The document provides information on the evaluation and management of trauma to the extremities. It discusses taking a thorough history, performing a comprehensive physical examination including special tests, appropriate investigations, fracture classification systems, and treatment approaches for various upper extremity injuries including fractures of the clavicle, proximal humerus, humeral shaft, forearm, distal radius, and hand. Common fracture types are defined and indications for nonoperative versus operative management are outlined.

1. DR UZAIR HANIF BHATTI
PGR ORTHOPEDIC
SURGERY
TRAUMA TO EXTREMITIES

2. HISTORY
• Mechanism of injury
• Amount of force involved in injury
e.g: Fall on outstretched hand------ wrist ,elbow , clavicle injuries.
Information beyond that injury:
• A - Allergies
• M - Medication
• P – Past medical and surgical history
• L – Last time (something to eat or drink)
• E - Events that lead to injury

3. EXAMINATION
Look :
look for whole limb front and back for any swelling, bruise any
deformity, any break in the skin, previous scar or abrasion. E.g. slightly
flexed, internally rotated and adducted limb might suggest posterior
dislocation of hip.
Feel:
Feel for any bony tenderness , degree of swelling, tenseness of
compartment, crepitus of subcutaneous air, pulses.
DISTAL NEUROVASCULAR STATUS.
Move:
• Active: Movement initiated and maintained by patient itself.
• Passive: When examiner moves the limb

4. SPECIAL TESTS
• Knee injuries ---- straight leg raise test to evaluate the extensor
mechanism intact
• Elbow injuries ---- extension at elbow joint to evaluate triceps
muscle intact
• Achilles tendon ---- planter flexion at ankle joint
NEUROVASCULAR EXAMINATION
• Radial nerve palsy associated with humeral shaft fracture
• In 30% of Knee joint dislocations , vascular injury might occur
• Neurovascular status distal to fracture site should me examined
properly

5. INVESTIGATIONS
• Hematological investigations
• Ultrasound
• Radiography
• 2 views ( AP and Lateral view )
• 2 joints ( Above and Below the trauma site )
• 2 occasions ( Before and After treatment )
• CT scan
• MRI
• Nuclear medicine scans ( osteoblastic activity)

6. FRACTURE & CLASSIFICATION
A bone fracture is a medical condition where the continuity of the
bone is broken.
Closed fracture:
◦ Simple fracture
◦ No open wounds of skin near fracture
Open fracture:
◦ Mostly compound fracture
◦ Cutaneous (open wounds) of skin near fracture site. Bone may
protrude from skin
◦ Open fractures are open complete displaced or comminuted.

8. AO CLASSIFICATION
(ARBEITSGEMEINSCHAFT FUR OSTEOSYNTHESEFRAGEN)
• 1st number = long bone
• 2nd number = bone segment
• Letter = fracture type (A,B,C)
• Then 3rd & 4th numbers classify fracture group &
subgroup

10. SALTER-HARRIS CLASSIFICATION
• Only used for pediatric fractures that involve the growth plate
(physis)
• Five types (I-V)

11. SALTER-HARRIS TYPE I FRACTURE
• Type I fracture is when
there is a fracture
across the physis with
no metaphysial or
epiphysial injury

12. SALTER-HARRIS TYPE II FRACTURE
• Type II fracture is when
there is a fracture
across the physis which
extends into the
metaphysis

13. SALTER-HARRIS TYPE III FRACTURE
• Type III fracture is when
there is a fracture
across the physis which
extends into the
epiphysis

14. SALTER-HARRIS TYPE IV FRACTURE
• Type IV fracture is when
there is a fracture
through metaphysis,
physis, and epiphysis

15. SALTER-HARRIS TYPE V FRACTURE
• Type V fracture is when
there is a crush injury to
the physis

16. UPPER EXTREMITY
TRAUMA

17. CLAVICLE FRACTURES

18. CLAVICLE FRACTURES
 Mechanism
– Fall onto shoulder
– Direct blow
– Fall onto outstretched
hand

19. CLAVICLE FRACTURES
 Clinical Evaluation
– Inspect and palpate for deformity/abnormal motion
– Thorough distal neurovascular exam
– Auscultate the chest for the possibility of lung injury
or pneumothorax
 Radiographic Exam
– AP chest radiographs.

