do toe touch weight bearing right away

Prosthetic replacement for the elderly, chronically ill or neurologically impaired patients

Mobilize all patients ASAP with physical therapy

Complications

Malunion or Non-union apparent by 12 months by groin or buttock pain, pain on hip extension or pain

with weight bearing.

Osteonecrosis may present as groin, buttock or proximal thigh pain.

Fixation failure usually related to osteoperotic bone or technical problems (malreduction, poor

implant insertion)

Prominent hardware may occur secondary to fracture collapse and screw back out.

Pulmonary (Im assuming from a PE that may develop from being bed ridden after surgery)

Prognosis not given, but its got to depend on the fracture type

Femoral Shaft fracture

A femoral shaft fracture is a fracture of the femoral diaphysis occurring between 5 cm distal to the

lesser trochanter and 5 cm proximal to the adductor tubercle.

Can occur in any age, most common in young males after high energy trauma or Old females after a

low energy fall

Risk of compartment syndrome is lower due to the larger volume of the 3 fascial components of the

thigh.MOI

Femoral shaft fracture in adults are the result of high energy trauma (MVA, fall from height, getting

capped in the leg) Pathologic fractures especially in the elderly, commonly occurring at the metaphyseal-diaphyseal

junction.

Stress fractures occur mainly in military recruits or runners. Most patients report a recent increase in

training intensity just before the onset of pain.Signs and Symptoms/Physical Exam

A full trauma survey is warranted due to the high energy injuries that cause femur fractures

Signs of multiple trauma

The Dx is usually obvious, with the Pt presenting non-ambulatory with pain, variable gross

deformity, swelling and shortening of the affected extremity

A careful neurovascular exam is essential (although it is uncommon associated w/ femoral shaft

fractures)

Thorough exam of the ipsilateral hip and knee should be performed, including systematic inspectionand palpation. ROM testing is often not feasible, but Ligamentous knee injuries do need to be assessedafter fracture fixation 50% have knee injury.

Major blood loss to the thigh may occur (Avg. blood loss is 1200mL and 40% of patients required

transfusions). Therefore, a carefully preoperative assessment of hemodynamic stability is essential(regardless of presence or absence associated injury)

Associated Injury

These are common and may present in up to 5-15% of cases, w/ patients presenting with multisystem

trauma, spine, pelvis and ipsilateral lower extremity injuries

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Ligamentous and meniscal knee injuries of the ipsilateral knee are present in 50% of patients with

closed femoral shaft fracturesRadiograph

AP and lateral views of the femur, hip and knee as well as an AP view of the pelvis should be obtained.

The radiographs should be critically evaluated to determine the fracture pattern, bone quality,

presence of bone loss, associated comminution, presence of air in the soft tissues and the amount of

fracture shortening Evaluate the proximal femur for evidence of an associated femoral neck or intertrochanteric fracture

Usually obvious, dont forget 2 views

Also x-ray the pelvis and proximal femur for associated fractures

Stability Im assuming this is not stableManagement

Closed reduction only done in those not able to tolerate open reduction

Traction may be a temporary Tx prior to surgery to stabilize the fracture and prevent shortening

Standard of care is operative reduction and intramedullary nailing (should be performed within 24

hours)

Get patient out of bed and mobilizing as soon as possible, early range of knee motion indicated.

Non-operative, skeletal traction

Currently, closed management as definitive Tx is limited to adult patients with such significant medicalcomorbidities that operative management is contraindicated.

The goal of traction is to restore femoral length, limit rotational deformities, reduce pain and minimize

blood loss into the thigh.

20-40lbs of traction applied and then a lateral x-ray is done to assess fracture length

Traction is usually used as a stabilizing measure prior to surgery

?? Distal femoral and proximal tibia pins are placed in an extracapsular location to avoid the possibility

of septic arthritis (medial to lateral on distal femur, lateral to medial at proximal tibia)

Problems of traction for definitive traction Tx knee stiffness, limb shortening, prolonged hospitalization,

malunion, respiratory and skin ailments.Operative

Operative stabilization with Intramedullary nailing is the standard of care for femoral shaft fractures

Surgical stabilization should occur within first 24 hours, if possible Early stabilization is important in the multiple injured patient

Intramedullary Nailing (IM)

Standard of care

Its IM location results in lower tensile and shear stresses on the implant than fixation. IM nailing is

better than plate fixation because nailing results in less extensive dissection, lower infxn rate and lessquadriceps scarring.

