Applied ER Ortho: Upper Limb Fractures “Tips and Tricks…”
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Transcript of Applied ER Ortho: Upper Limb Fractures “Tips and Tricks…”
Applied ER Ortho:Upper Limb Fractures
“Tips and Tricks…”
Matt Petrie
University of CalgaryAcademic Rounds September 26, 2009
Applied ER OrthoA whirlwind tour…
Introduction questions…
Today’s MenuToday’s MenuAppetizers: Appetizers: - OrthopedeseOrthopedese- ReductionsReductions
Main’s:Main’s: - WristWrist- ForearmForearm- Selected Carpal Selected Carpal
BonesBones- ElbowElbow- MetacarpalsMetacarpals- Phalanges/PhalanxPhalanges/Phalanx
SidesSides::- HumerusHumerus- Pediatric ElbowPediatric Elbow
DessertDessert: : - Elbow Dislocation Elbow Dislocation
PearlsPearls- Shoulder Shoulder
Dislocation PearlsDislocation Pearls
DISLAIMER:
‘A note on Eponym’s’
- May be helpful for pattern recognition or older surgeons
- Use anatomical terms
How to speak orthopedese
Case: Mrs. Colles
Describing Fractures: I ABCD2 O• I) Intro:
• A) Area• B) Bone• C) Character• D) Displacement (where)
• A) Angle/Apex• B) Bone Length• C) Closed• D) Dysfunction
• O) Other injuries/info
• 56yo RHD female pianist
• Right, Distal• Radius• Comminuted• 20% displaced (radial)
– And which fragment
• 30 degrees, apex volar• Shortened (1cm)• Closed• Neurovascular status• Ulnar styloid fracture• Surgical pertinent facts
– Rotation– Intra-articular: gap/step– Mortise, DRUJ, etc.
Describing Fractures: Mrs. Colles
Description Please?
General Management Principles• Analgesia
• Evaluation
• Anesthesia
• Reduction
• Immobilization
• Instruction
• Disposition/Referral
*Note: Anesthesia ≠ Analgesia
General GuidelinesAcceptable angulation of Fractures:
-Adults: 10 degrees
-Pedes: 30 degrees
-Exceptions: 4th, 5th MC
Immobilization Time: 6-8 weeks
-Exceptions: Tibia, Scaphoid, Elderly
Choice of Material:
-Displaced/Reduced: plaster
-Undisplaced: dealer’s choice
General Guidelines
Fractures that don’t need ortho
(but still need follow up)
- non-displaced buckle fracture (non salter harris)
- Minimally displaced phalangeal/phalanx
- Small avulsion fractures (most)
- Minimally displaced clavicle fracture
- Distal phalanx
General Guidelines• Fractures which require a phone call
– *Open*– Neurovascular compromise (esp. post reduction)*– Intra-articular with step/gap of >1mm– All Salter Harris II and up– Angulation >10 deg in adults
• 30 deg. In pedes (post reduction)
– > 50% Displaced long bone fracture• Midshaft forearm, humerus
General GuidelinesFractures which require a phone call: continued– ++ comminuted fractures– All fracture dislocations– Unstable fractures
Fracture ReductionPrinciples:
- Think about the mechanism
- Adequate analgesia
- Prolonged traction (muscle tension)
- Accentuate deformity
- Correct deformity
- Maintain traction
- Splint/Cast to correct deformity- Three point molding
Analgesia and Treatment?Reduction Technique?
Casting position?
Distal Radius Fracture PrinciplesA) Length (wrt ulna) B) Volar Tilt Angle
Wrist Normals
Radial Inclincation: 23 deg.
Volar Tilt:
Volar Angle: 11 deg.
90Normal:11 degrees
11
Type of Fracture?
Barton: Subluxation of Carpus
Smith: Flexion FOOSH
Type/Name of Fracture?Monteggia
Type/Name of Fracture?Both Bones Forearm Fracture
- Management?- Reduction as necessary (+- fluoro)- Cast?
