Describing Fractures: I ABCD 2 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.
General Guidelines Acceptable angulation of Fractures: -Adults: 10 degrees -Pedes: 30 degrees -Exceptions: 4 th, 5 th 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 Guidelines Fractures which require a phone call: continued –++ comminuted fractures –All fracture dislocations –Unstable fractures
Fracture Reduction Principles: -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?
Metacarpal Fractures Reduction: -Hematoma block or regional technique -MCP and PIP at 90 degrees -‘upward pressure’ on middle phalange -Traction -Pressure on dorsal aspect of fracture Treatment: -Volar or ulnar splint -In ‘safe’ position -Refer to hand/plastics
Metacarpal Fractures Guidelines: ( i.e. ok for clinic f/u) Metacarpal Shaft: -Length: < 5mm shortening -Rotation: minimal -*No scissoring -*No weakness -Angulation: -10 degrees at 2 nd and 3 rd -20 degrees at 4 th -30 degrees at 5th
Metacarpal Fractures Neck Fractures: -Tolerate greater angulation -Up to 40 degrees for 4 th and 5 th (volar) -Jahss maneuver -Gutter/Volar in safe position -Clinic F/U
Metacarpal Fractures Metacarpal Head Fractures: -Surgery if >25% articular surface -> 1mm displacement at joint surface -Otherwise: splint and refer
Metacarpal Fractures Metacarpal Base Fractures: -Less tolerance for angulation/displacement -Less able to accommodate at CMC -4 th and 5 th 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 Fractures Distal 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
Elbow Reduction Reduction? 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 Dislocation Treatment: -Test and document stability/laxity post reduction -Splint at 90 degrees -Refer to Ortho/hand and upper limb -Physio at 2-3 weeks
Shoulder Reduction Scapular 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
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
Reduction: Posterior Dislocation Mechanism? - 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.
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