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Fracture Review New Format

Fracture Review New Format






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    Fracture Review New Format Fracture Review New Format Presentation Transcript

    • Jeffrey Gehring, MD
      University of Florida, Jacksonville
      September 11, 2008
      Fractures Review
    • Review of basic orthopedic radiographs
      Brief discussion/description of fractures
      ED management of described fractures
    • Name this Fracture
    • Lisfranc Fracture
      Second metatarsal acts as stabilizing force of the metatarsal-tarsal complex
      Divided into homolateral and divergent
      Normally medial aspect of middle cuneiform in line with medical aspect of second metatarsal
      Emergent orthopedic referral
    • Name this Fracture
    • Calcaneus Fracture
      Multiple types, with 10 percent associated with compression fractures of the lumbar spine
      Bohler’s angle is angle formed by line from posterior tuberosity and apex of the posterior facet, and line form apex of posterior facet to the apex of the anterior process (angle of less than 20 degrees suggests compression fracture)
      Immobilization in bulky compressive dressing with early orthopedic consultation
    • Name this Fracture
    • Jones fracture
      Transverse fracture through the base of the 5th metatarsal 10-20mm distal to the proximal part of the metatarsal
      Nonunion/malunion is a complication
      NWB cast for 6 weeks
    • Name this Fracture
    • Pseudo-Jones Fracture
      “Pseudo-Jones” is avulsion of the tuberosity, and treated with cast shoe
    • Name this Fracture
    • March Fracture
      Stress fracture of the metatarsals
      Third metatarsal is most common
      Initial radiographs often “negative”
      Later radiographs show callous formation
      Symptomatic relief with crutches, and possibly walking cast
    • Name this Fracture
    • Distal Phalanx Fracture
      Classified as extra-articular or intra-articular fractures
      Must look for associated nail bed injuries, subungal hematomas
      Dorsal or hairpin splint with follow up
    • Name this Fracture
    • Middle Phalanx Fracture
      Both the flexor digitorum superficialis and extensor digitorum insert here
      Splint in position of function
      Degree of angulation and displacement will determine urgency of orthopedic referral
    • Name this Fracture
    • Proximal Phalanx Fracture
      No tendons attach to proximal phalanx
      Splint in position of function
      Degree of angulation and displacement will determine urgency of orthopedic referral
    • Name this Fracture
    • Boxer’s Fracture
      Up to 40 degrees of angulation is acceptable for 5th metacarpal fractures
      Up to 15 degrees of angulation is acceptable for 4th metacarpal fractures
      Accurate anatomic reduction is essential for 2nd and 3rd metacarpal fractures
      Reduce, splint, with orthopedic follow-up
    • Name this Fracture
    • Bennett’s Fracture
      Fracture combined with subluxation or dislocation of the metacarpal joint
      CT often necessary to evaluate carpometacarpal joint
      Immobilize (thumb abducted and MCP joint should not be hyperexteded)
      Emergent orthopedic referral (possible percutanous wiring)
    • Name this Fracture
    • Rolando Fracture
      Second type of intraarticular 1st metacarpal fracture
      T or Y fracture involving joint surface
      Splint with orthopedic referral
      Has poor prognosis, and is dependent on degree of comminution
    • Name this Fracture
    • Scaphoid Fracture
      Most commonly fractured carpal bone
      No direct blood supply to proximal portion, so susceptible to avascular necrosis
      The more proximal the fracture, the higher the risk of avascular necrosis
      Check for “snuff box tenderness” and pain with axial loading of thumb
      Splint all fractures and suspected fractures, and prompt orthopedic follow-up
    • Name this Fracture
    • Pisiform Fracture
      Caused by direct blow or FOOSH
      Deep branch of ulnar nerve and artery pass in close proximity
      Flexor carpi ulnaris attaches to volar surface
      Splint with orthopedic follow-up
      Will need short arm cast
    • Name this Fracture
    • Hamate Fracture
      Fractures of the body normally seen with routine radiographs
      Hamate hook fractures may require carpal tunnel view or CT
      Ulnar nerve and artery injuries frequently occur
