17 skeleton - irp-cdn.multiscreensite.com Li… · Upper limb fractures Mithun Nambiar ....
Transcript of 17 skeleton - irp-cdn.multiscreensite.com Li… · Upper limb fractures Mithun Nambiar ....
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Upper limb fractures
Mithun Nambiar Orthopaedic Resident Royal Melbourne Hospital
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http://janeaustensworld.files.wordpress.com/2010/10/17_skeleton.jpg
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Principles of fracture management
Restoration of anatomy Stable fracture fixation Preservation of blood supply Early mobilisation of limb and patient
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Restoration of anatomy Length Alignment Rotation
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Stable fracture fixation Allows for fracture healing Prevention of loss of anatomy ◦ Length ◦ Alignment ◦ Rotation
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Preservation of blood supply Soft tissue protection ◦ Periosteum ◦ Muscle ◦ Arteries ◦ Veins
http://www.ubortho.buffalo.edu/tree3.j
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Early mobilisation Limb ◦ Joint stiffness ◦ Muscle atrophy ◦ Contracture formation
Patient ◦ Pneumonia ◦ DVT/Pulmonary embolus ◦ Pressure sores ◦ Hospital acquired infections
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Management Operative Conservative Weight bearing status Wound management Antiobiotics Anticoagulation Smoking Immunomodulators
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Clavicular fractures
http://en.wikipedia.org/wiki/File:Gray326.png
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Clavicular fractures
Medial 1/3 (5%) ◦ Usually non-operative, operative if post.
displacement Middle 1/3 (80%) ◦ Non-operative if <100% displacement ◦ Operative if >100% displaced
Lateral 1/3 (10%) ◦ Neer classification
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http://eorif.com/clavicle-fracture-classification
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http://www.orthobullets.com/trauma/1011/clavicle-fractures
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https://www.jaaos.org/content/19/7/392/F1.large.jpg
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Clavicular fractures
Non operative management ◦ Sling vs Figure of 8 ◦ NWB 6 weeks ◦ Range of movement exercises 2-4 weeks
Risks ◦ Non union Lateral 1/3 (up to 50%) Fracture displacement/shortening >2cm ◦ Decreased shoulder strength
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Clavicular fractures Operative management ◦ Sling 7-10 days, then active range of motion ◦ NWB 6 weeks, once union confirmed and
pain free range of motion- strengthening ◦ Full activity in 3 months
Benefits ◦ Faster union ◦ Improved functional outcomes ◦ Improved cosmesis ◦ Improved shoulder function strength
Risks ◦ Implant removal
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Clavicular fractures
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Clavicular fractures
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Clavicular fractures
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Clavicular fractures
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Scapular fractures Usually high energy mechanism Location ◦ Acromion ◦ Corocoid process ◦ Neck of scapula ◦ Body of scapula
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Scapular fractures
http://a248.e.akamai.net/7/248/432/20120426151227/www.msdlatinamerica.com/ebooks/ChapmansOrthopaedicSurgery/files/023489cd701b474692bcdaec6c52f9a8.gif
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Scapular fractures Non operative management ◦ 2 weeks sling, early motion
ORIF ◦ Glenohumeral instability >25% glenoid >5mm step-off Medialisation of glenoid ◦ Open fracture ◦ Scapula neck (>40 degrees, 1cm) ◦ Coracoid >1cm displacement
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Humerus fractures Location ◦ Proximal ◦ Shaft ◦ Distal
http://upload.wikimedia.org/wikipedia/commons/a/ad/Gray207.png
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Humerus fractures- proximal Non operative management ◦ Minimally displaced surgical neck (1,2,3) ◦ Greater tuberosity <5mm displacement ◦ Consideration for age, bone quality ◦ Early range of motion in 14 days
Operative management ◦ CRPP ◦ ORIF ◦ IM rod ◦ Hemi arthroplasty ◦ Total shoulder arthroplasty
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http://eorif.com/Shoulderarm/Images/proxhmcpp3.jpg
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http://www.eorif.com/Shoulderarm/Images/prxhmorif3.jpg
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http://www.tstsan.com/resimler/urun/b_Porx_Humerus_web2.jpg
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http://www.synthes.com/sites/NA/Products/Trauma/IntramedullaryNailingSystems/PublishingImages/MultiLoc_309.jpg
