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Common Fractures

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Common Fractures

  1. 1. Fractures 26/11/12 – 30/11/12
  2. 2. Skeletal System • Function: allow movement, carry loads, protect the neural structures • Disorder causes: PAIN, neurological deficit and physical deformity • Lumbar spine moves the most so most commonly affected – L1/L2 in particular. 5cm extension in Schobers test is normal • Spine exam – LOOK. FEEL. MOVE. – Skin, shape and posture, walking – Palpitation of muscles and spinous processes – Flexion, extension, lateral flexion, schobers test. – Neurological examination for any nerve compression etc • Spina bifida – hairy patch, dimples/sinus, blue patch. • Nerve tension signs: – Straight leg raise – sciatic stretch – Crossed straight leg raise – Femoral stretch test (Lasegue)
  3. 3. Spine • Investigations: – CRP – Plain x-ray: AP&LATERAL • 30% loss of bone mass for OP to show • 50% destruction of interior bone for tumour to show – CT/MRI are over sensitive for causes of nerve root compression • Simple low back pain – 20-55 – Mechanical in nature – increased by activity/posture – Pain fluctuates, sleep disturbed. – Rx: analgesia, KEEP MOBILE • Chronic low back pain – Pain persists after 3months – <5% LBP patients. Multiple factors: disc, facet joints, ligaments – Psychosocial factors, surgery rarely helpful • Acute disc prolapse: – bed rest, NSAIDS, nerve root injection 90% relief rate. – Surgical Rx – 10-15% need it, more rapid relief but same end point. If leg pain the worst will have Sx
  4. 4. RED FLAGS!!! • 20-55 • Non-mechanical pain • Thoracic pain • PHx carcinoma, steroids, HIV • Systemic symptoms: weight loss • Saddle anaesthesia, incontinence (urinary or faecal) • Widespread neurology • Structural deformity • Causes: – cauda equina, – MET – spinal tumour
  5. 5. Orthopaedic Trauma • Initial assessment: detailed Hx, mechanism of injury, patterns of injury, signs of trauma, complications of injury • BONDS – Bones involved? – Open or closed? – Neurovascular intact? – Deformity of length, alignment or rotation – Soft tissue compartment tight? • Fracture location: – Epiphysis, metaphysis, diaphysis,apophysis (not length) – Vertebral – Proximal, distal, middle – Head, neck, body – Intra-trochanteric – Supracondylar
  6. 6. Fracture Patterns • Fracture Patterns: – Transverse – Oblique – Butterfly fragment (triangle chip) – Spiral – Multi-fragmental – comminuted - >2parts of bone – Segmental (2 parts) – Axial loading: impacted/crushed giving wedge # • Deformity – Displacement: • Angulation: valgus/varus (distal end of bone is Va… to the proximal end) • Translation – full or partial, one end sitting beside/slightly on the other • shortening • Rotation – cortical line doesn’t match up
  7. 7. Fractures • Clavicle # – Most common childhood #, majority heal without intervention – Common in cyclists, jockeys, skiers – AP view clavicle – Coraco-clavicular ligs important!!! – Mainly conservative Mx, surgery if more than 2cm shortening due to angle of break, if skin compromised or unlikely to heal. – Hx & Ex – neurovascular, skin integrity and feel bump! • Osteoporosis in the young – Alcohol abuse – Steroids – Chronic underlying condition e.g. DM
  8. 8. Fractures • Proximal Humeral # – Humeral head, greater and lesser tuberosities and humeral shaft – FRAGILITY # – Osteoporosis • Radius and Ulna # – Children associated with greenstick (one side) – Adults – more often displaced – Children remodel much more so leave it!
