This document provides information on fractures of the radius and ulna shafts (forearm fractures). It discusses the epidemiology, anatomy, classification systems, clinical evaluation, imaging, and management including both closed and open reduction techniques. Surgical indications include displaced fractures of both bones, isolated fractures with over 10 degrees of angulation or rotation, and fracture dislocations. Acceptable postoperative alignment is discussed as well as postoperative care involving splinting and rehabilitation. Specific fracture patterns like Monteggia and Galeazzi fractures are also summarized.
Calcaneum fracture- pathoanatomy & various fracture patternGirish Motwani
DR. GIRISH MOTWANI
Consultant Foot & Ankle surgeon (Paediatric & Adult)
1)Sushrut Hospital, Research Centre & PostGraduate Institute of Orthopaedics, Nagpur west
2)Aman hospital,Nagpur east
3)South point clinic, Nagpur south
Can read freely here
https://sethiortho.blogspot.com/
Challenges and Solutions in
Management of Distal Humerus Fractures
Epidemiology
Anatomy
Classification
Controversies and Recent studies
Approach
Implants selection
Plate configuration
Ulnar nerve transposition
Role of total elbow arthroplasty in DHF
Role of hemiarthroplasty in DHF
Metaphyseal comminution –
Anatomic complexity of the distal humerus
Positioning of the plates
TBW –
Skin closure
Osteoporotic nature of the bone –
Less BMD/Thin metaphysis
Screw Pullout strength is low
DHF account for 2% of all adult fractures
The common pattern of fracture
Intraarticular and involves both columns
Bimodal distribution
Peak incidence in young male and in older female patients
Young male – High-velocity injury
Older female - Osteoporosis
The distal humerus is flattened and expanded bony structure
It is composed of lateral and medial columns with the trochlea situated between these columns.
The location of the trochlea is central rather than medial
Formed by Medial SCR + M/Epicondyle
The distal end has 450 angulation with humeral shaft
M/ Epicondyle gives attachment for MCL & Common Flexor Origin
The MCL originates from the undersurface of the medial epicondyle where it is vulnerable to excessive dissection
Ulnar nerve
Formed by Lateral SCR and L/Epicondyle and Capitulum
Distal end has 200 with humeral shaft
L/ epicondyle gives attachment for LCL & common extensor origin
Its posterior surface is non articular and can be used as a site for a plate fixation
The lateral column curves anteriorly
Placement of a straight plate on the posterolateral surface of the humerus risks straightening of distal humerus.
The medial column including the medial epicondyle is in line with the humeral shaft.
It forms the center of the triangle
It has 30 - 80 – external rotation & 250 anterior divergent with the shaft
It forms a 40 - 80 degree valgus direction
X-ray -
Anterior-posterior view
lateral View
Traction View – This can help to define articular fragments and aid in pre-operative classification of the fracture.
NCCT – Elbow
Articular surfaces
Position of the fracture fragments
useful for identifying impacted fracture fragments that make reduction challenging
Olecranon Osteotomy Approach – 52-57%
Triceps sparing VS Olecranon osteotomy approach
The lateral column was often the first to fail as a result of excessive varus forces acting on the elbow during normal activities of daily living. Small anterior-posterior diameter
Smaller diameter of the humerus, permitting only one or two short screws for fixation.
Interruption of blood supply to the lateral column
blood supply to the lateral column is also derived from posterior segmental vessels. Sagittal plane plating has less risk of injuring these structures, which may improve the chances of union
Calcaneum fracture- pathoanatomy & various fracture patternGirish Motwani
DR. GIRISH MOTWANI
Consultant Foot & Ankle surgeon (Paediatric & Adult)
1)Sushrut Hospital, Research Centre & PostGraduate Institute of Orthopaedics, Nagpur west
2)Aman hospital,Nagpur east
3)South point clinic, Nagpur south
Can read freely here
https://sethiortho.blogspot.com/
Challenges and Solutions in
Management of Distal Humerus Fractures
Epidemiology
Anatomy
Classification
Controversies and Recent studies
Approach
Implants selection
Plate configuration
Ulnar nerve transposition
Role of total elbow arthroplasty in DHF
Role of hemiarthroplasty in DHF
Metaphyseal comminution –
Anatomic complexity of the distal humerus
Positioning of the plates
TBW –
Skin closure
Osteoporotic nature of the bone –
Less BMD/Thin metaphysis
Screw Pullout strength is low
DHF account for 2% of all adult fractures
The common pattern of fracture
Intraarticular and involves both columns
Bimodal distribution
Peak incidence in young male and in older female patients
Young male – High-velocity injury
Older female - Osteoporosis
The distal humerus is flattened and expanded bony structure
It is composed of lateral and medial columns with the trochlea situated between these columns.
