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Lower Extremity Trauma
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Lower Extremity Trauma
Hip Fractures / Dislocations Femur Fractures Patella Fractures Knee Dislocations Tibia Fractures Ankle Fractures Foot Fracture
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Hip Fractures Hip Dislocations Femoral Head Fractures
Femoral Neck Fractures Intertrochanteric Fractures Subtrochanteric Fractures
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Hip Dislocations Significant trauma, usually MVA
Posterior: Hip flexion, IR, Add Anterior: Extreme ER, Abd/Flex
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Anatomic classification
posterior dislocation (90%) occur with axial load on femur, typically with hip flexed and adducted axial load through flexed knee (dashboard injury) associated with osteonecrosis posterior wall acetabular fracture femoral head fractures sciatic nerve injuries ipsilateral knee injuries (up to 25%) anterior dislocation associated with femoral head impaction or chondral injury occurs with the hip in abduction and external rotation
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Anterior Dislocation 7-10% of hip dislocations Mechanism:
Forced abduction with external rotation of hip. Anterior hip capsule is torn or avulsed. Femoral head is levered out anteriorly.
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Epstein Classification of Anterior Hip Dislocations
Type I Superior (pubic and subspinous) Type II Inferior (obturator and perineal) A No associated fracture B Associated fracture of the femoral head/neck C Associated fracture of the acetabulum
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Thompson and Epstein Classification of Hip Dislocations
Type I Pure dislocation with at most a small posterior wall Type II Dislocation with large posterior wall Type III Dislocation with comminuted posterior wall Type IV Dislocation with “acetabular floor” fracture Type V Dislocation with femoral head fracture
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Hip Dislocations Emergent Treatment: Closed Reduction
Dislocated hip is an emergency Goal is to reduce risk of AVN and DJD Allows restoration of flow through occluded or compressed vessels Literature supports decreased AVN with earlier reduction Requires proper anesthesia Requires “team” (i.e. more than one person)
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Hip Dislocations Emergent Treatment: Closed Reduction
General anesthesia with muscle relaxation facilitates reduction, but is not necessary Conscious sedation is acceptable Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make subsequent attempts at reduction more difficult
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Hip Dislocations Emergent Treatment: Closed Reduction Allis Maneuver
Assistant stabilizes pelvis with pressure on ASIS Surgeon stands on stretcher and gently flexes hip to 90deg, applies progressively increasing traction to the extremity with gentle adduction and internal rotation Reduction can often be seen and felt Insert hip Reduction Picture
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Hip Dislocations Following Closed Reduction
Check stability of hip to 90deg flexion Repeat AP pelvis Judet views of pelvis (if acetabulum fx) CT scan with thin cuts through acetabulum R/O bony fragments within hip joint (indication for emergent OR trip to remove incarcerated fragment of bone)
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Hip Dislocations Following Closed Reduction
No flexion > 60deg (Hip Precautions) Early mobilization with P.W.B. for 4-6 weeks MRI at 3 months (follow risk of AVN)
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Complications Post-traumatic arthritis
up to 20% for simple dislocation, markedly increased for complex dislocation Femoral head osteonecrosis 5-40% incidence Increased risk with increased time to reduction Sciatic nerve injury 8-20% incidence associated with longer time to reduction Recurrent dislocations less than 2%
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Femoral Head Fractures
Concurrent with hip dislocation due to shear injury
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Femoral Head Fractures
Pipkin Classification I: Fracture inferior to fovea II: Fracture superior to fovea III: Femoral head + acetabulum fracture IV: Femoral head + femoral neck fracture
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Femoral Head Fractures
Treatment Options Type I Nonoperative: non-displaced ORIF if displaced Type II: ORIF Type III: ORIF of both fractures Type IV: ORIF vs. hemiarthroplasty
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Epidemiology 250,000 Hip fractures annually At risk populations
Expected to double by 2050 At risk populations Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition Young: high energy trauma
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Femoral Neck Fractures
Garden Classification I Valgus impacted II Non-displaced III Complete: Partially Displaced IV Complete: Fully Displaced Functional Classification Stable (I/II) Unstable (III/IV) I II III IV
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Femoral Neck Fractures
Treatment Options Operative ORIF Hemiarthroplasty (Endoprosthesis) Total Hip Replacement
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Femoral Neck Fractures
Young Patients Urgent ORIF (<6hrs) Elderly Patients ORIF possible (higher risk AVN, non-union, and failure of fixation) Hemiarthroplasty Total Hip Replacement
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Hemi ORIF THR
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Intertrochanteric Hip Fx
Intertrochanteric Femur Fracture Extra-capsular femoral neck To inferior border of the lesser trochanter
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Intertrochanteric Hip Fx
Intertrochanteric Femur Fracture Physical Findings: Shortened / ER Posture Obtain Xrays: AP Pelvis, Cross table lateral
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Intertrochanteric Hip Fx
Classification # of parts: Head/Neck, GT, LT, Shaft Stable Resists medial & compressive Loads after fixation Unstable Collapses into varus or shaft medializes despite anatomic reduction with fixation Reverse Obliquity
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Intertrochanteric Hip Fx
Reverse Obliquity Stable Unstable
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Intertrochanteric Hip Fx
Treatment Options Stable: Dynamic Hip Screw Unstable/Reverse: IM Recon Nail
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Subtrochanteric Femur Fx
Classification Located from LT to 5cm distal into shaft Intact Piriformis Fossa? Treatment IM Nail Cephalomedullary IM Nail ORIF
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Femoral Shaft Fx Winquist
Type 0 - No comminution Type 1 - Insignificant butterfly fragment with transverse or short oblique fracture Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex intact Type 3 - Larger butterfly leaving less than 50% of the cortex in contact Type 4 - Segmental comminution