      Splint with orthopedic referral
    • Name this Fracture
    • Colles Fracture
      Extension fracture of distal radius
      60% associated with fracture of ulnar styloid
      Most common cause is FOOSH
      Must check for median and ulnar nerve involvement
      Reduce, splint (sugar tong with 15 degrees of flexion and ulnar deviation)
      Urgent orthopedic referral
      Joint involvement requires emergent orthopedic referral
    • Name this Fracture
    • Both Bones Fracture
      Great amount of force needed to break both bones
      Seen often in MVC’s
      Splint with urgent orthopedic referral(ORIF)
    • Name this Fracture
    • Smith Fracture
      Often called “reverse colles”
      Uncommon fracture, and rarely involves radioulnar joint
      Emergent orthopedic referral if available
      Reduce and long arm splint
      Barton’s fracture is push-off dorsal rim fracture of radius
      Hutchinson’s fracture is push-off fracture of radial styloid
    • Name this Fracture
    • Nightstick Fracture
      Isolated fracture of the ulna
      Often caused by a direct blow (hence the name)
      Non-displaced factures can be splinted with orthopedic follow-up
      Displaced fractures may require ORIF
    • Name this Fracture
    • Olecranon Fracture
      Assume intra-articular involvement, so near perfect reduction is necessary for regaining full range of motion
      Must document ulnar nerve function
      Non-displaced fractures can be placed in long arm splint at 90 degrees flexion
      Displaced fractures will need emergent orthopedic referral for possible ORIF
    • Name this Fracture
    • Radial Head Fracture
      Fairly common injury
      FOOSH is most common cause
      Pain to palpation over radial head
      Presence of posterior fat pad or bulging anterior fat pad may be seen
      Radiocapitellar line (line through center of radius should pass through middle of capitellum) may be only sign in children
      Long arm splint with urgency of referral based on displacement
    • Name this Fracture
    • Coronoid Process Fracture
      Rarely seen as isolated injury
      More often seen with posterior dislocation of elbow
      Tenderness over antecubital fossa
      Treatment based on associated injury ie: posterior elbow dislocation
    • Name this Fracture
    • Intercondylar Fracture
      Usually occur in patients over 50
      Actually a supracondylar fracture with vertical component (T or Y)
      Most often caused by direct blow
      Neurovascular injuries are not frequently associated
      Splint, with likely admission (in consult with orthopedics)
    • Name this Fracture
    • Supracondylar Fracture
      Most common in children 3-11 y.o.
      25% of these fractures in children are greenstick (making radiographic diagnosis difficult)
      Need to look at anterior humeral line (line drawn along anterior surface of humerus normally transects the middle third of the capitellum) also look for pathologic fad pads
      BAM (brachial artery and median nerve)
      Splint with emergent orthopedic referral
      Only reduce if there is neurovascular compromise
    • Name this Fracture
    • Capitellum Fracture
      30% have associated proximal radius fracture
      Rarely seen in children
      Splint in hyperflexion
      Adequate reduction difficult with closed techniques, will often need ORIF
    • Name this Fracture
    • Lateral Epicondyle Fracture
      Caused by direct or indirect mechanisms
      Lateral epicondylar ossification center appears at age 10-11, but not complete until second decade of life
      Posterior splint with elbow at 90 degrees and forearm neutral
      Orthopedic referral
    • Name this Fracture
    • Monteggia Fracture
      Fracture of the proximal one third of the ulnar shaft combined with a radial head dislocation
      Paralysis of deep branch of radial nerve is frequent (usually due to contusion and returns without treatment)
      Emergent orthopedic referral
    • Name this Fracture
    • Galeazzi Fracture
      Fracture of the distal one third of the radius with instability of the distal radioulnar joint
      Should be suspected when there is distal radioulnar joint tenderness or ulnar head prominence
      Commonly associated with distal radioulnar subluxations which can be acute or delayed
      Emergent referral for possible ORIF
    • Name this Fracture
    • Midshaft Humerus Fracture
      Location of the fracture will determine the displacement
