Wrist forearm elbow

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By Prapassorn Pattarananakul, MD

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  • a)DiBenedetto et al.: A and B 2 points bisecting radius 4 and 8 cm proximal to radiocarpal joint to make line X. Line Y is drawn through C, which is distal sigmoid notch, and D, which is the tip of the radial styloid. Z is drawn perpendicular to line X through point C. Radial inclination angle between lines Z and Y. E is a point on line Z to allow radial height to be measured between D and E. Radial inclination angle is 22° ± 3° b)Matashita, Firrel, and Tsai. This method is a modification of that of DiBenedetto et al., in which the central axis (X) of the ulna is drawn through midpoints A and B at 2 cm and 4-5 cm proximal to the distal end of the ulna.
  • Wrist forearm elbow

    1. 1. Tintinalli's Emergency Medicine Section 22. Injuries to Bones and Joints Chapter 266,267 Rosen's Emergency Medicine: Concepts and Clinical Practice, Chapter 48,49 Prapassorn Pattarananakul ,MD
    2. 2. <ul><li>Wrist </li></ul><ul><ul><li>Distal Radius and Ulna Fractures </li></ul></ul><ul><ul><ul><li>Colles,Smith,Barton,Radial Styloid fractures </li></ul></ul></ul><ul><ul><ul><li>Distal Radioulnar Joint Disruption </li></ul></ul></ul><ul><li>Forearm </li></ul><ul><ul><li>Fractures of Both Radius and Ulna </li></ul></ul><ul><ul><li>Ulna Fractures </li></ul></ul><ul><ul><li>Radius Fractures </li></ul></ul><ul><li>Elbow </li></ul><ul><ul><li>Soft Tissue Injuries </li></ul></ul><ul><ul><li>Elbow Dislocation </li></ul></ul><ul><ul><li>Fractures About the Elbow </li></ul></ul>
    3. 3. <ul><li>Most common injuries affecting the wrist </li></ul>
    4. 4. <ul><li>Distal radial metaphysis fracture </li></ul><ul><li>Dorsally angulated and displaced proximally and dorsally </li></ul><ul><li>&quot;dinner-fork,&quot; deformity. </li></ul><ul><li>Palmar paresthesias </li></ul>
    5. 5. <ul><li>Dorsal angulation </li></ul><ul><li>Distal radius fragment is displaced proximally and dorsally </li></ul><ul><li>Ulnar styloid may be fractured </li></ul>
    6. 6. <ul><li>>20 degrees of dorsal angulation, </li></ul><ul><li>Intra-articular involvement, </li></ul><ul><li>Marked comminution, or </li></ul><ul><li>More than a centimeter of shortening. </li></ul>
    7. 7. <ul><li>Closed reduction, using local anesthesia, </li></ul><ul><li>Cast immobilization </li></ul>
    8. 8. Stable fractures may be treated with a compression dressing and splint until they can be evaluated by an orthopedic surgeon; otherwise, closed reduction is performed.
    9. 9. <ul><li>&quot;reverse Colles fracture“ </li></ul><ul><li>Volar angulated fracture of the distal radius. </li></ul><ul><li>&quot;garden-spade deformity&quot; </li></ul>
    10. 10. <ul><li>Volar angulation </li></ul><ul><li>Distal radius fragment is displaced proximally and volarly </li></ul><ul><li>The fracture line extends obliquely from the dorsal surface to the volar surface 1–2 cm proximal to the articular surface </li></ul>
    11. 11. <ul><li>Barton fractures are dorsal or volar rim fractures of the distal radius </li></ul><ul><li>Minimally displaced fractures can be treated acutely in a sugar tong splint </li></ul><ul><li>Unstable fractures involving </li></ul><ul><ul><li>>50% of the radial articular surface </li></ul></ul><ul><ul><li>accompanying carpal subluxation </li></ul></ul>
    12. 12. <ul><li>comminuted fracture of the distal radial metaphysis. </li></ul><ul><li>intra-articular fracture of the volar or dorsal rim of the radius, </li></ul><ul><li>which may be accompanied by carpal subluxation in the same direction </li></ul>
    13. 13. <ul><li>Hutchinson's fracture, or chauffeur's fracture, </li></ul><ul><li>Intra-articular fracture of the radial styloid </li></ul>
    14. 14. <ul><li>Fall on the outstretched hand with either hyperpronation, hypersupination </li></ul><ul><li>Radiographs :reported as normal </li></ul><ul><li>Immobilizing the wrist in supination ( dorsal dislocations), pronation(volar dislocations) </li></ul>
    15. 18. <ul><li>None displaced :long arm cast 8 wk </li></ul><ul><li>Displaced : ORIF </li></ul><ul><li>compartment syndrome </li></ul><ul><li>Volkmann contractures </li></ul>