The location of the trochlea is central rather than medial
Formed by Medial SCR + M/Epicondyle
The distal end has 450 angulation with humeral shaft
M/ Epicondyle gives attachment for MCL & Common Flexor Origin
The MCL originates from the undersurface of the medial epicondyle where it is vulnerable to excessive dissection
Ulnar nerve
Formed by Lateral SCR and L/Epicondyle and Capitulum
Distal end has 200 with humeral shaft
L/ epicondyle gives attachment for LCL & common extensor origin
Its posterior surface is non articular and can be used as a site for a plate fixation
The lateral column curves anteriorly
Placement of a straight plate on the posterolateral surface of the humerus risks straightening of distal humerus.
The medial column including the medial epicondyle is in line with the humeral shaft.
It forms the center of the triangle
It has 30 - 80 – external rotation & 250 anterior divergent with the shaft
It forms a 40 - 80 degree valgus direction
X-ray -
Anterior-posterior view
lateral View
Traction View – This can help to define articular fragments and aid in pre-operative classification of the fracture.
NCCT – Elbow
Articular surfaces
Position of the fracture fragments
useful for identifying impacted fracture fragments that make reduction challenging
Olecranon Osteotomy Approach – 52-57%
Triceps sparing VS Olecranon osteotomy approach
The lateral column was often the first to fail as a result of excessive varus forces acting on the elbow during normal activities of daily living. Small anterior-posterior diameter
Smaller diameter of the humerus, permitting only one or two short screws for fixation.
Interruption of blood supply to the lateral column
blood supply to the lateral column is also derived from posterior segmental vessels. Sagittal plane plating has less risk of injuring these structures, which may improve the chances of union
a summary of the pertinent elbow anatomy, mechanism of injury, primary and secondary stabilizers of the elbow, and treatment options of elbow terrible triad
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
1. DEPARTMENT OF ORTHOPAEDICS
BMC SAGAR
• PRESENTED BY -
• DR MAYANK SHROTRIYA
• MODERATOR-
• DR GAURAV AGARWAL
• DR PROF. RAJESH JAIN
SIR
(HEAD OF DEPARTMENT
OF ORTHOPAEDICS)
4. EPIDEMIOLOGY
• IN AO documentation 1980-1996,10-14% of fracture
recorded occur in FOREARM.
• FROM 1996-2006,MORE than 200% increase in the
volume of surgically treated FOREARM fractures.
5. SPECIAL CHARACTERSTICS
• Forearm fractures associated with JOINT
DISLOCATIONS either in the PROXIMAL or DISTAL
ASPECT of the fore arm
• High Rate of delayed union or non union despite usually
being closed injury with simple fracture pattern.
6.
7. ANATOMY
• Ulna is relativlely straight bone WHICH IS
POSTERIOMEDIALLY POSITIONED
• two bones are bond proximally by the capsule of
elbow joint and annular ligament and distally by dorsal,
volar radioulnar ligaments and TFCC.
• interosseous space is greater distally due lateral curve
of radius.
• central portion of interosseous memberane is 2.5cm
thick and accounts for most of the longitudinal support
of radius.
9. RADIAL BOW
• ALLOWS INCREASED RANGE OF PRONATION.
• RADIUS ROTATES OVER AXIS BETWEEN PROXIMAL
AND DISTAL RADIOULNAR JOINTS
• IN SUPINATION BOWING TIGHTENS OBLIQUE AND
INTEROSSEOUS LIGAMENTS INCREASING
PROXIMAL RADIOULNAR STABILITY.
10. ANATOMY
• Studies shown that incison of central band of
interosseous membreane reduce STABILITY BY 74% IN
COMPARISION TO INCISON OF TFFC WHICH
REDUCE 11% STABILITY.
• Radius ulna mainly joined by 3 muscles: 1. supinator
• 2.pronator
teres
• 3.pronator
quadratus.
11. LIGAMENTS
1. ANNULAR LIGAMENT--
• PRIMARY STABILIZER OF PROXIMAL RADIO ULNAR
JOINT.