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http://www.eorthopod.com/images/ContentImages/shoulder/shoulder_humeral_head_osteonecrosis/humeral_head_osteonecrosis_hemiarthroplasty.jpg
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http://www.lima.it/repository/fck/image/Special%20edition%20usa%202012/protesi-smr-america.jpg
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http://www.orthop.washington.edu/orthodev/drupal/sites/default/files/Portals/21/LiveContent/8149/Images/figure6.jpg
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Humerus fractures- shaft Non operative management Splint then functional bracing ◦ <20 degrees anterior angulation ◦ <30 degrees varus/valgus angulation ◦ <3cm shortening
ORIF or IM nail ◦ Brachial plexus injury ◦ Open fracture ◦ Pathological fracture ◦ Spiral/oblique
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Humerus fractures- distal Supracondylar Single/double column fracture
Non operative ◦ Non displaced single column
Operative ◦ CRPP ◦ ORIF ◦ Total elbow arthroplasty
Risks ◦ Heterotropic ossification ◦ Joint stiffness ◦ Degenerative joint disease ◦ Cubital valgus/varus
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http://www.orthobullets.com/trauma/1017/distal-humerus-fract res
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http://images.radiopaedia.org/images/535540/fa226724fc4371512eda2a95de
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http://www.tornier-us.com/upper/elbow/elbrec001/images/latitude-back.jpg
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Olecranon fractures Non operative Non displaced fractures Immobilisation in 45-90 degrees of
flexion, for 3 weeks, then mobilise Operative TBW IM fixation Plate and screw fixation Fragment excision and triceps
advancement
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http://www.orthobullets.com/trauma/1022/olecranon-fractures
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http://www.orthobullets.com/trauma/1022/olecranon-fractures
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Monteggia fractures
http://www.orthobullets.com/trauma/1024/monteggia-fractures
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Monteggia fractures Non operative- closed reduction ◦ More common in children ◦ Casting with forearm supination
Operative- ORIF ulnar +/- open radial head reduction ◦ Comminuted ulna ◦ Unable to reduce radius
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Galeazzi fractures
http://www.orthobullets.com/trauma/1029/galeazzi-fractures
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http://www.orthobullets.com/trauma/1029/galeazzi-fractures
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Galeazzi fractures Operative all cases ◦ ORIF radius, stabilisation of DRUJ
DRUJ ◦ If stable- cast in supination 6 weeks ◦ Percutaneous pin fixation ◦ Open reduction- ECU ◦ ORIF ulnar styloid
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http://upload.orthobullets.com/topic/1029/images/galeazzi%20fracture%20orif.jpg
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http://a248.e.akamai.net/7/248/432/20120426191700/www.msdlatinamerica.com/ebooks/HandSurgery/files/ed13b53e950d1a4efdb3aef6853269cf.gif
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Forearm fractures Non operative
Distal 2/3 ulna (nightstick) <50% displacement, <10degrees
angulation ORIF
Proximal 1/3 ulnar All radial shaft fractures Both bone fractures
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http://fprmed.com/Medical/Ortho/Nightstick%20fx.jpg
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Distal radius fractures
http://img.medscape.com/pi/emed/ckb/radiology/336139-398406-7418.jpg
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Distal radius fractures
http://www.orthobullets.com/trauma/1027/distal-radius-fractures#4713
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Distal radius fractures
http://rad.desk.nl/images/thmb_477a59f6ebe6fTEK-Barton2x.jpg
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Distal radius fractures
http://www.orthobullets.com/trauma/1027/distal-radius-fractures#4713
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Distal radius fractures Non operative
Extraarticular <5mm shortening Dorsal angulation <5degrees**
Surgical fixation Displaced/intraarticular- >2mm step Comminution Loss of volar tilt and radial length after
casting >5mm shortening, >5 degrees dorsal
angulation**
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Summary Management plan for upper limb fractures
based on AO principles: Restoration of anatomy Stable fracture fixation Preservation of blood supply Early mobilisation of limb and patient
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Acknowledgements
◦ https://aotrauma.aofoundation.org Orthobullets ◦ http://www.orthobullets.com/
Wheeless’ Textbook of Orthopaedics ◦ http://www.wheelessonline.com/