  9. 9. Distal Radius • Colles – – Distal 2cm radius – Over 65 years old – Dorsally displaced – Radially displaced – Dorsally tilted – Radially tilted – Impaction – Supinated – (Comminuted fracture) – 30-40 deg angulation – FRAGILITY #
  10. 10. Fractures • Scaphoid # – Young men, difficult diagnosis – High clinical suspicion with Anatomical SnuffBox tenderness – Repeat Xray in 10days – Bone scan, CT, MRI useful – RETROGRADE blood supply – distal to proximal so risk of avascular necrosis • Retrograde blood supply – Scaphoid – Navicular – Proximal humerus – Femur – talus
  11. 11. Fractures • Pelvic # – Young adults in RTA or elderly with simple fall – AP pelvis – inlet, outlet view, Judet views – CT scan – Contents include bowel: faecal peritonitis risk, 50% mortality • Neck of Femur – intracapsular # – OP and simple fall – Garden classification: Garden stage I : undisplaced incomplete, including valgus impacted fractures. Garden stage II : undisplaced complete. Garden stage III : complete fracture, incompletely displaced. Garden stage IV : complete fracture, completely displaced. – Above trochanteric line • Neck of Femur – extracapsular – OP and simple fall – Intertrochanteric, sub-trochanteric
  12. 12. • When femoral neck # occurs, intraosseous cervical vessels are disrupted; - incidence of AVN in undisplaced fractures is 11%; - only 1/3 of patients with AVN will require additional surgery where as 3/4 patients with non union will require reoperation; - risk of AVN generally corresponds to degree of displacement of the fracture of the femoral neck on the initial radiographs; - minimally displaced femoral-neck #: is at low risk (< 10%) for osteonecrosis if displacement of the fracture remains unchanged; - displaced frx: - incidence AVN > 80% in displaced #; - most of retinacular vessels are disrupted; - femoral head nutrition is then dependent on remaining retinacular vessels and those functioning vessels in the ligamentum teres;
  13. 13. Fractures • Tibial plateau # – Life changing injury: intra-articular # – Cartilage is worn away with the damage. – Cannot regrow so permanent problems with the joint. Ankle # – Injoint – Subluxed – Dislocated – Not much soft tissue around ankle so tissue may be compromised! • Calcaneal – Associated with spinal #
  14. 14. Compartment syndrome• Painful condition that occurs when pressure within the muscles builds to dangerous levels. • Pressure decreases blood flow, preventing nourishment and O2 reaching cells. • Can be acute or chronic. • Acute – medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage. • Chronic compartment syndrome (exertional compartment syndrome), is usually not a medical emergency. It is most often caused by athletic exertion. • Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily. • Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged. • ACUTE - unless pressure is relieved quickly, premanent disability and tissue death can occur. • Most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks. • TEST: passive stretch of toe
  15. 15. Compartment syndrome • Pain out of proportion to apparent injury • History – Pain unresponsive to analgesia, increasing – Usually a closed # • Examination – Pain increases with passive movement stretching muscle group transversing compartment (2nd toe) • Investigation – Compartment measurement: • Isolated or continuous • >30mmHg or within 30mmHg of diastolic BP • Treatment – Surgical release of compartment by fasciotomy PAIN PAIN PAIN PAIN PAIN PAIN PAIN
  16. 16. Abduction Pillow • Abduction pillow: prevents adduction and internal rotation which could cause dislocation of the hip prosthesis. Should be used when patient is sleeping and lying in bed. Typically worn for 6-12 weeks, this allows a pseudo-capsule to form around the joint and muscle strengthening. Patients who have had previous hip surgery are more likely to dislocate the hip prosthesis and are therefore always given the abduction pillow.