• MAINTAIN THE RADIAL HEAD IN RADIOULNAR
NOTCH THROUGHOUT THE RANGE OF MOTION
2.QUADRATE LIGAMENT(LIGAMENT OF DENUCE)
STABILIZE RADIAL HEAD IN ROTATION
3.OBLIQUE LIGAMENT(LIGAMENT OF WEITBRECHT)
13. TRIANGULAR FIBROCARTILAGE COMPLEX
• SHARES THE LOAD AND STRESS TO ABOUT 20-30%
produced AXIAL COMPRESSION.
• MAINTAINS THE STABILITY OF DRUJ FOR SMOOTH
ROTATION OF FOREARM.
• DISTAL CONNECTION SUSPENDS THE ULNAR SIDE
OF CARPUS WITH ULNA WHICH IS NEEDED FOR
ADEQUATE GRIP STRENGTH.
23. IMAGING
• MILCH anatomic criteria criteria to determine alignment of
forearm bones:
1. CORONOID PROCESS OF ULNA POINTS
ANTERIORLY AND STYLOID PROCESS POINTS
POSTERIORLY IN LATERAL PROJECTION.
2. RADIAL STYLOID IS NOT SEEN IN NORMAL LATERAL
PROJECTION WITH FOREARM SUPINATED.
3. 3. IN NORMAL AP VIEW CORONOID AND STYLOID
PROCESS OF ULNA ARE HIDDEN BUT RADIAL
STYLOID AND BICIPTAL TUBEROSITY SEEN.
24. IMAGING
• MACLAUGHLIN’S LINE:
• A LINE DRAWN THROUGH RADIAL SHAFT,NECK AND
HEAD SHOULD PASS THROUGH THE CENTRE OF
THE CAPITULLUM ON ANY RADIOGRAPHIC VIEW OF
ELBOW.
26. EVANS VIEW
• BICIPITAL TUBEROSITY VIEW.
• X RAY TUBE TILTED 20 DEGREE TOWARDS
OLECRANON WITH SUBCUTANEOUS BORDER OF
ULNA FLAT ON CASSETTE.
27. EVALUATION AND DIAGNOSIS
• CASE HISTORY AND PHYSICAL EXAMINATION
1. MODE OF TRAUMA
2. SYMPTOMS
3. PHYSICAL EXAMINATION
28. MODE OF TRAUMA
• DIRECT
• INDIRECT
• MOST COMMON IS INDIRECT FORCE SUCH AS
LANDING ON OUTSTRECHED UPPER EXTERIMITY.
• RADIUS USUALLY FOLLOWED BY ULNA.
• IN YOUNGER CHILDREN SHAFT FRACTURE MORE
COMMON BECAUSE CORTICAL BONE IS MORE
POROUS AND TRANSITION FROM METAPHYSIS TO
DIAPHYSIS IS LESS DISTINCT THAN OLDER
CHILDREN.
31. CLOSED MANAGEMENT
• GREEN STICK VS COMPLETE FRACTURES.
• EVEN WITH MINIMALLY ANGULATED GREENSTICK
FRACTURES,ELBOW SHOULD BE EVALUATED
CAREFULLY TO RULEOUT MONTEGGIA TYPE 4.
32. CLOSED MANAGEMENT
• SHOULD GREENSTICK FRACTURES BE MADE
COMPLETE?
• FAVOUR: Angulation will reccur if it is not done.
• resorption zone developed on broken side of cortex
leading to refracture in future.
• AGAINST:chances of rotational deformity increases.
33. CLOSED MANAGEMENT
• IF BOTH BONE FRACTURES ARE COMPLETE THEN
MUSCLE PULL ON THE FRAGMENTS BECOMES
IMPORTANT SO ROTATION OF PROXIMAL
FRAGMENT IS DETERMINED AND DISTAL FRAGMENT
IS PLACED IN SAME ROTATION.
• MANUAL CLOSED REDUCTION
• TRACTION THROUGH FINGERTRAPS
35. AFTERCARE
• DISTAL NEUROVASCULAR STATUS
• LIMB ELEVATION
• IMMEDIATE POSTOP XRAY FOLLOWED BY SERIAL
IMAGING AT 1,2,3 WEEKS AFTER REDUCTION.
• SLING APPLIED PROXIMALLY TO FRACTURE.