Closed IM nailing can be performed. Other advantages are earlier functional extremity use, restoration

of length and low re-fracture rates.

The types are Antegrade IM Nailing, Retrograde Inserted IM, External fixation, Plate fixation and much

more!!Complications

Fat embolism. DVT and pulmonary embolism.

Nerve injury: uncommon because the femoral and sciatic nerves are encased in muscle throughout thelength of the thigh. Most injuries occur as a result of traction or compression during surgery.

Vascular injury: as a result of tethering of the femoral artery at the adductor hiatus. Get vascular

surgeon if foot is cold, pulseless, pale.

Compartment syndrome: occurs with SIGNIFICANT bleeding. Presents as passive quad stretch,

numbness or parasthesias to medial thigh, tense thigh swelling

Infection: greater risk with open than closed fractures

Re-fracture: patients vulnerable during early callus formation, usually associated with plate or external

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fixation

Non or delayed union: its unusual. Delayed is defined as healing taking > 6mos (insufficient blood

supply). Non-union is Dx when the fracture has no further potential to unite.

Malunion: usually varus, internal rotation, and shortening owing to muscular deformity or muscle pull.

Fixation device failure

Heterotopic ossificatation may occur.

Prognosis none given

Ankle fracture (2 classifications)Medial Malleolus Fractures

Can occur at any portion of the joint

Lateral malleolus

-Medial malleolus-Posterior lip of the tibia (posterior

malleolus)

Often causes severe disruption to the

ligaments or syndesmosis Stable fractures involve only 1 side of the joint

Unstable fractures can be

Bimalleolar

Fractures of both medial and lateral

malleoli

Fracture of distal fibula with disruption of

deltoid ligament

Trimalleolar

Lauge-Hansen Classification

4 injury patterns: supination-adduction (SA)

supination external rotation (SER),pronation-abduction (PA), and pronationexternal rotation (PE).

The names indicate the initial position of the

foot and hindfoot (supination or pronation) andthe direction of the injuring force acting on thetalus(adduction, abduction)

Supination adduction

The foot is supinated (inverted), and an

adducting force is exerted on the talus,resulting in 2 sequential injuries

Transverse fracture of lateral

malleolus

Oblique medial malleolus fracture

Supination external rotation This is the most common mechanism for a

"twisted ankle" injury. The foot is supinated,and an external rotation force acts on thetalus, resulting in up to 4 sequential injuries

Anteroinferior tibiofibular ligament

tear

Short oblique fracture of fibula

Posterior malleous fracture

Fibular FracturesDanis-Weber Classification

Used in treatment decision- making

Based on the level of the fibular fracture

Co-exists with Lauge-Hansen so you need to

know both

Classification Danis-Weber A the fracture is distal to the

ankle mortiseTreatment is closed reduction with casting

Danis-Weber B the fibular fracture is oblique

and begins at the level of the ankle mortise andextends proximally Treatment is closedreduction and casting unless there is asyndesmotic disruption

Danis Weber C the fibular fracture is

proximal to the ankle mortise (high) and the

syndesmosis is disrupted. Treatment is openreduction with internal fixation (ORIF)

USE LAUGE-HAUSEN WHEN IT HITS THEMEDIAL MALLEOLUS

USE DANIS-WEBER WHEN THE FRACTUREAFECTS THE FIBULA

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Distal Fibular Fracture

Fibula shaft fractures are usually due to trauma

and account for a high percentage of lowerextremity injuries.