  17. 17. Management of common # • Principles of treatment – Reduction – Immobilisation – Rehabilitation • Fracture = loss of continuity in the substance of the bone • Dislocation = complete loss of congruity between articulating surfaces • Subluxation = partial loss of congruity • Causes of # – Direct trauma: high impact – Fatigue #: repetitive stress to a bone – Pathological #: bony MET – Osteoporotic • Defining fractures – Angulation: varus/valgus or dorsal/volar
  18. 18. Common # • Defining # – Age of pt: skeletal maturity (presence of growth plate, bone elasticity by greenstick # or buckle # - one side of bone affected) – Salter harris classification
  19. 19. Diagnosis of # • History – Nature of activity – Nature of incident – Point of impact and direction of force – Site of pain – Loss of function: weight bearing – Significant co-morbidities: cause of fall/affect on Rx • Examination – LOOK: asymmetry, swelling, discoloration, skin damage – FEEL: site of tenderness, crepitus, pulses (distal to #) – MOVE: pain or tenderness, reduced ROM • Investigation – Bloods – X-ray – US – Maybe MRI/CT
  20. 20. Treatment of # • Want to attain sound bony union without deformity • Want to restore function to as close to previous as possible • Want to prevent complications • Want quickest fixing and recovery possible • Management – Multiple injuries: fracture fixed after soft tissues – Analgesia – Manipulation of limb: overlying skin threatened, obvious # dislocation, NV compromise – Compound # (OPEN): IV abx, NV status, remove contaminants, photo, sterile saline soaked gauze, splint, 1o Sx- debridement, # stabilise – Isolated #: relocation by 1)manipulation 2)traction 3)external fixation 4)open reduction (surgery)
  21. 21. Immobilisation • Plaster • Continuous traction • External skeletal fixation • Internal fixation: – Plates – Wires – Intramedullary nails • Complications – Haemorrhage – Infection: of wound or pneumonia from lying flat – Visceral damage – Metabolic response to trauma – Pressure sores – DVT/PE – Muscle wasting – Joint stiffness – Nonunion/malunion/unsuccessful treatment
  22. 22. Complications • Factors influencing bone healing – Biological: type of bone, age, infection, disturbance of blood supply – Mechanical: type of injury, separation of bone ends (level of displacement), type of fixation • Complication – Malunion: • Clinical deformity: varus/valgus deformity, axial, shortening • Osteoarthritis – Avascular necrosis: neck of femur, talus, scaphoid – Osteoarthritis: intraarticular # or malunion – Growth arrest – Joint stiffness – Complex regional pain – Neurological compromise: early/late, e.g. carpal tunnel – Tendon rupture – Implant complications – Fat embolism (Adult Respiratory Distress Syndrome): long bones like femur and pelvis, fat escapes into circulation causing an unexplained deterioration in clinical condition. – Compartment syndrome
  23. 23. Fragility Fractures • Osteoporosis – Skeletal disease characterised by low bone mass and deterioration of bone tissue, leading to bone fragility and low trauma fractures – Bone density measured relative the that of 25-30year olds of same gender – T score given for the amount of standard deviations you are away from that 25-30 year old – Z score is for how many SDs you are away from your own age group – Normal bone mineral density is above 1 SD below average – Osteopenia BMD 1-2.5 below average – Osteoporosis is <2.5 below average – RFs: early menopause, smoking, alcohol, sedentary lifestyle, diet, malabsorption – Common # - neck of femur, L3, wrist – 1/3 women, 1/12 men get OP – 70% of 70yo women have OP – Investigations: rule out other cause e.g. tumour or infection. Hx&Ex. X-ray requires 30% bone loss to show up. DEXA. bloods
  24. 24. Osteoporosis • DEXA scan – Dual emission x-ray absorptiometry – 2 x-ray beams passed through the body, low radiation – Can be performed on hip, spine and wrist • Prevention – Exercise YOUNG, especially women – Stop smoking, reduce alcohol, and drugs – Monitor at risk groups – those on steroids for e.g. COPD – Measures to prevent falls: OT – HRT – best prevention method – Calcium: normal requirement 750mg/day adult, 1000 child, 1500 pregnant • Treatment – Depends on presentation: fix fracture etc if necessary – Calcium, vitamin D, calcitonin, calcitriol – HRT, Bisphosphonates, selective oestrogen receptor modulators