36. SURGICAL INDICATIONS
• DISPLACED FRACTURES OF BOTH THE RADIAL
AND ULNAR SHAFT IN ADULTS.
• DISPLACED,ROTATED (10 DEGREE) OR
ANGULATED(>10 DEGREE) isolated fracture of either
bone
MONTEGGIA,GALEAZZI AND ESSEX LOPRESTI TYPE
FRACTURE DISLOCATIONS.
OPEN FRACTURES
37. TIMING OF SURGERY
• IDEALLY CLOSED FOREARM FRACTURES BEST
OPERATED WITH IN FIRST 24 HOURS OF INJURY.
• PROLONGED DELAY MAY INCREASE THE RISK OF
RADIOULNAR SYNOSTOSIS.
• OPEN FRACTURES SHOULD UNDERGO
DEBRIDEMENT AND IRRIGATION AND FIXATION
38. IMPLANT SELECTION
• 3.5 MM DCP, LC DCP IS THE IDEAL SIZE
• LIMITED CONTACT DYANMIC COMPRESSION PLATE
IS RECOMMENDED.
• WHEREVER POSSIBLE AN INTERFRAGMENTARY
LAG SCREW INSERTED INDEPENDENTLY OR
THROUGH A PLATE HOLE. 3.5,2.7 OR 2.4mm CORTEX
SCREWS .
• FOR MOST FOREARM FRACTURES NON LOCKING
SCREW GIVE GOOD RESULT.
41. IMPLANT SELECTION
• ROLE OF INTERMEDULLARY NAILS--- STILL TO BE
DEFINED AS QUESTION PERSIST ON THEIR ABLITY
TO CONTROL ROTATION.
• ELASTIC NAILS GIVE ECELLENT RESULT IN
PEDIATRIC FOREARM FRACTURES.
• BUT THIS MODE OF FIXATION DOES NOT GIVE
ADEQUATE STABILITY FOR EARLY RANGE OF
MOTION IN ADULTS.
42. IMPLANT SELECTION
• SAGE NAIL ADRESSED THE ISSUE OF RADIAL
BOW,ALLOWING IMPROVED MOTION AND
DECREASE RATE OF NON UNION.
• FORESIGHT NAIL THAT CAN BE CONTOURED TO
RECREATE THE RADIAL BOW.
• DESPITE OF SATISFACTORY OUTCOMES,PLATE
FIXATION REMAIN SUPERIOR.
• WE RESEVRVE INTERMEDULLARY NAILING OPTION
WHERE SOFT TISSUE LOSS IS EXTENSIVE.
44. SURGICAL APPROACHES
• ULNA---- STRAIGHT INCISON ALONG
SUBCUTANEOUS BORDER.
• PLATE IS PLACED ON THE POSTERIOLATERAL
(EXTENSOR) OR ANTERIOR(FLEXOR) ASPECT OF
BONE.
• RADIUS--ENTIRE DIAPHYSIS: HENARY APPROACH
• MODIFIED HENARY
APPROACH
• RADIUS----PROXIMAL AND MIDDLE THIRD OF
DIAPHYSIS
45. SURGICAL APPROACHES
• AS A RULE, A SEPRATE INCISON FOR EACH BONE
SHOULD BE USED,PRESERVING A BROAD SKIN
BRIDGE BETWEEN THE TWO INCISIONS.
• ATETEMPTING TO FIX BOTH BONES THROUGH
SINGLE APPROACH INCREASES THE RISK OF
NERVE INJURY AND RADIOULNAR SYNOSTOSIS.
51. FIXATION
• REDUCTION IS FIRST PERFOMED ON THE BONE
WITH SIMPLER FRACTURE.
• PUSH PULL TECHNIQUE
• SLIGHT PREBENDING PREVENT FRACTURE GAP
OPPOSITE TO THE PLATE
• IF BONE GRAFT IS NECESSARY IT SHOULD BE
PLACED AW
• AY FROM INTEROSSUS MEMBERANE.
52.
53. AFTERCARE
• A VOLAR SPLINT FOR FIRST WEEK TO REDUCE PAIN
OR EVEN LONGER IN UNRELIABLE PATIENTS.
• EARLY ACTIVE MOTION OF THE FINGERS
,WRIST,ELBOW TO AVOID COMPLEX REGIONAL PAIN
SYNDROME.
• WEIGHT BEARING USUALLY ALLOWED 6-8 WEEKS
AFTER SURGERY.