    16. 19. <ul><li>Isolated Ulna Fracture (Nightstick Fracture) </li></ul><ul><li>direct blows </li></ul><ul><li>Nondisplace :immobilized </li></ul><ul><ul><li>distal third > short arm cast </li></ul></ul><ul><ul><li>Middle/proximal >long arm cast </li></ul></ul><ul><li>Displace : R/O radial head dislocation </li></ul><ul><li>(>10° ,> 50% diameter ulnar) </li></ul>
    17. 20. <ul><li>Fx proximal third of the ulna with a radial head dislocation </li></ul><ul><li>! Posterior interosseus nerve </li></ul>Type II Monteggia fracture-dislocation
    18. 21. <ul><li>Consultation in the ED : </li></ul><ul><ul><li>- ORIF </li></ul></ul><ul><ul><li>- children : closed reduction and long arm splinting supination </li></ul></ul>Fx radial head dislocation Type I Prox. or middle ulnar anterior Type II Prox.or middle ulnar posterior Type III distal to coronoid process lateral Type IV Prox. or middle ulna Prox. radius anterior
    19. 22. <ul><li>Fx distal third of the radial shaft c DRUJ dislocation </li></ul><ul><li>reverse Monteggia fracture </li></ul><ul><li>Consultation : ORIF </li></ul><ul><li>Radiographs : </li></ul><ul><ul><li>AP :increased DRUJ space </li></ul></ul><ul><ul><li>Lateral : ulna dorsal displacement </li></ul></ul>
    20. 26. <ul><li>A. Radial nerve innervation. </li></ul>
    21. 27. <ul><li>B. MEDIAN NERVE INNERVATION. </li></ul><ul><li>C. ULNAR NERVE INNERVATION. </li></ul>
    22. 30. <ul><li>Proximal Biceps Rupture </li></ul><ul><li>(long head) </li></ul><ul><li>result of repetitive microtrauma, overuse and Steroids </li></ul><ul><li>middle-aged and older individuals </li></ul>
    23. 31. <ul><li>Distal biceps injuries </li></ul><ul><li>middle-aged men </li></ul><ul><li>Pain : antecubital fossa </li></ul><ul><li>&quot;biceps squeeze test,&quot; </li></ul><ul><li>ED Tx : sling, ice, analgesics, </li></ul><ul><li>and refer for definitive care. </li></ul>
    24. 32. <ul><li>Young men </li></ul><ul><li>Fall on an outstretched hand causing a forceful flexion of an extended elbow </li></ul><ul><li>Direct blow to the olecranon </li></ul><ul><li>Spontaneous ruptures from systemic illnesses, ( hyperparathyroidism) </li></ul><ul><li>The ability to extend the elbow is lost . </li></ul><ul><li>modified Thompson test </li></ul>
    25. 33. <ul><li>&quot;tennis elbow,“ </li></ul><ul><li>Repetitive movement </li></ul><ul><li>Tenderness over the lateral epicondyle </li></ul><ul><li>Pain with forced extension and supination </li></ul><ul><li>Tx : rest, ice, medications,and immobilization, counterforce brace </li></ul>
    26. 34. <ul><li>&quot;golfer's elbow“ </li></ul><ul><li>Tenderness over the medial epicondyle </li></ul><ul><li>Pain with forced flexion and pronation </li></ul><ul><li>Ulnar neuropathy </li></ul>
    27. 36. <ul><li>fall on an outstretched hand </li></ul><ul><li>Elbow flexion in 45 ° </li></ul><ul><li>Olecranon is prominent </li></ul><ul><li>First priority of care </li></ul><ul><ul><li>neurovascular status brachial a., ulnar, radial, and median nerves </li></ul></ul>
    28. 37. <ul><li>Look for associated fractures </li></ul><ul><ul><li>coronoid process and radial head. </li></ul></ul><ul><ul><li>In a child: Fx medial epicondyle </li></ul></ul><ul><li>Tx : Reduction long arm posterior mold 90 ° of flexion </li></ul><ul><li>Consultation : </li></ul><ul><ul><li>irreducible dislocations, </li></ul></ul><ul><ul><li>neurovascular compromise, </li></ul></ul><ul><ul><li>joint capsule disruption, </li></ul></ul><ul><ul><li>associated fractures, </li></ul></ul><ul><ul><li>open dislocations </li></ul></ul>
    29. 39. <ul><li>Children age 1 to 3 years </li></ul><ul><li>“ nursemaid's elbow or pulled elbow” </li></ul><ul><li>Sudden longitudinal pull on the forearm while pronation </li></ul><ul><li>X-rays are not required </li></ul><ul><li>Recurrence rate of about 20% </li></ul>
    30. 40. <ul><li>Supination of the forearm while slight pressure on the radial head </li></ul>
    31. 41. <ul><li>RADIOGRAPHS </li></ul><ul><li>&quot;sail sign&quot; </li></ul><ul><li>Posterior fat pad : fat from the olecranon fossa </li></ul><ul><li>Anterior fat pad: hemarthrosis </li></ul>