  25. 25. Fragility # • Hip # – Annually 10/1000 population – 33% die within one year post # – 5% male and 15% female lifetime risk – Usually following a fall at home, elderly patient who then cannot walk – May have pain in hip prior to fall – OA or METs – Lower limb may be shortened and externally rotated. • Assessment – Hx, Ex, MMSE – Bloods, ECG, CXR, ECHO – look for cause of fall – X-rays: AP and lateral – CT, MRI or isotope bone scan if in doubt • Intra or Extracapsular – Intra is treated with hemiarthroplasty – Extra given dynamic hip screw
  26. 26. • Intracapsular: – Displaced: • Young: screw, allow to heal itself • Old: replace – hemiarthroplasty – Undisplaced: fix in situ – screw • Intertrochanteric/Extracapsular – Reduced non-displaced: DHS – Reduced and displaced: IM Nail
  27. 27. Performing surgery • Operate on patients with the aim to allow them to fully weight bear (without restriction) in the immediate postoperative period. • Perform replacement arthroplasty in patients with a displaced intracapsular fracture. • Offer total hip replacements to patients with a displaced intracapsular fracture who: – were able to walk independently and – are not cognitively impaired and – are medically fit for anaesthesia and the procedure. • Use a proven femoral stem design rather than Austin Moore or Thompson stems for arthroplasties. • Use cemented implants in patients undergoing surgery with arthroplasty. • Consider an anterolateral approach in favour of a posterior approach when inserting a hemiarthroplasty. • Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2). • Use an intramedullary nail to treat patients with a subtrochanteric fracture.
  28. 28. Fragility # • 5 branches of medial circumflex femoral artery – Superficial, ascending, acetabular, descending and deep branch • Blood supply to femur – MCFA – LCFA – Intramedullary – Ligamentum teres (children only) • Management – Orthogeriatric support for management of co-morbidities – Analgesia and rehydration – VTE thromboprophylaxis – Theatre within 36hours • Surgical Mx – Intracapsular – displaced : hemiarthroplasty if over 65 – Intracapsular undisplaced : internal fixation with DHS/CHS – Extracapsular: internal fixation with DHS or intramedullary device – Young intracapsular # pt is a high energy injury. Can be left to heal as replacement will cause lifelong problems and is always an option if they fail to heal themselves – Intramedullary – metal pin – Extramedullary – metal plate – Fixation: NAIL (intracapsular) or DHS (extracapsular)
  29. 29. Surgery Hip # • Hemiarthroplasty – Blood supply to femoral head is at risk – this negates the risk – Usually cemented – Indication for THR: active independent patient – Only replace femoral head • DHS – intracapsular # – Internal fixation indicated for undisplaced in all age droups and displaced in >65 – Non-union 20-30%, AVN 10-20%, deep infection 0.4% – 20% need further Sx within a year – 25-30% converted to THR – Lower early mortality for internal fixation than arthroplasty • Mortality – Near 100% if not treated – Limited indications for conservative Mx – 9% mortality at 30days, 20% at 90days, 30% at 12months – Mortality rate increases if Sx >4days after
  30. 30. OP Vertebral # • Reduction in anterior vertebral height • Chronic pain, increasing kyphosis, limited mobility and Fx • Decreased lung capacity • Possibly neurological compromise • Commonly at thoracolumbar junction • Treatment – Conservative: bed rest, analgesia, physio – Bracing: >30% collapse – Sx if neuro unstable or unstable # – Medical treatment to prevent further collapse – Percutaneous vertebroblasty: needle inside to broken bone, acts as a jack and fill with cement
  31. 31. OP wrist # • Common – 1/6 of all # • Bimodal distribution: young high energy and old females • Colles: dorsal displacement/tilt, radial shortening, ulnar deviation – dinner fork deformity • Smiths: volar displacement • Barton: volar or dorsal # and dislocation of radiocarpal joint • Wrist # – Fall on outstretched hand – AP and lateral x-rays – In undisplaced and stable: SA POP – If displaced then MUA and SA POP – If displaced and unstable then MUA and K-wiring, ORIF or external fixation • Fixation in OP bone – OP shell thin and weak, will take longer to heal so fixation needs to last longer. Screws often fail so metal plates best
  32. 32. Fragility # • Improving Fixation – Increase number of screws – Augment bones with bone cement, calcium phosphate cement – New techniques: locking/fixed angle plates, new nails and Ilizarov frames • Soft tissues – Care of soft tissues vital in elderly to prevent infection, pressure sores and wound breakdown.