• RADIOGRAPHIC IMAGES TAKEN AT 6 AND 12 WEEKS
POSTOPERATIVLEY.
54. MONTEGGIA FRACTURE
• “SHAFT FRATURE OF ULNA WITH AN ANTERIOR OR
LATERAL DISLOCATION OF RADIAL HEAD AT THE
PROXIMAL RADIOULNAR JOINT”.
• according to watson-jones no fracture present so many
problems,no injury is beset with greater difficulty,no
treatment is characterized by more general failure.
• can be treated conservativley in children.
55. MECHANISM OF INJURY
• FOR TYPE 1
1. DIRECT BLOWS TO ULNAR ASPECT(SPEED AND
BOYD)
2. HYPERPRONATION THEORY(EVANS).
• HYPEREXTENSION THEORY
• FOR TYPE 2
1. PENROSE THEORY-forearm loaded inlongitudnal
direction with elbow bent 60*
• FOR TYPE 3
1. MULLICK THEORY OF VARUS STRESS
57. BADO’S CLASSIFICATION
• TYPE 1: FRACTURE OF MIDDLE OR PROXIMAL THIRD
ULNA WITH ANTERIOR DISLOCATION OF RADIAL
HEAD AND APEX ANTERIOR ANGULATION OF ULNA.
• TYPE2: FRACTURE OF MIDDLE OR PROXIMAL THIRD
ULNA WITH WITH POSTERIOR DISLOCATION OF
RADIAL HEAD AN D OFTEN FRACTURE OF RADIAL
HEAD AND APEX DORSAL ANGULATION OF ULNA.
58. BADO’S CLASSIFICATION
• TYPE 3: FRACTURE OF ULNA JUST DISTAL TO
CORONOID PROCESS WITH LATERAL DISLOCATION
OF RADIAL HEAD.
• TYPE 4: FRACTURE OF PROXIMAL OR MIDDLE THIRD
ULNA,ANTERIOR DISLOCATION OF RADIAL HEAD
AND FRACTURE OF PROXIMAL THIRD RADIUS
BELOW THE BICIPITAL TUBEROSITY.
• TYPE 1 IS FAR EXCEEDS ALL OTHER IN FREQUENCY.
• ALTOUGH CHILDREN’ INJURIES INCLUDED IN MOST
SERIES.
63. MANAGEMENT
• BOYD AND BOALS recommended RIGID INTERNAL
FIXATION of fractured ULNA either with compression
plate or a medullary nail and closed reduction of RaDIAL
HEAD.
• RING AND JUPITER recommended good results with
RADIAL HEAD REPLACEMENT FOR COMMUNITED
RADIAL HEAD FRACTURE.
• RYENDERS et al. recognized that early resection of head
as contributing to delayed union or non union of the ulnar
fracture by allowing INCREASED ANGULAR FORCES.
64. MANAGEMENT
• ANATOMIC OPEN REDUCTON AND INTERNAL
FIXATION OF ULNA WITH STABLE FIXATION ALMOST
ALWAYS ALLOW CLOSED REDUCTION OF RADIAL
HEAD.
• CONTINUED RADIOCAPITELLAR INSTABILITY most
frequently caused by MALREDUCTION OF ULNA.
• An APEX DORSAL MALREDUCTION can force the radial
head posteriorly.
• jupiter and kellam recommended a DORSAL PLATE in
this situation.
65. MANAGEMENT
• UNCONTOURED PLATE will malreduced the fracture
and prevent radial head from remaining reduced.
• IN a series of 121 patients MARYLAND SHOCK
TRAUMA report noted:
• IN 17% patients radial head was not reduced and
ANNULAR LIGAMENT ENTRAPTMENT was the cause.
66. MONTEGGIA EQUIVALENTS
• ISOLATED DISLOCATION OF RADIAL HEAD.
• RADIAL NECK FRACTURE ISOLATED
• RADIAL NECK FRACTURE IN COMBINATION WITH
FRACTURE OF ULNAR DIAPHYSIS.
• POSTERIOR DISLOCATION OF ELBOW
• ULNAR FRACTURE WITH DISPLACED FRACTURE OF
LATERAL CONDYLE.