    32. 42. <ul><li>Most common fracture about the elbow in children </li></ul><ul><li>Gartland Classification of Pediatric Supracondylar Fractures </li></ul>Extension type Flexion type Nondisplaced Nondisplaced Displaced, but posterior cortex intact Displaced, but anterior cortex intact Completely displaced Completely displaced
    33. 43. <ul><li>Fall on an outstretched hand with the elbow in extension </li></ul><ul><li>Displaced fractures : emergent orthopedic consultation CRPP/ORIF </li></ul>
    34. 44. <ul><li>Direct anterior force against a flexed elbow </li></ul><ul><li>Often open </li></ul><ul><li>Displaced fractures : emergent orthopedic consultation CRPP/ORIF </li></ul>
    35. 45. <ul><li>Early complications </li></ul><ul><ul><li>Neurologic </li></ul></ul><ul><ul><ul><li>Radial nerve Median nerve (anterior interosseous branch) Ulnar </li></ul></ul></ul><ul><ul><li>Vascular </li></ul></ul><ul><ul><ul><li>Volkmann ischemic contracture (compartment syndrome of the forearm) </li></ul></ul></ul><ul><li>Late complications </li></ul><ul><ul><li>Nonunion </li></ul></ul><ul><ul><li>Malunion </li></ul></ul><ul><ul><li>Myositis ossificans </li></ul></ul><ul><ul><li>Loss of motion </li></ul></ul>
    36. 46. <ul><li>Lateral condyle fractures (second most common fractures involving the elbow in children) </li></ul><ul><li>Medial Condyle Fractures </li></ul>
    37. 47. <ul><li>Nondisplaced : long arm posterior immobilization </li></ul><ul><li>Displaced : immediate orthopedic consultation (CRPP/ORIF ) </li></ul>Milch Classification I/II>Salter Harris type IV/II
    38. 48. <ul><li>Direct trauma to the elbow that drives the olecranon against the humeral articular surface </li></ul><ul><li>adults in 50-60 y </li></ul><ul><li>Tx :ORIF </li></ul>
    39. 49. <ul><li>Little Leaguer's Elbow </li></ul>
    40. 50. <ul><li>Tx : controversial </li></ul><ul><li>simple immobilization </li></ul>
    41. 51. <ul><li>associated with posterior elbow dislocations </li></ul><ul><ul><li>Classification of Coronoid Fractures </li></ul></ul><ul><ul><li>Type I Anterior tip of coronoid </li></ul></ul><ul><ul><li>Type II Up to 50% of the height of the coronoid </li></ul></ul><ul><ul><li>Type III The base of the coronoid </li></ul></ul><ul><ul><li>II/III > ORIF, poor outcome </li></ul></ul><ul><li>Tx : Long arm posterior immobilization and refer 24hr (elbow flexion /forearm supination ) </li></ul>
    42. 52. <ul><li>Direct trauma / fall with forced hyperextension </li></ul><ul><li>MayoClassification of Olecranon Fractures </li></ul><ul><ul><li>Type I Nondisplaced, stable fracture </li></ul></ul><ul><ul><li>Type II Displaced, stable joint </li></ul></ul><ul><ul><li>Type III Displaced, unstable ulnohumeral joint </li></ul></ul><ul><li>Type I can be conservative </li></ul><ul><li>long arm posterior immobilization (elbow flexion and forearm neutral) </li></ul><ul><li>Refer 24 hr </li></ul>
    43. 53. <ul><li>Associated injuries are common </li></ul><ul><li>“ Essex-Lopresti lesion” disruption of the triangular fibrocartilage </li></ul>
    44. 54. <ul><li>Pain on pronation and supination forearm </li></ul><ul><li>Obliques and a radial head-capitellum view </li></ul>
    45. 55. <ul><ul><li>radiocapitellar line </li></ul></ul><ul><ul><li>abnormal fat pad </li></ul></ul><ul><li>Nondisplaced :sling immobilization with the elbow in flexion refer within 1 week </li></ul><ul><li>Displaced : Refer in 24 hours </li></ul>
    46. 57. <ul><li>Colles fracture </li></ul><ul><li>Smith fracture </li></ul><ul><li>Barton fracture </li></ul>A B C
    47. 58. <ul><li>Galeazzi Fracture </li></ul><ul><li>Nightstick Fracture </li></ul><ul><li>Monteggia Fracture </li></ul>
    48. 59. <ul><li>Supracondylar Fractures </li></ul><ul><li>Intercondylar Fractures </li></ul><ul><li>Lateral Epicondyle Fractures </li></ul><ul><li>Lateral condyle fractures </li></ul>
    49. 60. <ul><ul><li>Volkmann ischemic contracture </li></ul></ul><ul><ul><li>Myositis ossificans </li></ul></ul><ul><ul><li>anterior interosseous palsy </li></ul></ul><ul><ul><li>Cubitus varus </li></ul></ul><ul><ul><li>None of above </li></ul></ul>

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