Type/Name of Fracture?• Galleazzi
• MUGR
• Monteggia: ulna #
• Galleazzi: Radial #
Diagnosis?Scapho-lunate dissociation, and?
- 1-2mm normal, >3mm abnormal
Don’t miss this one…• Peri-lunate dislocation
Your Honour…
Lunate Dislocation
• Perilunate
• Lunate:
Diagnosis?
Scaphoid- Snuffbox tenderness- Blood supply distal to proximal- Zones: waist- Risk of AVN- Prolonged casting: SPICA- 10 days x-ray vs bone scan
MRI/CT
Mid-shaft humerus Fracture90 y.o. female
Management?
40 y.o. male hockey player
Management?
Sugar Tong Splint, ClinicReduction, ST splint, OR
Management?75 y.o. female 14 yo Male
Elbow:• Xray Pearls
• Injury/Fracture Patterns
Elbow: The Lateral is KeyNormal Ant./Post. Fat pad
Elbow: The Lateral is Key
Elbow: The Lateral is KeyRadiocapitellar Line (Dot on the i)
Anterior Humeral Line
Middle 1/3 Capitellum
Elbow: Lateral
Monteggia #
Supracondylar Fracture: Type 1
Supracondylar FracturesType I: minimal/no displacement conservative
Type II: Posterior cortex intact ortho/ORIF
Type III: No cortical contact ORIF
II III
** Beware neurovascular compromise
Adult: Intercondylar Usually ‘T’ type
- Splint: 3 sided*
- Ortho referral
Elbow: ContinuedDiagnosis: Olecranon Fracture
Mechanism: Forced extension in flexion, +- blow
Management: ORIF
Elbow:Radial Head Fracture
- Minimal displacement (<1mm):- Sling, ROM, Fracture Clinic (arm immobilizer)
Metacarpal FracturesReduction and treatment?
Metacarpal FracturesReduction:- Hematoma block or regional technique- MCP and PIP at 90 degrees- ‘upward pressure’ on middle phalange- Traction- Pressure on dorsal aspect of fractureTreatment:- Volar or ulnar splint- In ‘safe’ position- Refer to hand/plastics
Metacarpal FracturesGuidelines: ( i.e. ok for clinic f/u)
Metacarpal Shaft:
- Length: < 5mm shortening
- Rotation: minimal
- *No scissoring
- *No weakness
- Angulation:- 10 degrees at 2nd and 3rd - 20 degrees at 4th
- 30 degrees at 5th
Metacarpal FracturesNeck Fractures:- Tolerate greater angulation- Up to 40 degrees for 4th
and 5th (volar)- Jahss maneuver - Gutter/Volar in safe position- Clinic F/U
Metacarpal FracturesMetacarpal Head Fractures:
- Surgery if >25% articular surface
- > 1mm displacement at joint surface
- Otherwise: splint and refer
Metacarpal FracturesMetacarpal Base Fractures:
- Less tolerance for angulation/displacement- Less able to accommodate at CMC
- 4th and 5th tend to be unstable
- Reduce, splint, refer
Metacarpal Fracture:Fracture?
Bennet Fracture
- Fracture dislocation CMC
- Unstable: Ad.P.Longus
- Intra-articular
- Reduce, spica, call
- Needs surgery if large
fragment
Metacarpal Fracture:Same thing?
Rolando’s Fracture
- 3 part intra-articular
- Comminuted
- Similar to Bennet
- Needs ORIF
Phalanx FracturesDistal Phalanx: stable, good reduction
- Splint and follow up
Proximal Phalanx: reduce, splint
-usually ORIF transverse/unstable
- splint hand and wrist
Middle Phalanx: Variable
Intra-Articular: > 20% Splint and ORIF
Condylar, Fracture/dislocation, Spiral = ORIF
Phalange Fractures
Phalanges ContinuedSame Fracture?
Same Treatment?A) Consideration for ORIF (>20% articular surface)
B) Avulsion of distal extensor attachment: Mallet Finger: splint
A B
Same Again?• Dorsal extension splint, followed by buddy tape
DiagnosisOuch!