67. GALEAZZI FRACTURE
• “
• FRACTURE OF RADIAL SHAFT WITH DISLOCATION
OF THE DISTAL RADIOULNAR JOINT”
68. • MECHANISM OF INJURY
• WHETHER THE DIRECT OR INDIRECT --- RADIAL
FRACTURE OCCURS FIRST FOLLOWED BY
DISRUPTION OF DRUJ.
• COMBINATION OF AXIAL LOADING AND AXIAL
ROTATION.
• DISLOCATION IS THE RESULT OF COMBINATION
AXIAL LOADING AND HYPERPRONATION OF WRIST.
• IN ELDER ,FRACTURE OCCUR AT HEIGHT OF
MAXIMAL RADIAL BOWING
• AND DISTAL FOREARM PIVOTS THE FRACTURE SITE
69. MECHANISM OF INJURY
• RADIAL FRACTURE is made more unstable by following
5 factors
1. pronator quadratus-rotates distal fragment
ULNAR,VOLAR AND PROXIMAL DIRECTION.
2. ABDUCTOR POLLICIS LONGOUS AND EXTENSOR
POLLICIS LONGUS-----RESPONSIBLE FOR
RELAXATION OF RADIAL COLLATERAL LIGAMENTS
AND RADIAL SHORTENING AND DISPLACEMENT OF
70. MECHANISM OF INJURY
3.BRACHIORADIALIS--UTILIZE DRUJ AS A POINT TO
ROTATE DISTAL FRAGMENT .
4. INTEROSSEOUS MEMBERANE:ATTACHED TO
DISTAL FRAFMENT OF RADIUS AND PREVENT RADIAL
SHORTENING.
• RADIAL SHORTENING >5MM ASSOCIATED
ASSOCIATED WITH TFCC TEAR.
• RADIAL SHORTENING > 10 MM ASSOCIATED WITH
SIGNIFCANT TEAR OF INTEROSSEOUS
75. GALEAZZI EQUIVALENT IN CHILDREN
1.
• WHERE RADIAL FRACTURES AT ABOUT 6-8CM
PROXIMAL TO WRIST WITH DISTAL ULNAR
EPIPHYSEAL SEPRATION
• OCCUR BEACAUSE EPIPHYSEAL PLATE OF DISTAL
ULNA IS WEAKER THAN TFCC.
• HENCE NO SUBLUXATION AND DISLOCATION OF
DRUJ.
76. GALEAZZI EQUIVALENT IN ELDER
• RADIAL SHAFT FRACTURES AT ABOUT 6-8CM
PROXIMAL TO WRIST ASSOCIATED WITH ULNAR
FRACTURE 2CM PROXIMAL TO WRIST.
• DUE WEAKER OSTEOPOROTIC ULNA THAN THE
ARTICULAR DISC OF TFCC.
78. IMAGING
• 4 RADIOLOGICAL CARDINAL SIGNS:
1. RADIAL FRACTURE BETWEN INSERTION OF
PRONATOR TERES AND PRONATOR QUADRATUS
ASSOCIATED WITH RADIAL SHORTENING OF > 5
MM.
2. 2.FRACTURE STYLOID PROCESS OF ULNA WHICH
IS STRUCTURAL EQUIVQLENT OF TEAR IN TFCC.
3. WIDENING OF LOWER END OF RADIUS AND ULNA
I.e DIASTASIS.
4. DORSAL DISPLACEMENT OF DISTAL ULNA IN
79.
80. ESSEX-LOPRESTI LESION
• “PROXIMAL RADIAL SHAFT OR RADIAL NECK/ HEAD
FRACTURE COMBINED WITH IN STABILITY OF DRUJ”
• PROXIMAL MIGRATION OF THE RADIUS TEARS THE
INTEROSSEOUS MEMBERANE AND CAUSES AXIAL
INSTABILITY.
• FAILURE TO ADRESS RADIOULNAR INSTABILITY AT
ONSET CAN RESULT IN PERSISTENT AXIAL
MIGRATION OF RADIUS.
• SO DIFFICULT TO TREAT IN LATE STAGE.
• ORIF OF PROXIMAL RADIAL FRACTURE AND
81.
82.
83. NIGHT STICK FRACTURES
• “ISOLATED FRACTURE OF ULNA WITHOUT RADIAL
HEAD INSTABILITY”
• CLASSIFIED AS :
1. UNDISPLACED SIMPLE FRACTURE
2. DISPLACED MORE THAN 50% OF DIAMETER OF
DIAPHYSIS,ANGULATED> 10*
3. UNUSAL FRACTURES
84. MANAGEMENT
• ISOLATED DIAPHYSEAL FRACTURE WITH
DISRUPTION MORE THAN 50%-- ORIF WITH 3.5MM
LC DCP/ DCP.