20. CLAVICLE FRACTURES
 Allman Classification of Clavicle Fractures
– Type I
– Type II
Middle Third (80%)
Distal Third (15%)
– Type III Medial Third (5%)

21. CLAVICLE FRACTURE
 Closed Treatment
– Sling immobilization for usually 3-4 weeks
 Operative intervention
– Fractures with neurovascular injury
– Fractures with severe associated chest injuries
– Open fractures
– Cosmetic reasons, uncontrolled deformity
– Nonunion

22.  Associated Injuries
– Brachial Plexus Injuries
 Contusions most common, penetrating (rare)
– Vascular Injury
– Rib Fractures
– Scapula Fractures
– Pneumothorax
CLAVICLE FRACTURES

23. PROXIMAL HUMERUS FRACTURES

25. PROXIMAL HUMERUS FRACTURES
 Mechanism of Injury
– Most commonly a fall onto an outstretched arm from
standing height
– Younger patient typically present after high energy
trauma such as Motor Vehicle Accident

26. PROXIMAL HUMERUS FRACTURES
 Clinical Evaluation
– Patients typically present with arm
held close to chest by contralateral
hand. Pain and crepitus detected
on palpation
– Careful NV exam is essential,
particularly with regards to the
axillary nerve. Test sensation over
the deltoid. Deltoid atony does not
necessarily confirm an axillary
nerve injury

27. PROXIMAL HUMERUS FRACTURES
 Neer Classification
– Four parts
 Greater and lesser
tuberosities,
 Humeral shaft
 Humeral head
– A part is displaced if
>1 cm displacement or
>45 degrees of
angulation is seen

28. PROXIMAL HUMERUS FRACTURES
 Treatment
– Minimally displaced fractures- Sling immobilization, early motion
– Two-part fractures-
 Anatomic neck fractures likely require ORIF. High incidence of
osteonecrosis
 Surgical neck fractures that are minimally displaced can be treated
conservatively. Displacement usually requires ORIF
– Three-part fractures
 Due to disruption of opposing muscle forces, these are unstable so
closed treatment is difficult. Displacement requires ORIF.
– Four-part fractures
 In general for displacement or unstable injuries ORIF in the young
and hemiarthroplasty in the elderly and those with severe
comminution. High rate of AVN (13-34%)

29. HUMERAL SHAFT FRACTURES

30. HUMERAL SHAFT FRACTURES
 Mechanism of Injury
– Direct trauma is the most common especially RTA
– Indirect trauma such as fall on an outstretched hand
 Clinical evaluation
– Patients typically present with pain, swelling, and
deformity of the upper arm
– Careful NV exam important as the radial nerve is in
close proximity to the humerus and can be injured

31. HUMERAL SHAFT FRACTURES

32. HUMERAL SHAFT FRACTURES
 Conservative Treatment
– Goal of treatment is to establish
union with acceptable alignment
– >90% of humeral shaft fractures
heal with nonsurgical
management
 Most treatment begins with
application of a splint or a hanging
arm cast followed by placement of
a fracture brace

33. HUMERAL SHAFT FRACTURES
 Treatment
– Operative Treatment
 Indications for operative treatment include
inadequate reduction, nonunion, associated
injuries, open fractures, segmental fractures,
associated vascular or nerve injuries
 Most commonly treated with plates and screws
but also IM nails

34. HUMERAL SHAFT FRACTURES
 Holstein-Lewis Fractures
– Distal 1/3 fractures
– May entrap or lacerate radial nerve as the fracture
passes through the intermuscular septum

35. FOREARM FRACTURES

36. FOREARM FRACTURES
 Mechanism of Injury
– Commonly associated with RTA, direct trauma
missile projectiles, and falls
 Clinical Evaluation
– Patients typically present with gross deformity of the
forearm and with pain, swelling, and loss of function
at the hand
– Careful exam is essential, with specific assessment of
radial, ulnar, and median nerves and radial and ulnar
pulses
 Radiographic Evaluation
– AP and lateral radiographs of the forearm

37. FOREARM FRACTURES
 Ulna Fractures
– These include nightstick and Monteggia fractures
– Monteggia denotes a fracture of the proximal ulna
with an associated radial head dislocation
 Monteggia fractures classification- Bado
 Type I- Anterior Dislocation of the radial head with fracture
of ulna at any level-
 Type II- Posterior/posterolateral dislocation of the radial
head-
 Type III- Lateral/anterolateral dislocation of the radial head
with fracture of the ulnar metaphysis-
 Type IV- anterior dislocation of the radial head with
fracture of radius and ulna at the same level.

