2Sesamoid bone, found on the palmar surface. Found within the flexor pollicis brevis tendons at the MCP. Constant in position.DPMPBiconcave with a median ridgePPConcave articular surfaceCancellous boneMCCMC joint Saddle type joint (limited movement)Carpals
4Common Fracture sitesFractures of the Phalanges are more common than the metacarpalsFractures of the distal phalanx account for over 50% of all phalangeal fracturesFractures of the middle phalanx are least common, 9-12%
5Common Fracture sitesCrush, vary from sever to marginal chip fracturesTransverseSpiralAvulsionOblique
6Transverse and Longitudinal fractures are less common. Result of a direct blowDPMarginal Chip fracture2nd MC1st
7Avulsion of the Flexor Digitorum Profundus Tendon MOI:Flexed finger being forcefully extendedE.g. pulling at some ones garment whilst they are pulling away.Physical signs : inability to Flex finger at the DIPThe tendon retracts proximally to the level of the PIPWith an occasional avulsion fracture at the DIPA small fracture fragment lying over the volar aspect at the PIP may be seen.The fragment should not be confused with a fracture of base of the middle phalanx.DIPPIP
8Bones, Cartilage , Swelling. Joint spaces Which joint ? History--22-year-old male who comes to the A&E after being injured in a basket ball game. Swelling and deformity to the left index fingerAdequacy, Alignment,Bones, Cartilage , Swelling.Joint spacesWhich joint ?What type of # ?Where – Dorsal / Volar ?LT. Index
9Diagnosis—Intra-articular, avulsion # on dorsal aspect of DIP, at the site of extensor tendon insertion.MOI This injury is due to flexion of a forcibly extended finger, which therefore results in either a tendon injury or a dorsal intra articular avulsion fracture at the dorsal aspect of the distal phalanx.Mallet FingerOr Baseball fingerForced Flexion
10Hyperextension at DIPFlexion at PIPDiagnosis--Avulsion fracture on dorsal aspect ,At the base of the PIP joint
11What is this deformity called ? DIPWhat is this deformity called ?PIPBoutonniere injury and deformity. (Button hole)Flexed PIPExtended DIPForced flexion
12Struck a wall with fist. Where is the fracture ? Boxers fracture
13History--30-year-old female injured while skiing History--30-year-old female injured while skiing. Swelling and point tenderness over the MC joint.film2URfilm1Findings--Films 1 and 2 represent a stress view of the left thumb with the normal right thumb also stressed for comparison. There is subluxation of the MCP of the left when compared to the right. There is no evidence of fracture. Diagnosis?
14The ulnar collateral ligament injury is due to a valgus stress The ulnar collateral ligament injury is due to a valgus stress. If there is an intraarticular avulsion fracture fragment at the base of the proximal phalanx of the thumb on its ulnar side, the diagnosis is easy.If you do not see such a fracture fragment, stress views may be required to make the diagnosis. Should be compared with the opposite normal side.PoleHyperabduction
15Described in 1881 by Dr. Edward Bennett; An oblique, intra-articular # at base of the 1st MC (thumb). The fracture extends into the CMC joint with a dorsal subluxation.Due to forced abductionUnstable # pulled by Abductor Pollicis Longus Tendon, in a radial and dorsal directionA small triangular fracture fragment on the volar lip of the base of the MC. This anchored in position by the anterior oblique ligament attached to the volar tubercle of the trapezium.Prior to the advent of radiography.
16Rolando`s Fracture: 1910.A comminuted fracture at the base of the 1st MC, asscociated with dorsal subluxation.Less common than BennettsT or Y typeORIF
17CarpusHighly complex arrangement of bones and ligaments to allow an infinite variety of movementsDuring injury stresses are focused on certain sites which lend to the predictability of the site of fracture
19Mechanism of injury Generally a variation of “foosh” Injury depends on many variables –Flexion, extension, rotation, deviation etc.Results in force focused between radial styloid & capitate across the scaphoidProximal row tightly bound to the radius
20Frequency of Carpal # Carpal injuries rare in under 12yrs 70%-80%Scaphoid10% dorsal chip # usually Triquetrium10% others
23Scaphoid # 15 – 40 yr of age (rare in children & 60+) 70% waist 20% proximal pole10% distal poleThe scaphoid occupies a vulnerable position, bridging between both rows.With dorsi flexion of hand an wrist, producess greater stresss at the waist of the scaphoid.