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Transverse fracture of medial

malleolus or tear of deltoid ligament

Pronation abduction

The foot is in a pronated position (everted),

and an abducting force is exerted on thetalus, resulting in up to 3 sequential injuries

transverse fracture of the medialmalleolus

tear of the anteroinferior tibiofibular

ligament

oblique fracture of the distal

fibula

Pronation external rotation

The foot is in a pronated position (everted),

and an external rotation force acts throughthe talus, resulting in up to 4 sequentialinjuries

Medial malleolar fracture

Injury to syndesmosis Short spiral or oblique fibular

fracture

Posterior malleolus fracture

TRI MALLEOLAR FRACTURE

------------------------------------------------------------------------------------Avulsion Fractures

Occur often at the malleoli due to tendon

attachment

Therefore examination will reveal mild

laxity

Fragment may migrate into the ankle mortise

Management The goal is anatomic restoration of the joint,

with fibular length restored and ability to rotatethe joint

Closed reduction for displaced fractures

and splinting

If stable and nondisplaced short-leg cast

and weight-bear as tolerated

Everyone else- operative repair

Complications

malunion or nonunion

Posttraumatic arthritis

Loss of range of motion Rarely foot compartment syndrome

Mechanism of injury is critical in determining

the fracture type and management

Compartment syndrome is a high risk, if unable

to monitor or associated with a tibial fracture-refer to an Orthopedist.

Mechanism of injury (Danis-Weber)

supination alone Supination/external rotation

Pronation

Presentation

Variable degrees of pain and

ambulation

Limp to unable to weight

bear.

Swelling and tenderness to palpation

+ deformity

Soft tissue injury with effusion

and/or blistering

Radiographs Type A - transverse fracture of fibula

occurring below the syndesmosis

Type B an oblique or spiral fracture

occurring at or near the level of thesyndesmosis

Type C Fracture of the fibula above

the level of the syndesmosis (Lookfor the inevitable medial malleousfracture!)

Management

Type A and stable Type B If the fracture is

< 2mm, treat with splint then cast.Gradual addition of weight bearingbiweekly over 6 weeks.

It is essential that you re-x-ray after a

week to ensure the fracture has notwidened if so refer for operativerepair.

Unstable, wide Type B or Type C

Operative repair

Complications


Malunion usually rotated and

shortened

Fusing of syndesmosis Loss of ankle range of motion

MOI

The pattern of ankle injury depends on many factors, including mechanism (axial vs. rotational

loading), chronicity, patient age, bone quality, position of the foot at time of injury, and the magnitude,direction and rate of loading.

Signs & Symptoms/Physical Exam

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Variable presentation ranging from a limp to non-ambulatory in significant pain and discomfort, with

swelling, tenderness, and variable deformity.

Neurovascular status should be carefully documented and compared with the contralateral side.

The extent of the soft tissue injury should be evaluated, with particular attention to possible open

injuries and blistering. The entire length of the fibula should be palpated for tenderness (associatedfibular fractures may be high). Squeeze test performed 5cm proximally to the intermalleolar axis.

A dislocated ankle should be reduced and splinted immediately (before x-rays if evident) to preventpressure of impaction injuries to the talar dome and to preserve neurovascular integrity.

Associated Injury ligament sprain, fractured fibula.Radiograph

AP, lateral and mortise view of the ankle should be obtained

AP view Tibiofibular overlap 5mm is abnormal and implies syndesmotic injury. Talar tilt: a difference in width of the medial andlateral aspects of superior joint space of >2mm is abnormal and indicates medial or lateral disruption

Lateral view The dome of the talus should be centered in tibia and congruent with tibial plafond.

Posterior tibial tuberosity fractures can be indentified. Avulsion fractures of the talus may be identified.

Mortise View taken with the foot 15-20 degrees internally rotated. A medial clear space of > 4-5mm is

abnormal and indicates lateral talar shift. Talar shift >1mm is abnormal. Talofibular overlap

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Calcaneous fracture

Often confused with ankle sprains

Majority of these fractures occur in adult males, usually industrial accidents. 7-15% are open

fractures

Due to MOI, up to 50% have other associated injuries including lumbar spine fractures, other lower

extremity fractures or a fracture of the opposite calcaneous.MOI

Axial loading: falls from height are responsible for most intraarticular fractures. They occur as the

talus is driven down into the calcaneous. May occur in MVAs when the brake/gas pedal impacts theplantar aspect of the foot.

