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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
    Objectives
  • 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