24Fractures of the distal pole result from compressive forces tansmitted by the index finger and thumb,through the trapezium and trapezoid bones70 to 80%
25Physical ExaminationTenderness directly over the scaphoid which lies directly under the anatomical snuff box. There is often swelling in the wrist, and pain with range of motion. Particularly on ulna deviation or making a fist.Tenderness over the ASB is not a specific sign of a scaphoid fracture. 40% with tenderness at this site prove NOT to have a fracture.
27The scaphoid has a very poor blood supply The scaphoid has a very poor blood supply. It receives its blood supply from the radial artery primarily via lateral volar , dorsal and distal branches. Thus, in one third of waist (mid) fractures, there is diminished blood supply to the proximal fracture fragment This may produce a non-union and lead avascular necrosis .AVNFractures at each site has specific rates of healing relating to the blood supply of the scaphoid bone
302nd most common site amongst the carpal bones Fractured Triquetrum2nd most common site amongst the carpal bonesThe most common site is a fracture on the dorsal surface of the Triquetral bone.A fractured is generally only seen on the lateral wrist image, always check your laterals for this appearance.This is quite a common fracture.Dorsal radio-triquetral ligament avulsion fracture
31Pisiform : acts like a sesamoid bone and lies within the Flexor carpi ulnaris tendon Lateral with 20 degree supination< 1% of carpal bone fractures
32Trapezium Accounts for 3-5 % of the carpal fractures. Located between the base of the thumb, distal surface of the scaphoid and lateral border of the trapezoidMOI; Abduction of the thumb results in a compression of the radial margin of the trapezium
33Fractures - hook of the hamate may be sustained in a fall, more often occurs in sports such as tennis, baseball, and golf, in which a handle sharply impacts the proximal hypothenar palm. Patients who participate in racket sports and present with chronic hand and wrist pain should be suspected of this type of fracture.
40Note the overlapping of the proximal and distal carpal rows in addition to the pyramidal appearance of the lunate. Disruption of Gilulas arcs
41Peri-lunate Dislocation The lunate remains in it’s normal position but the capitate and neighbouring carpal bones are now out of position.This injury is 2 – 3 times more common than a lunate dislocation and is associated with a Scaphoid fracture 75% of the time.
42This injury also has a high incidence of associated scaphoid fracture. Mid Carpal dislocationBoth the Lunate AND Capitate are dislocate. This is known as a midcarpal dislocationThis injury also has a high incidence of associated scaphoid fracture.CLCLRR
45Abraham Colles` in 1814 Most common fractures of the forearm. Age group-adult group over age 40.More common in females than in males owing to the higher incidence of osteoporosis in women.9% of proximal humerus also have colles #8% of hip # also have colles #
46Mechanism “foosh” compression & tension MOI-- FooshMechanism “foosh” compression & tensionCompression results in comminution of the dorsal surfaceDorsal displacement of # fragment+/- ulna styloid # 60% ( ligamentus traction)70% intra-articular, 30% extra articularDisruption of distal radioulnar joint 35%
48Smith’s # Oposite of Colles - “Reverse Colles” Volar displacement Fall onto back of hand – wrist supinatedDiagnosis on Lateral X-ray
49If treated and reduced as a Colles the deformity is maintained Smith`s fractureIf treated and reduced as a Colles the deformity is maintained
50John Barton1838, American surgeon- a fracture of the distal end of the radius involving the dorsal rim, with intra-articular extension of the fracture. This injury results from dorsiflexion and pronation of the forearm. Radiographically the fracture is sometimes difficult to distinguish from Colles` fracture, but lateral films show that Barton's fracture does not violate the volar surface of the radius.
51Pronator fat pad sign:- Displaced pronator fat pad. The ventral bulging of the fat overlying the pronator quadratus muscle (PQM) has been coined the "pronator sign." Although it typically means an underlying fracture is present, it may also be seen in simple soft-tissue injury of the same region.PQMNormalAbnormal
53Monteggia #Fractured of the proximal Ulna and dislocation of radial headDirect blow of great force to the forearm(night stick injury)
54# UlnaDisloc- radial headIsolated ulnar fractures are unusual, one should also search for a fracture or dislocations.The general rule suggesting that if both bones of the forearm are not fractured, a dislocation should be sought.
55The other forearm fracture dislocation pattern involves a fracture of the radius with a dislocation of the distal radial ulnar joint (RUJ), termed a fracture dislocation.GalleazziRadiusDislocation of the RUJ