  33. 33. The Limping Child • Limp means abnormal gait • Gait cycle: – Heel strike, stance, toe off and swing • Required for gait cycle: – Control centre: brain and spinal cord – Bony alignment, architecture, stability – Muscle control • Types of gait – Antalgic – painful, less time in stance – Trendelberg – weak abductors, waddling – Spastic – Short leg – Normal variant – in toeing, genu varum/valgrum – Shuffling: PD – wide stance, difficult to start and stop – Ataxic: neurological deficit, wide stance
  34. 34. Limping child • RED symptoms – Asymmetric – Progressive – Painful – Reduced ROM – Falls, trips, late development • Assessment – Birth Hx – Developmental Hx – walking by 2years – Family Hx: DDH, Perthes, SUFE – Hx of limp – Duration, pain, trauma, night pain (TUMOUR), swelling, weight bearing, systemically unwell – Joint involvement • Investigations – Examine: LOOK FEEL MOVE, observe Gait – X-rays, USS, MRI – Bloods: CRP, ESR, CK (duchennes), FBP
  35. 35. Limping child • Infection – Can be bone or joint – Unwell child with raised temperature, refusing to weight bear – Red, swollen, tender area – Investigations: temp, bloods, culture, X-ray, USS, joint aspiration – Brodies abscess – round, symmetrical lesion in bone on x-ray • Irritable hip – Transient synovitis – diagnosis of exclusion – Inflammation associated with viral illness presenting with limp and loss of motion – Investigations: normal temp, bloods normal, USS +/- aspiration – Rx: pain management and rest • Muscular weakness (proximal myopathy) – Hx of tripping and losing balance, inability to climb stairs – Family history – Investigations: CK level, Gowers sign – climb up legs to stand
  36. 36. Limping child • 0-5 – DDH • Family history, breech baby • Limited hip abduction • “dipping” painless hip • Skin creases, ortlani and barlows test • Diagnosed on x-ray once over 4months – Toddlers fracture • Hx of fall, point tenderness, refusal to weight bear, x-ray can be normal initially • LL POP (long leg plaster of paris) the re x-ray 7-10days later – Neurological • Walks with limp, possible upper limb involvement, walks on tiptoes • Thinner leg, weak/spastic muscles, brisk reflexes • Do neuro assessment and MRI brain/spine
  37. 37. Limping child • 5-10 – Perthes disease • Idiopathic avascular necrosis of capital epiphysis of femur • Presents with painful limp, can be hip pain OR KNEE PAIN!!! • Long history, 4-6wks increasing limp • Boys > girls, the younger the age on onset, the better the prognosis as bone has longer to remodel and heal • Boys do better than girls, 75-80% do well regardless of treatment • EXAMINATION: decrease in internal rotation, abduction and flexion • INVESTIGATION: x-ray: AP and Lauenstein (lateral with legs abducted). Loss of spherical shape of femoral head due to AN • Rx: containment achieved by regaining motion – Trauma: # – Infection – Inflammation – Osteochondritis • Kohlers disease or navicular: Rx rest • Severs disease: os calcis • Osgood schlatters disease – tibial tuberosity pain (GP!!!)