      Many neurovascular structures near by (brachial plexus, radial nerve, etc)
      Non-displaced fractures get coaptation splint and orthopedic referral
      Displaced/angulated fractures need emergent orthopedic referral
    • Name this Fracture
    • Proximal Humerus Fracture
      Occur commonly in elderly
      Include all fractures proximal to the surgical neck
      Neer classification divides proximal humus into 4 parts (grater tuberosity, lesser tuberosity, anatomic neck, surgical neck)
      3 and 4 part fractures often associated with dislocation
      Must assess brachial plexus, axillary nerve/artery
      80% of these fractures are one part fractures that only need sling and swath
    • Name this Fracture
    • Greater Tuberosity Humeral Fracture
      Neer 2 part fracture
      Sling and swath with orthopedic referral
      Early mobilization associated with better outcomes
    • Name this Fracture
    • Hill Sachs Fracture
      Impaction fracture of the postero-lateral aspect of humeral head
      Bankart lesion is disruption of lower part of labrum, and is definite if inferior rim of glenoid has fracture
    • Name this Fracture
    • Clavicle Fracture
      Most common childhood fracture
      80% involve middle third
      Must do thorough neurovascular exam
      Sling and orthopedic referral
    • Name this Fracture
    • Scapula Fracture
      Relatively uncommon
      High degree of force needed (look for other injuries)
      Non-displaced fractures often only get sling
      Displaced fractures may need defining with CT and require ORIF
    • Name this Fracture
    • Pelvic Fracture
      Another lecture in itself
      Mortality 5-20%
      Remember pelvis is a “ring” structure
      Many associated injuries ie: urogenital
      Often require CT for better classification and operative planning
      Emergent orthopedic consultation
    • Name this Fracture
    • Acetabular Fracture
      More pelvic fractures
      Judet-Letournel classification (post wall, post column, ant wall, ant column, transverse)
      Follow all lines of the pelvic x-ray for subtle fractures ie: ilioischial and iliopubic lines
    • Name this Fracture
    • Proximal Femur Fracture
      Injury may compromise blood supply to proximal femur
      Look at Shenton’s line and neck-shaft angle to detect occult fracture
      Multiple classifications
      Look for associated injuries
      Emergent orthopedic consultation with admission
    • Name this Fracture
    • Intertrochanteric Fracture
      Extracapsular fracture
      Good vascular supply to this area
      Emergent orthopedic consultation with admission
    • Name this Fracture
    • Patellar Fracture
      Three general types are transverse (most common), comminuted (second most common), vertical (10-20%)
      “Skyline/sunrise view” may be helpful
      Knee immobilized, long leg posterior splint
      Orthopedic referral for possible ORIF or patellectomy
    • Name this Fracture
    • Tibial Plateau Fracture
      Caused by violent varus or valgus stress along with axial loading
      High association with MVC’s
      May need CT for preoperative planning
      Splint and orthopedic consultation
    • Name this Fracture
    • Osgood-Schlatter Disease
      Disturbance in development of tibial tuberosity caused by repeated stress
      Typically seen in girls 8-10 y.o. and boys 10-15 y.o. with males affected 3 times more often
      Pain and swelling over tibial tuberosity
      Treat with NSAIDS and reduced activity
    • Name this Fracture
    • Fibular Neck Fracture
      Must suspect significant knee injury
      Other associated injuries ie: common peroneal nerve
      Symptomatic relief if all other associated injuries excluded
    • Name this Fracture
    • Maisonneuve Fracture
      Remember that tib-fib forms a ring
      Originally described as ankle injury with fracture of the proximal third of the fibula
    • Name this Fracture
    • Medial Maleolus Fracture
      Fractures often associated with ligamentous injury
      Isolated one part fracture can be splinted with orthopedic referral
      Danis-Weber classification based on level of the fibular fracture: the more proximal, the greater the risk of syndesmotic disruption and associated instability
      Unstable 2 or 3 part fractures will necessitate more prompt orthopedic involvement
    • Name this Fracture
    • Trimalleolar Fracture
      Unstable fracture
      Will need emergent orthopedic referral