38. FOREARM FRACTURES
 Radial Diaphysis Fractures
– Fractures of the proximal two-thirds can be considered truly
isolated
– Galeazzi refer to fracture of the radius with disruption of
the distal radial ulnar joint
– A Reverse Galeazzi denotes a fracture of the distal ulna
with disruption of radioulnar joint
 Mechanism
– Galeazzi fractures may result from direct trauma to the wrist,
typically on the dorsolateral aspect, or fall onto outstretched
hand with pronation
– Reverse Galeazzi results from fall with hand in supination

39. DISTAL RADIUS FRACTURES

40. DISTAL RADIUS FRACTURES
 Mechanism of Injury
– Most commonly a fall on an outstretched extremity
with the wrist in dorsiflexion
 Clinical Evaluation
– Patients typically present with gross
deformity of the wrist with variable
displacement of the hand in relation to the
wrist.

41. DISTAL RADIUS FRACTURES
– Colles Fracture
 Combination of intra and extra articular fractures of the distal radius
with dorsal angulation (apex volar), dorsal displacement, radial
shift, and radial shortenting
 Most common distal radius fracture caused by fall on outstretched
hand
– Smith Fracture (Reverse Colles)
 Fracture with volar angulation (apex dorsal) from a fall on a flexed
wrist
– Barton Fracture
 Fracture with dorsal or volar rim displaced with the hand and carpus
– Radial Styloid Fracture (Chauffeur Fracture)
 Avulsion fracture with extrinsic ligaments attached to the fragment
 Mechanism of injury is compression of the scaphoid against the
styloid

42. DISTAL RADIUS FRACTURES
 Treatment
– Displaced fractures require and attempt at reduction.
 Reproduce the fracture mechanism and reduce the fracture
 Place in sugar tong splint
– Operative Management
 For the treatment of intraarticular, unstable, malreduced
fractures.
 As always, open fractures must go to the ORIF

44. OLECRANON FRACTURE
Direct force on
elbow
Surgery usually
needed

45. RADIAL HEAD FRACTURE
Fall on outstretched arm
X ray signs:
Radiocapitellar line
Appearance of abnormal fat pad

46. TYPES OF RADIAL HEAD FX

47.  Non-displaced:
 <1 mm separation
 Tx: sling, early motion
 Displaced:
 Long arm posterior
splint, followed by
early motion
 Excision of radial head,
followed by early
motion in the elderly
 Surgical fixation in
young pts
 Severely comminuted
 Initially apply posterior
long arm
 Consider surgical excision
of radial head

48. RADIUS SHAFT FRACTURE
Because of protection by musculature, most
radial shaft fx require significant force
Most are associated with ulna fx
Most are displaced fx
TX:
Non-displaced: long arm cast
Displaced: surgical fixation

49. ULNA SHAFT FRACTURE
Non-displaced
Proximal 1/3: requires open reduction &
internal fixation (ORIF)
Distal 2/3: long arm volar splint
Displaced:
Required ORIF

50. MONTEGGIA’S FRACTURE/DISLOCATION
Proximal 1/3 ulnar shaft fx with radial head
dislocation
Always obtain elbow X ray in displaced
shaft fx to avoid missing
TX: surgical fixation

52. GALEAZZI FRACTURE/DISLOCATION
Displaced distal radius fx with associated distal
radioulnar joint(DRUJ) dislocation
Fractures at junction of middle and distal 1/3 of
radius more commonly associated with DRUJ
dislocation
Requires surgical fixation

53. GALEAZZI FRACTURE/DISLOCATION
Always obtain wrist X ray in displaced radius
shaft fracture to avoid missing a Galeazzi
fracture/dislocation
To determine DRUJ dislocation, look for:
Over 5mm shortening of radius
Fracture of ulnar styloid

54. DISTAL RADIUS FRACTURES
Colles fracture
Smith’s fracture
Barton’s fracture
Radial styloid fracture

55. COLLES FRACTURE
Most common wrist fracture due to forceful
wrist extension, usually by fall on out
stretched hand
Distal radial metaphysis fracture; Dorsal
angulated; Displaced proximally and dosally

57. CLOSED REDUCTION OF COLLES FX
 Indications for closed reduction
 Over 5 mm loss in radial length
 Over 10 degree dorsal tilt
 Method
 Manupulate by applying pressure dorsally
to restore normal length and volar tilt
 Apply a cylindrical short arm cast and
immobilize with wrist in slight flexion and
ulnar deviation