  38. 38. Limping child • 10-15 – SUFE • Boy, 10-15, heavy with sore hip!!! Overweight and sexually under developed • Presents with groin pain and KNEE pain • Exam: in flexion hip goes into abduction or lateral rotation • INVESTIGATIONS: x-ray 2views (AP and frog lateral) • Rx: internal fixation with NO attempted reduction – screw in situ • Degree of slip: 1,2 or 3 or complete. Stable or unstable. Acute, chronic or acute on chronic. • Risk of same on other side so may prophylactically fix it with screw too (25-33% chance if over 12, 50% chance if <12) • Under age of 10 consider hypothyroidism and fix other side – Trauma – Infection – inflammation
  39. 39. Clinic • Open # – Benodine soak – Check neurovascular status – Give antibiotics – Check they are up to date with tetanus • # proximal femur – Intra/extra capsular – Intratrochanteric: along trochanteric line – THR / DHS • Radial # – <2cm from radial head – short arm cast – >2cm from radial head – long arm cast to prevent ligaments moving – Colles: dorsally angulated. Cast flexed and ulnarly deviated – Smiths: volarly angulated. – Bartons: intra-articular – Frykman classification • Lisfranc # – 2nd metatarsal – Holds foot together so can be catastrophic
  40. 40. Frykman Classification • Frykman classification of distal radial fractures • Based on the AP appearance and encompasses a the eponymous entities of Colles fracture, Smith fracture, Barton fracture, chauffeur fracture etc • Assesses the pattern of fractures, involvement of the radio-ulnar joint and presence of distal ulnar fracture. • Although it appears complicated, it is actually only a 4 type classification (odd numbered types) with each type having a subtype which includes ulnar styloid fracture (these are the even numbered types). • type I : transverse metaphyseal fracture – this includes both a Colles and Smith fracture as angulation is not a feature • type II : type I + ulnar styloid fracture • type III : fracture involves the radiocarpal joint – this includes both a Barton and reverse Barton fractures • type IV : type III + ulnar styloid fracture • type V : transverse fracture involves distal radioulnar joint • type VI : type V + ulnar styloid fracture • type VII : comminuted fracture with involvement of both the radiocarpal and radioulnar joints • type VIII : type VII + + ulnar styloid fracture
  41. 41. Principles of Management • REDUCE – Manipulation – surgical repositioning and pinning • IMMOBILISE – Cast/sling – External fixation device – Plates and screws • REHABILITATION – physiotherapy
  42. 42. Ankle # • Most common weight bearing # (70%) hip, wrist not weight bearing • Fragility # • Increased weight puts more pressure on joint so increases likelihood of # • 2 peaks: young, active men and women >60 • NOT RELATED TO OP • Complicated joint, made up of bones, ligaments and held in place by muscles • Thin soft tissue envelope, much thicker in children : periosteal envelope. This provides all nutrition to the bone. In childrens ankle # this tissue flips over and often needs surgically reduced before healing can occur
  43. 43. Lateral Ligaments
  44. 44. Medial (deltoid) Ligament
  45. 45. Ankle #• Syndesmosis – Distal tiobiofibular joint – Bones overlap – Hard to see on x-ray: just look for pattern – Ankle has a syndesmosis joint between the tibia and fibula, held together by interosseous membrane, anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligaments – Injury can cause dislocation of the joint – If there is a # of fibula need to check for syndesmosis injury
  46. 46. Ankle # • Can get tri-maleolar # where MM, LM and posterior malleolus (on posterior aspect of talus) are all # • Tauls is prone to AN due to retrograde blood supply • Sign of # is bony tenderness, soft tissue pain is more likely ligament damage. MRI good to differentiate • MRI will find #, CT will define it • Ankle ROM is – 20 degrees extension – 40 degrees flexion – If ankles need fused for arthritis/# the patient will not notice much of a change • To visualise the ankle you need 2 x-rays perpendicular to eachother • At least 10 degrees of dorsiflexion is needed for normal gait • 1 mm of lateral talar shift decreases tibiotalar surface contact up to 40% • Can do stress view X-rays: force joint apart. Too sore.