• SEGMENTAL FRACTURE ARE PLATED WITH 2
OVERLAPPING DCP ON IPSILATERAL SURFAFCE OF
ULNA.
• CULIBALY et.al. RECOMMENDED SURGERY IF 50%
DISPLACEMENT AND ANGULATION MORE THAN 8
DEGREE.
85. OPEN FRACTURES OF RADIUS AND ULNA
• PRINCIPLES OF MANAGEMANT:
1. WOUND CULTURE SHOULD BE TAKEN FOLLOWED
BY PROPHYLACTIC ANTIBIOTIC.
2.EXTENSIVE DEBRIDEMENT
3.ORIF OR EXTERNAL FIXATION?
4.IF POSSIBLE ,SOFT TISSUE INJURY SHOULD BE
RECONSTRUCTED WITHIN 72 HOURS.
86. • IF COMPARTMENT HAS BEEN DIAGNOSED OR IF
OPERATIVE WOUND CANNOT BE CLOSED WITH OUT
TENSION PORTION OF WOUND PROXIMALLY AND
DISTALLY ARE CLOSED.
• REMANING WOUND IS LEFT OPEN AND COVERED
WITH ANTIBIOTIC IMPREGNATED GAUGE.
• WOUND IS CLOSED SECONDARILY WITH SPLIT
THICKNESS GRAFTS 3 TO 5 DAYS AFTER PRIMARY
SURGERY.
92. EARLY COMPLICATIONS
1. NERVE PALSY: POSTERIOR INTEROSSEOUS
NERVE
SUPERFICIAL RADIAL NERVE
DORSAL BRANCH OF ULNAR
NERVE
2.COMPARTMENT SYNDROME:
MORE COMMON AFTER HIGH ENERGIES INJURIES
IMMEDIATE DECOMPRESSION OF THE TWO
ANTERIOR COMPARTMENT AND ONE POSTERIOR
FASCIAL COMPARTMENT.
93. LATE COMPLICATIONS
1.COMPLEX REGIONAL PAIN SYNDROME:
• MORE COMMON AFTER FOREARM AND WRIST
FRACTURES.
• APPROPRIATE ANALGESIA REGIMEN AND EARLY
MOVEMENT IS THE TREATMENT OF CHOICE
2. RADIOULNAR SYNOSTOSIS: CROSS UNION
UNCOMMON BUT TROUBLESOME
INCIDENCE 2-6%
94. LATE COMPLICATIONS
• POSSIBLE RISK FACTORS OF SYNOSTOSIS ARE:
• FRACTURE OF RADIUS ULNA AT SAME LEVEL.
• INJURY TO INTEROSSEOUS MEMBERANE.
• DELAYED FIXATION
• COMBINED SINGLE APPROACH FOR FIXATION
• POSTOPERATIVE CAST IMMOBILIZATION
• SEVRE SOFT TISSUE DAMAGE AND
MULTIFRAGMENTARY FRACTURE.
95. LATE COMPLICATIONS
• TREATMENT OF SYNOSTOSIS ARE:
• EXCISION FO HETEROTOPIC OSSIFICATION
,CONTRACTED SOFT TISSUE AND EARLY RANGE OF
MOTION.
• HETEROTOPIC OSSIFICATION SHOULD BE MATURE.
• NONUNION:
96. SUMMARY
• goal of treatment is:
1.COMPLETE OSSEOUS HEALING
2.RESTORATION OF STABLE FOREARM ROTATION
WITH FULL ELBOW AND WRIST RANGE OF MOTION.
3.FUNCTIONAL OUTCOME LARGELY DEPENDS ON
RECONSTRUCTION OF RADIAL BOW AND PERFECT
ANATOMICAL RESTORATION OF PRUJ AND DRUJ.
97. BIBLIOGRAPHY
• CAMPBELL’S OPERATIVE ORTHOPAEDICS 14TH
EDITION VOL 3
• AO PRINCIPLES OF FRACTURE MANAGEMENT 3RD
EDITION 2020(RADIUS ULNA SHAFT BY JOHN T
CAPO)
• ROCKWOOD AND GREEN’S FRACTURE IN ADULTS
8TH EDITION