58. INDICATIONS FOR SURGICAL FIXATION
After closed reduction there remains
Over 5 mm loss in radial length
Over 15 degree dorsal tilt
Open fx
Comminuted fx
Intraarticular fx

59. SMITH’S FRACTURE
 Flexion fracture with volar displacement of distal
radius
 “Reverse Colles fracture”
 TX:
 Closed reduction
 Often unsuccessful due to flexor muscle pull
 Surgical fixation usually necessary

61. BARTON’S FRACTURE
Intraarticular rim fracture of
distal radius
TX:
Non-displaced fx: short arm
cast with wrist in neutral
position
Displaced: closed reduction &
casting

62. RADIAL STYLOID FX (CHAUFFEUR’S FX)
Non-displaced: cast
immobilization
Displaced: surgical
fixation

64. SCAPHOID FRACTURE
 Most common carpal fx
 Common after a fall onto an outstretched hand
 Pain over radial aspect of wrist
 Clinically suspect when anatomic “snuff box” tenderness present
 When clinically suspected:
 Short arm thumb spica splint

66. TX FOR SCAPHOID FX
Nondisplaced:
Long arm thumb spica cast for 2-4 wks
Followed by short arm thumb spica for 4-6 wks
Displaced:
> 1 mm separation
Closed reduction followed by a thumb spica cast
Surgical fixation if closed reduction unsuccessful

67. THUMB SPICA
SPLINT

68. LUNATE FRACTURE
Highest incidence of avascular
necrosis(Keinbock’s disease) of any carpal
fx
Suspect when there is tenderness in lunate
fossa regardless of whether or not
confirmed by radiograph
Palpate just distal to the center of distal radius
Wrist flexion causes lunate to move against the
examiner’s finger and increases tenderness

69. LUNATE FRACTURE
When clinically suspected
Short arm thumb spica splint
Follow up in 7~10 days
Non-displaced
Short arm cast for 4-6 wks
Displaced
Surgical fixation

70. LUNATE DISLOCATOIN
 Most commonly dislocated carpal bone
 Volar displacement most common
 Dorsal displacement rare
 Associated with median nerve injury
 PA view: triangular “piece of pie” appearance
 Lateral view:
 Lunate volarly or dorsally displaced in relation to lunate fossa
of radius and not associated with proximal surface of capitate
 Spilled teacup appearance

72. TX OF LUNATE DISLOCATION
Immobilize in neutral
position
Surgical reduction
Closed reduction(volar
dislocation)
Dorsiflexion of wrist
while applying volar to
dorsal force on lunate to
reduce into lunate fossa
Palmar flexion of wrist t
reduce capitate into
concavity of distal lunat
o
e

73. PERILUNATE
DISLOCATION
Dorsal dislocation most common
PA view: distal capal row overrides proximal
carpal row and creates “crowded carpal sign”
Lateral view:
Lunate in lunate fossa
Capitate proximal surface dorsally or volarly
displaced out of concavity of distal lunate

75. TX OF PERILUNATE DISLOCATION
 Immobilize in neutral position
 Closed reduction
 Dorsiflexion of wrist
 Longitudinal traction
 Volar flexion so capitate can reduce over dorsal rim of
lunate
 Surgical fixation usually necessary

76. METACARPAL FRACTURES
Non-displaced: splinting at ED
Unstable fx: operative fixation
Bennett’s fracture
Boxer’s fracture

77. BENNETT’S FRACTURE
Intraarticular fx at base
of 1st metacarpal
Associated with
dislocation or
subluxation of the
carpometacarpal joint
(CMC), by pull of the
abductor pollicis brevis
and longus

79. TREATMENT OF BENNETT’S FX
Initial tx: thumb spica splint
Definitive tx: surgical fixation with
percutaneous pinning

80. BOXER’S FRACTURE
Fx of distal 5th metacarpal bone
Striking with closed fist
Indications for sugical fixation
Rotational deformity
Angulation over 40 degree

81. ROTATIONAL DEFORMITY

83. LOWER EXTREMITY TRAUMA

84. LOWER EXTREMITY TRAUMA
• Femur Fractures
• Patella Fractures
• Knee Dislocations
• Tibia Fractures
• Ankle Fractures

85. Femur Fractures
 Femoral Head Fractures
 Femoral Neck Fractures
 Intertrochanteric Fractures
 Subtrochanteric Fractures