  47. 47. Ankle # • Looking at the x-ray: – Tibiofibular overlap: <10mm implies syndesmotic injury – Tibial clear space: >5mm implies syndesmotic injury – Talar tilt: >2mm is abnormal • Mortise view: – 15deg INT ROT – AP view – Abnormal findings: • Medial joint space widening • TIBFIB overlap <1mm
  48. 48. Ankle #• Examination – Note obvious deformities – Neurovascular exam – Pain to palpation of malleoli and ligaments – Palpate along the entire fibula – Pain at the ankle with compression (shouldn’t really do, too painful) • syndesmotic injury – Examine the hindfoot and forefoot for associated injuries • WEBER CLASSIFICATION - Based on location and appearance of fibula fracture • Type A – Below syndesmosis – Internal rotation and adduction • Type B – At level of syndesmosis – External rotation leads to oblique fracture • Type C – Above syndesmosis – Syndesmotic injury • Medial and posterior malleolar fractures, deltoid ruptures may occur with any of these
  49. 49. Ankle # • Duputrens/Maisonneuve # – Higher fibula # – Technically a Weber C • Management of Webers # – Type A: weight bearing cast/bandage – Type B: not displaced: cast. Displaced: ORIF (MM affected too) – TypeC: implies syndesmosis injury so surgery!!! • Mx
  50. 50. Management Ankle #• MM # – Nondisplaced fractures may be treated nonoperatively – Displaced fractures require anatomic reduction and fixation – High nonunion rate – Open reduction, Remove interposed soft tissue and intraarticular fragment, Anti- glide plate for vertical fractures • LM # – Nonoperative managmement – 2-3 mm displacement – NO medial widening or syndesmotic injury – Patient in extremis – Cast or boot immobilization 6 wks – Follow closely! • Ix Sx – Bimalleolar / trimalleolar fractures – Syndesmotic disruption – Talar subluxation – Joint incongruity / articular stepoff
  51. 51. Management Ankle #• Posterior malleolus – Repair if >25% of articular surface – Reduce by ankle dorsiflexion – Clamp through fibular incision – Anterior lag screws • Maisonneuve # – Fracture of proximal 1/3 of fibula – +/- medial malleolar fracture – Pronation-external rotation mechanism – Requires reduction and stabilization of syndesmosis • Post-Op – Well padded splint/cast immobilization, Ice and elevation, Non weight bearing for 6 weeks but Early weight bearing is possible • Consent/Risks – Infection, neurovascular injury, DVT/PE, ongoing pain and stiffness, Non/Mal union, failure of procedure, further procedure, anaesthetic risk-MI/CVA/renal dysfx
  52. 52. Prevention of Infection • Pre-Op – Screened for infection: FBC and swabs – Prophylactive Abx – Separate room on ward – Nice clean room • Intra-Op – Abx before any wound made – Anti-septic to skin- excessively – Double gloving and frequent glove changes – Minimal staff in theatres – Double drapes – Masks – Laminar air flow – Cleaned between surgeries • Post-Op – Antibiotics for 24hours, single rooms, barrier nursing for MRSA
  53. 53. Wrist # • Hx&Ex – ATLS – Isolated injury? – Open or closed? (any tenting of the skin?) – Neurovascular status – Age/Handedness/Profession • Usually both bones are involved so check each – from joint to joint • Need AP and lateral views on x-ray • General treatment – Child “greenstick” # - MUA (manipulation) – Adults: ORIF shaft fractures (open reduction, internal fixation)
  54. 54. Colle’s• Colles’ fracture – Distal 2cm radius – Over 65 years old – Dorsally displaced – Radially displaced – Dorsally tilted – Radially tilted – Impaction – Supinated – FOOSH • Colles cast: – Flexed – Ulnar deviation • Any dorsally displaced # in someone <65 is colles like OP BONE ALWAYS IMPACTS!!!!!! !!!!