Structures?.
Elbow ReductionReduction?
1. Parvin Method
- Pt. supine, arm at 90
- Humerus on table with pad
- Traction to pronated hand/wrist
2. Traction/Counter-traction
- Elbow at 90, traction to humerus (prox/post.)
- Traction to forearm
Elbow DislocationTreatment:
- Test and document stability/laxity post reduction
- Splint at 90 degrees
- Refer to Ortho/hand and upper limb
- Physio at 2-3 weeks
Additional Topics:• Proximal humerus fractures
• Shoulder Dislocation
• CRITOE
Questions?
References• www.nysora.com
• www.acep.org
• www.emedicine.com
• Wheeless’ textbook of orthopedics
• www.aafp.com
What view?• Identify the structures please
• Axillary view
Shoulder dislocation and reduction
What is going on here?• Hint?
luxatio erecta
Post reduction film• What is the arrow pointing at?
Hill Sach’s Lesion
What is this?• How did it happen?
Bony Bankart
Anterior Shoulder reductionMechanism?
- External rotation, abduction
Reduction?
1. Stimson: prone, weights on arm
2. Traction/Countertraction
Shoulder Reduction• Traction Counter Traction
– Sheet around both participants
Shoulder Reduction• Spaso technique
• Supine
• Slow flexion to 90 deg.
• Traction
• External rotation at 90 deg.
• * 80% first time reduction
by residents
Shoulder Reduction*Kocher Method:
- Traction
- External rotation
- *Abduction
- Internal rotation as finish
Shoulder ReductionScapular Rotation:
- Prone
- Traction/weight to arm
- Tip of scapula medial
- Superior aspect lateral
- Trying to move glenoid
to humeral head
- Atraumatic: successful
in experienced hands
Shoulder ReductionExternal Rotation:
- Verbal anesthesia
- Elbow at 90 deg.
- SLOW external rotation
- + - abduction
Dislocation Treatment• No consensus on immobilisation
• Standard is sling for 2-3 weeks with pendulum/elbow ROM
• No evidence to show it makes a difference
• Must delay return to sport/activity
• New small (n=40) trial of splinting in external rotation (not definitive)– Itoi et al. , 2003, J Shoulder Elbow Surg– Decreased rate of dislocation, no other differences
Dislocation Treatment• Evidence in US and Canada to show early
surgical intervention decreases re-dislocation rate in young patients
• Consider early ortho referral for this subgroup
• Cochrane Review
Diagnosis?
Diagnosis?
Diagnosis?
Normal
Diagnosis?
Diagnosis?• Posterior shoulder Disloc.
• Rim sign: <6mm jt. Space
• Light bulb/Ice cream cone– Internal rotation– Need axillary or scapular
Diagnosis
Reduction: Posterior DislocationMechanism?
- Internal rotation and adduction
Reduction:
• Prolonged traction
• ? Lateral traction
• Anterior pressure on humeral head (gentle)
• Gentle, mild external rotation
Pitfall… Don’t miss this
Lisfranc Fracture Normal
LisFranc Fracture• Dr. LisFranc in Napolean’s army
– Quick amputation through the joint
• Fracture dislocation at TMT• Hyperflexion +- vertical loading +- torsion• Hints: large, swollen, bruised foot• Fall from height• Car accident, Stirrup fall• Look at alignment• Look for small fractures at base of MT’s• If in doubt CT
Pitfall… Don’t miss this– Lateral margin of the 1st metatarsal lines up with the lateral
margin of the medial cuneiform. – Medial margin of the base of the 2nd metatarsal lines up with the
medial margin of the lateral cuneiform
- Medial margin of the base of the 3rd metatarsal lines up with the medial margin of the lateral cuneiform.
– Lateral margin of the base of the 3rd metatarsal lines up with the lateral margin of the lateral cuneiform.
– Medial border of the 4th metatarsal and medial border of the cuboid should line up as well (may be 2-3mm offset).
– 4th and 5th metatarsals articulate with the cuboid. – The line of the metatarsals and phalanges should be straight.