Twisting forces may be associated with extraarticular calcaneus fractures, in particular fractures of

the anterior and medial processes. In diabetics, there is an increase incidence of tuberosity

fractures from avulsions by the Achilles tendon. Occasionally twisting forces, especially with pull form the Achilles tendon.

Signs & Symptoms/Physical Exam

Pts typically present with moderate to severe heel pain, associated with tenderness, swelling and

heel widening and shortening.

Ecchymosis around the heel extending to the arch is highly suggestive of calcaneous fracture.

Blistering may be present and results from massive swelling usually within the first 36 hours.

Open fractures are rare, but when present, they occur immediately

Careful evaluation if soft tissue and neurovascular status is essential. Compartment syndrome of

the foot must be ruled out (it occur in about 10% if calcaneous fractures and can result in clawing othe lesser toes).

Extraarticular fractures do not involve the posterior facet.

Associated Injury 50% have other associated injuries = lumbar spine fracture, other lower extremity fracture

Bilateral calcaneus fractures, 5-10%.Radiograph

If calcaneus fracture suspected, initial x-ray should include a lateral view of the hindfoot, an AP view

of the foot, a Harris axial view and an ankle series.

Lateral view Decrease in the Bohler angle. An increase in the Gissane angle.

AP view may show extension of the fracture line into the calcaneocuboid joint.

Harris axial view allows view of joint surface, loss of height, increase in width, and angulation of thetuberosity fragment.

Broden view patient supine, X-ray cassette beneath patients feet. These x-rays show the posteriorfacet as it moves from posterior to anterior. Most useful intraoperatively to assess fracturereduction.

CT scan is also helpful.

Loss of trabeculae, visible fracture line or areas of increased sclerosis, the fracture may extend into

the jointTreatment

Non displaced fractures associated with blistering or prolonged edema are treated with a bulky

dressing and supportive splint to allow absorption of the hematoma, then a fracture boot in neutralposition for 10-12 weeks.

Severe displacement fracture, most open fractures or fracture dislocations are treated operatively.

Despite adequate reduction and Tx, fractures of the calcis may be severely disabling w/ variable

prognosis. Tx remains controversialNon-operative

Nondisplaced or minimally displaced.

Initial Tx is placement of a bulky Jones dressing Supportive splint

Early ankle range of motion exercises, and NON-WEIGHT bearing restrictions

Operative

Displaced intraarticular fractures involving the posterior facet. Fracture-dislocation.

Surgery should be performed within 3 weeks of injury, before fracture consolidation.

Complication

Wound dehiscence: most common at the angle of incision. Treated with wet to dry dressing changes.

Calcaneal osteomyelitis: reduce risk by allowing soft tissue to resolve preoperatively

Posttraumatic arthritis: reflects articular damage.

Increased heel width: some degree of widening is expected

Loss of subtalar motion: common with operative and non-operative

Peroneal tendonitis: seen following non-operative treatment and results from lateral impingement.

Sural nerve injuries, Chronic pain (may be debilitating)

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Base of fifth metatarsal fractureMOI

These usually result from direct trauma

Fractures are separated into proximal base fractures and distal spiral fractures

Proximal 5th metatarsal fractures are further divided by the location of the fracture and presence of

prodromal symptoms Avulsion Pseudo-Jones Fracture (Zone 1) forcible inversion of the foot in plantar flexion. A direct blow

to the tuberosity can cause a comminuted fracture.-insertion of the plantar brevis at the plantar fascia-results from avulsion from the lateral plantar aponeurosis.

Jones Fracture (Zone 2 distal to the tuberosity) results from adduction or inversion of the forefoot

during plantar flexion of the ankle. The ligamentous attachments are a critical factor in the distributionof load.

-the fracture is caused by tensile stress along the lateral border of the metatarsal.

(Zone 3 proximal diaphyseal stress fracture) relatively rare and seen in athletes. Occur in the

proximal 1.5 cm of the diaphyseal shaft of the metatarsal.