86. FEMORAL HEAD FRACTURES
• Pipkin Classification
• I: Fracture inferior to fovea
• II: Fracture superior to fovea
• III: Femoral head + acetabulum fracture
• IV: Femoral head + femoral neck fracture

87. • Treatment Options
• Type I
• Nonoperative: non-displaced
• ORIF if displaced
• Type II: ORIF
• Type III: ORIF of both fractures
• Type IV: ORIF vs. hemiarthroplasty
FEMORAL HEAD FRACTURES

88. • Treatment Options
• Non-operative
• Skeletal traction
• Operative
• ORIF
• Hemiarthroplasty (Endoprosthesis)
• Total Hip Replacement
FEMORAL NECK FRACTURES

89. ORIF
Hemi
THR

90. FEMORAL NECK FRACTURES
• Young Patients
• Urgent ORIF (<6hrs)
• Elderly Patients
• ORIF possible (higher risk AVN, non-union, and failure of fixation)
• Hemiarthroplasty
• Total Hip Replacement

91. INTERTROCHANTERIC HIP FX
• Intertrochanteric Femur
Fracture
• Extra-capsular femoral
neck
• To inferior border of the
lesser trochanter

92. INTERTROCHANTERIC HIP FX
• Intertrochanteric Femur
Fracture
• Physical Findings: Shortened
Obtain Xrays: AP Pelvis

93. • Classification
• # of parts: Head/Neck, Greater Trochanter, Lesser
Trochanter, Shaft
• Stable
• Unstable
• Reverse Obliquity
INTERTROCHANTERIC HIP FX

94. Stable Reverse
Obliquity
Unstable
INTERTROCHANTERIC HIP FX

95. INTERTROCHANTERIC HIP FX
• Treatment Options
• Stable: Dynamic Hip Screw (2-hole)
• Unstable/Reverse: IM Recon Nail

96. SUBTROCHANTERIC FEMUR FX
• Treatment Options
• IM Nail with locking screws
• ORIF with plate/screw
• External fixation
• Consider traction pin if
prolonged delay to surgery

97. DISTAL FEMUR FRACTURES
• Distal Metaphyseal Fractures
• Look for intra-articular involvement
• Plain films
• CT

98. DISTAL FEMUR FRACTURES
• Treatment:
• Retrograde IM Nail
• ORIF Buttress plate
• Above depends on fracture
type, bone quality, and
fracture location

99. PATELLA FRACTURES
• History
• RTA, fall onto knee,
• Physical Exam
• Ability to perform straight leg raise
against gravity (ie, extensor
mechanism still intact?)
• Pain, swelling, contusions,
lacerations and/or abrasions at the
site of injury

100. PATELLA FRACTURES
• Radiographs
• AP/Lateral/Sunrise views
• Treatment
• ORIF if extensor mechanism is
incompetent TENSION BAND
WIRING
• Non-operative treatment with brace if
extensor mechanism remains intact

101. TIBIAL PLATEAU FRACTURES
• RTA, fall from height, sporting injuries
• Examine soft tissues, neurologic exam (peroneal N.), vascular
exam (esp with medial plateau injuries)
• Be aware for compartment syndrome
• Check for knee ligamentous instability

102. TIBIAL PLATEAU FRACTURES
• Xrays: AP/Lateral +/- traction films
• CT scan (after ex-fix if appropriate)

103. • Schatzker Classification of Plateau Fxs
Lower Energy
Higher Energy

104. TIBIAL PLATEAU FRACTURES
• Treatment
• Spanning External Fixator
may be appropriate for
temporary stabilization and to
allow for resolution of soft
tissue injuries
Insert blister
Pics of ex-fix here

105. TIBIAL PLATEAU FRACTURES
• Treatment
• Definitive ORIF for patients with
varus/valgus instability, >5mm
articular stepoff
• Non-operative in non-displaced
stable fractures or patients with
poor surgical risks

106. TIBIAL SHAFT FRACTURES
• Treatment Options
• IM Nail
• ORIF with Plates
• External Fixation
• Cast or Cast-Brace

107. ANKLE FRACTURES
 Indications for operative care:
– Bimalleolar fractures
– Trimalleolar fractures

108. ANKLE FRACTURES
 ORIF:
– Fibula
 Lag Screw if possible + Plate
 Confirm length/rotation
– Medial Malleolus
 Open reduce
 4-0 cancellous screws vs. tension band
– Posterior Malleolus
 Fix if >30% of articular surface

109.  Osseous Anatomy

110. THANK YOU