  55. 55. Smiths • Opposite of Colles • Volar displacement • Volar Tilt • UNSTABLE • Fall when holding something – volar tilt to wrist • Can use cast. Rarely. Supinates and extends. • Often Tx with ORIF
  56. 56. Bartons • Intra-articular fracture/subluxation • Volar displacement • UNSTABLE • Split up onto articular surface • Carpus falls off radius (subluxating) • Fix with plates
  57. 57. Radial Styloid # • Intra-articular fracture • Minimally displaced – Treat in plaster 6/52 – Check X ray at 1&2 weeks • Displaced – Fix • Look out for ulna styloid/scaphoid fracture – May indicate perilunate injury/ligament damage – Will need further imaging/aggressive Tx
  58. 58. Young adult wrist #• High energy • Risk of NV damage – median nerve. Test by touching index finger pulp and lifting thumb off the table (lateral lumbricals, opponens pollicus, abductor pollicus brevis) • Risk of compartment syndrome • Reduction must be perfect – Often unstable if comminuted/intra-articular • K-wire • ORIF • Ex-Fix
  59. 59. Children Wrist # • Childrens: – Buckle fracture: not a full cortical breach. Large periosteal border contains # to one side – Cast for 3 weeks, take off and leave it • Torus/Buckle fractures – Stable – Splint/bandage 2-4 weeks • Green stick – MUA if clinically deformed • Salter Harris – MUA if displaced
  60. 60. Parameters to assess • Radial height: normal 11mm, 8 acceptable. Tip ulnar styloid to tip radial styloid • Radial Inclination: 22degrees. Line drawn from radial tip to lateral ulna in gradient of radius • Volar Tilt: 11degrees. • Management aims are to restore these angles and lengths!!! • Extent of dorsal comminution • Status of articular surface: ,1mm congruity acceptable • Status of distal radio-ulna joint
  61. 61. Treatment wrist # • MUA • K-wire • ORIF • Ex-Fix
  62. 62. Scaphoid # • Blood supply retrograde • Risk of non-union/avascular necrosis • AVN: Proximal pole becomes sclerotic • Non-union: # line becomes sclerotic → Wrist instability/OA Treatment • Minimally displaced: – POP for 6-12 weeks – 90% heal • Displaced: – Percutaneous Herbert screw – ORIF
  63. 63. Notes • Any joint # will get arthritis in joint unless fixed within 1mm of articular step QUICKLY • Principles of Rx: – Reduce – Immobilise – Rehabilitate • 99% colles treated with cast. Must x-ray within 3 weeks of cast placement. After 3 weeks cannot change healing. • External fixator: helps maintain radial height, alternative to a cast • Wiring: percutaneous, good in non OP bone. Use if not happy with how it will heal and aged 30-60. • Thumb is always positioned more volar. Use it as a marker.
  64. 64. • DRUJ dislocation (distal radio-ulnar joint) – Monteggia • # Ulna + dislocated radial head • (at elbow!) – Galeazzi • # Radius + dislocated ulna head • (at wrist!) • Mx- surgery • If you break the ulna or radius and the other does not # - must give in some way. Here by dislocating out of joint
  65. 65. Bennetts # • # base of the first MCP • Extends into the carpometacarpal joint • Most common type of fracture of the thumb • Nearly always accompanied by some degree of subluxation or frank dislocation of the carpometacarpal joint.
  66. 66. Hangmans # – Extension injury – Bilateral fractures of C2 pedicles (white arrow) – Anterior dislocation of C2 vertebral body secondary to ALL tear (red arrow) – Unstable
  67. 67. Boxer’s # • Swelling over dorsal aspect of hand, most pronounced below the small finger. • # of fifth MCP • Usually associated with striking an object with a closed fist.
  68. 68. • Flexion Teardrop fracture – Flexion injury causing a fracture of the anteroinferior portion of the vertebral body – Unstable because usually associated with ligamentous injury

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