Dancers Fracture not resulting from trauma. Usually spiral, oblique fracture progressing from distal-

lateral to proximal-medial.-the mechanical injury is a rotational force being applied to the foot while axially loaded in a plantar

flexed position.

S & S/Physical Exam

Avulsion can mimic an ankle injury, pain and tenderness to palpation.

Jones Acute pain at base of 5th metatarsal, tenderness to palpation, ecchymoses and edema,

increased pain when bearingweight.

Zone 3 Patients usually have prodromal symptoms before complete fracture.

Dancer oblique fracture progressing from distallateral to proximalmedial.

Associated Injuries sprain, strain, who knowsRadiograph

Acute fractures are distinguished by a sharp, well-delineated fracture line

Older fractures demonstrate new bone growth (callus, sclerosis) and wider fracturesTreatment

Avulsion symptomatic Tx for pain, hard-soled shoes and pain management. Healing is the norm.

Jones Is based on the type

-Type I: nonweight-bearing immobilization for six to eight weeks or placement in a walking boot if stable-Type II: nonweight-bearing immobilization vs. surgical fixation for active athletes or patients preferringsurgical therapy-Type III: surgical fixation-Union is frequently a concern**Displaced fractures always have open reduction

Zone 3 has tendency to nonunion. Initial Tx is between casted non-weight bearing for up to 3 months

and surgical intervention with grafting and internal compression.

Dancers Symptomatic Tx for pain, hard soled shoes. Malunion are uncommon.

Complications

Historically Nonunion was a major complication. The is not true for the acute fracture


Prognosis Avulsion, Zone 3 and Dancers heal well. Jones is the only one that may no heal so well.

Phalanx fractureMOI

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A direct blow, such as a heavy object dropped onto the foot usually causes a transverse or comminuted

fracture.

A stubbing injury as a result of axial loading with secondary varus or valgus force resulting in a spiral or

oblique fracture pattern.-this axial loading can also result in avulsion or chip type fractures

The most common injury is to the forefoot and usually involves the proximal phalanx of the 5th digit.

S & S/Physical Assessment Patients typically present with pain, swelling and variable deformity of the affected foot.

Tenderness can be elicited over the site of the injury.

+/- subungual hematoma

Associated Injuries other broken toes, who knows.Radiograph

AP, lateral and oblique views of the foot should be obtained. Isolation of the digit of interest for the

lateral X-ray may aid in visualization of the injury (also, use of small dental radiographs between thetoes has been described).

MRI or bone scan may be helpful when the fracture injury is not apparent on plain radiographs.

Radiographs demonstrate the fracture and type thanks Nancy.

Management

Non displaced fractures (regardless of articular involvement) should be treated with a stiff-soled shoeand protective weight bearing.

Use of buddy taping between toes may provide pain relief and help stabilize.

Fractures with clinical deformity require reduction (closed reduction is usually adequate and stable).

Operative reduction for rare fractures with gross instability or persistent intraarticular deformity

(usually with a proximal phalanx of the great tow or multiple fractures of lesser toes).Complications

Nonunion uncommon.

Posttraumatic arthritis may complicate fractures with intraarticular involvement.

Prognosis strong to quite strong

Objective 11State and describe the mechanism of injury, signs/symptoms, physicalexamination, associated injuries, radiographic presentation (with aradiographic reading using the ABCs format), stability, management,complications and prognosis of the following common lower extremitydislocations or injuries:

Hip Dislocation (book only)

50% of patients sustain concomitant fractures at the time of dislocation.

Anterior dislocations constitute 10-15% with posterior dislocations accounting for the remainder. Sciatic

nerve injury is present in 10-20% of posterior dislocationsMOI

Almost always result from high energy trauma (MVA, fall form height, industrial accident)

Force of transmission to the hip joint occurs with application to 1 of 3 common sources: 1) The anteriorsurface of the flexed knee striking and object 2) The sole of the foot, with ipsilateral knee extension 3)

The greater trochanter

Less frequently, the force may be applied to the posterior pelvis with the ipsilateral foot of knee acting

as the counterforce

Anterior vs. Posterior dislocation determined by the direction of the pathologic force and position of

the lower extremity at the time of injury.

Anterior Dis

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