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Applied ER Ortho: Upper Limb Fractures “Tips and Tricks…” Matt Petrie University of Calgary Academic Rounds September 26, 2009.

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Presentation on theme: "Applied ER Ortho: Upper Limb Fractures “Tips and Tricks…” Matt Petrie University of Calgary Academic Rounds September 26, 2009."— Presentation transcript:

1 Applied ER Ortho: Upper Limb Fractures “Tips and Tricks…” Matt Petrie University of Calgary Academic Rounds September 26, 2009

2 Applied ER Ortho A whirlwind tour… Introduction questions…

3 Today’s Menu Appetizers: -Orthopedese -Reductions Main’s: -Wrist -Forearm -Selected Carpal Bones -Elbow -Metacarpals -Phalanges/Phalanx Sides: -Humerus -Pediatric Elbow Dessert: -Elbow Dislocation Pearls -Shoulder Dislocation Pearls

4 DISLAIMER: ‘A note on Eponym’s’ -May be helpful for pattern recognition or older surgeons -Use anatomical terms

5 How to speak orthopedese

6 Case: Mrs. Colles

7 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.

8 Describing Fractures: Mrs. Colles

9 Description Please?

10 General Management Principles Analgesia Evaluation Anesthesia Reduction Immobilization Instruction Disposition/Referral *Note: Anesthesia ≠ Analgesia

11 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

12 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

13 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

14 General Guidelines Fractures which require a phone call: continued –++ comminuted fractures –All fracture dislocations –Unstable fractures

15 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

16 Analgesia and Treatment? Reduction Technique? Casting position?

17 Distal Radius Fracture Principles A) Length (wrt ulna)B) Volar Tilt Angle

18 Wrist Normals

19 Radial Inclincation: 23 deg.

20 Volar Tilt:

21 Volar Angle: 11 deg. 90 Normal:11 degrees 11

22 Type of Fracture?

23 Barton: Subluxation of Carpus

24 Smith: Flexion FOOSH

25 Type/Name of Fracture? Monteggia

26 Type/Name of Fracture? Both Bones Forearm Fracture -Management? -Reduction as necessary (+- fluoro) -Cast?

27 Type/Name of Fracture? Galleazzi MUGR Monteggia: ulna # Galleazzi: Radial #

28 Diagnosis? Scapho-lunate dissociation, and? - 1-2mm normal, >3mm abnormal

29 Don’t miss this one… Peri-lunate dislocation

30

31 Your Honour…

32 Lunate Dislocation

33 Perilunate Lunate:

34 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

35 Mid-shaft humerus Fracture 90 y.o. female Management? 40 y.o. male hockey player Management? Sugar Tong Splint, Clinic Reduction, ST splint, OR

36 Management? 75 y.o. female 14 yo Male

37 Elbow: Xray Pearls Injury/Fracture Patterns

38 Elbow: The Lateral is Key NormalAnt./Post. Fat pad

39 Elbow: The Lateral is Key

40 Radiocapitellar Line (Dot on the i) Anterior Humeral Line Middle 1/3 Capitellum

41 Elbow: Lateral Monteggia #

42 Supracondylar Fracture: Type 1

43 Supracondylar Fractures Type I: minimal/no displacement  conservative Type II: Posterior cortex intact  ortho/ORIF Type III: No cortical contact  ORIF IIIII ** Beware neurovascular compromise

44 Adult: Intercondylar Usually ‘T’ type -Splint: 3 sided* -Ortho referral

45 Elbow: Continued Diagnosis: Olecranon Fracture Mechanism: Forced extension in flexion, +- blow Management: ORIF

46 Elbow: Radial Head Fracture -Minimal displacement (<1mm): -Sling, ROM, Fracture Clinic (arm immobilizer)

47 Metacarpal Fractures Reduction and treatment?

48 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

49 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

50 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

51 Metacarpal Fractures Metacarpal Head Fractures: -Surgery if >25% articular surface -> 1mm displacement at joint surface -Otherwise: splint and refer

52 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

53 Metacarpal Fracture: Fracture? Bennet Fracture -Fracture dislocation CMC -Unstable: Ad.P.Longus -Intra-articular -Reduce, spica, call -Needs surgery if large fragment

54 Metacarpal Fracture: Same thing? Rolando’s Fracture -3 part intra-articular -Comminuted -Similar to Bennet -Needs ORIF

55 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

56 Phalange Fractures

57 Phalanges Continued Same Fracture? Same Treatment? A)Consideration for ORIF (>20% articular surface) B)Avulsion of distal extensor attachment: Mallet Finger: splint A B

58 Same Again? Dorsal extension splint, followed by buddy tape

59 Diagnosis Ouch! Structures?.

60 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

61 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

62 Additional Topics: Proximal humerus fractures Shoulder Dislocation CRITOE

63 Questions?

64 References www.nysora.com www.acep.org www.emedicine.com Wheeless’ textbook of orthopedics www.aafp.com

65 What view? Identify the structures please

66 Axillary view

67

68 Shoulder dislocation and reduction

69 What is going on here? Hint? luxatio erecta

70 Post reduction film What is the arrow pointing at? Hill Sach’s Lesion

71 What is this? How did it happen? Bony Bankart

72 Anterior Shoulder reduction Mechanism? -External rotation, abduction Reduction? 1.Stimson: prone, weights on arm 2.Traction/Countertraction

73 Shoulder Reduction Traction Counter Traction –Sheet around both participants

74 Shoulder Reduction Spaso technique Supine Slow flexion to 90 deg. Traction External rotation at 90 deg. * 80% first time reduction by residents

75 Shoulder Reduction *Kocher Method: -Traction -External rotation -*Abduction -Internal rotation as finish

76 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

77 Shoulder Reduction External Rotation: -Verbal anesthesia -Elbow at 90 deg. -SLOW external rotation -+ - abduction

78 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

79 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

80 Diagnosis?

81

82 Normal

83 Diagnosis?

84 Posterior shoulder Disloc. Rim sign: <6mm jt. Space Light bulb/Ice cream cone –Internal rotation –Need axillary or scapular

85 Diagnosis

86 Reduction: Posterior Dislocation Mechanism? - Internal rotation and adduction Reduction: Prolonged traction ? Lateral traction Anterior pressure on humeral head (gentle) Gentle, mild external rotation

87 Pitfall… Don’t miss this Lisfranc Fracture Normal

88 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

89 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

90 - 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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