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Femoral Shaft Fx Treatment Options IM Nail with locking screws
ORIF with plate/screw construct External fixation Consider traction pin if prolonged delay to surgery
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Distal Femur Fractures
Distal Metaphyseal Fractures Look for intra-articular involvement Plain films CT
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Distal Femur Fractures
Treatment: Retrograde IM Nail ORIF open vs. MIPO Above depends on fracture type, bone quality, and fracture location
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Knee Dislocations High association of injuries Ligamentous Injury
ACL, PCL, Posterolateral Corner LCL, MCL Vascular Injury Intimal tear vs. Disruption Obtain ABI’s (+) Arteriogram Vascular surgery consult with repair within 8hrs Peroneal >> Tibial N. injury
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KNEE DISLOCATION Devastating injury resulting from high or low energyhigh-energy usually from MVC or fall from height commonly a dashboard injury resulting in axial load to flexed knee low-energy often from athletic injury generally has a rotational component morbid obesity is a risk-facto
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Associated Injuries vascular injury 5-15% in all dislocations
40-50% in anterior/posterior dislocations due to tethering at the politeal fossa proximal - fibrous tunnel at the adductor hiatus distal - fibrous tunnel at soleus muscle nerve injury usually common peroneal nerve injury (25%) tibial nerve injury is less common fractures present in 60% tibia and femur most common
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Classification Anterior most common type of dislocation (30-50%)
due to hyperextension injury arterial injury is generally an intimal tear due to traction posterior 2nd most common type (25%) highest rate of complete tear of popliteal artery lateral 13% of knee dislocations due to varus or valgus force highest rate of peroneal nerve injury Medial rotational
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Schenck Classification
KD I Multiligamentous injury with involvement of ACL or PCL KD II Injury to ACL and PCL only (2 ligaments) KD III Injury to ACL, PCL, and PMC or PLC (3 ligaments) KD IV Injury to ACL, PCL, PMC, and PLC (4 ligaments) KD V Multiligamentous injury with periarticular fracture
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vascular exam Rule out vascular injury on exam both before and after reduction palpate the dorsalis pedis and posterior tibial pulses if pulses are present and normal measure Ankle-Brachial Index (ABI) if ABI >0.9 then monitor with serial examination (100% Negative Predictive Value) if ABI <0.9 perform arterial duplex ultrasound or CT angiography if arterial injury confirmed then consult vascular surgery If pulses are absent or diminished confirm that the knee joint is reduced or perform immediate reduction and reassessment immediate surgical exploration if pulses are still absent following reduction ischemia time >8 hours has amputation rates as high as 86% if pulses present after reduction angiography
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Initial Treatment reduce knee and re-examine vascular status
considered an orthopedic emergency splint knee in degrees of flexion confirm reduction is held with repeat radiographs in brace/splint vascular consult indicated if
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Complications Stiffness (arthrofibrosis)
is most common complication (38%) more common with delayed mobilization Laxity and instability (37%) Peroneal nerve injury (25%) most common in posterolateral dislocations Vascular compromise in addition to vessel damage, claudication, skin changes, and muscle atrophy can occur
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Patella Fractures History Physical Exam
MVA, fall onto knee, eccentric loading Physical Exam Ability to perform straight leg raise against gravity (ie, extensor mechanism still intact?) Pain, swelling, contusions, lacerations and/or abrasions at the site of injury Palpable defect
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Patella Fractures Radiographs Treatment AP/Lateral/Sunrise views
ORIF if ext mechanism is incompetent Non-operative treatment with brace if ext mechanism remains intact
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Tibia Fractures Proximal Tibia Fractures (Tibial Plateau)
Tibial Shaft Fractures Distal Tibia Fractures (Tibial Pilon/Plafond)
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Tibial Plateau Fractures
MVA, fall from height, sporting injuries Mechanism and energy of injury plays a major role in determining orthopedic care Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with medial plateau injuries) Be aware for compartment syndrome Check for knee ligamentous instability
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Tibial Plateau Fractures
Xrays: AP/Lateral +/- traction films CT scan (after ex-fix if appropriate)
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Schatzker Classification of Plateau Fxs
Lower Energy Higher Energy
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Tibial Plateau Fractures
Treatment Definitive ORIF for patients with varus/valgus instability, >5mm articular stepoff Non-operative in non-displaced stable fractures or patients with poor surgical risks
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Tibial Plateau Fractures
Treatment Spanning External Fixator may be appropriate for temporary stabilization and to allow for resolution of soft tissue injuries Insert blister Pics of ex-fix here
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Tibial Shaft Fractures
Mechanism of Injury Can occur in lower energy, torsion type injury (e.g., skiing) More common with higher energy direct force (e.g., car bumper) Open fractures of the tibia are more common than in any other long bone
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Tibial Shaft Fractures
Open Tibia Fx Priorities ABC’S Associated Injuries Tetanus Antibiotics Fixation
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Tibial Shaft Fractures
Gustilo and Anderson Classification of Open Fx Grade 1 <1cm, minimal muscle contusion, usually inside out mechanism Grade 2 1-10cm, extensive soft tissue damage Grade 3 3a: >10cm, adequate bone coverage 3b: >10cm, periosteal stripping requiring flap advancement or free flap 3c: vascular injury requiring repair
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Tibial Shaft Fractures
Management of Open Fx Soft Tissues ER: initial evaluation wound covered with sterile dressing and leg splinted, tetanus prophylaxis and appropriate antibiotics OR: Thorough I&D undertaken within 6 hours with serial debridements as warranted followed by definitive soft tissue cover
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Tibial Shaft Fractures
Definitive Soft Tissue Coverage Proximal third tibia fractures can be covered with gastrocnemius rotation flap Middle third tibia fractures can be covered with soleus rotation flap Distal third fractures usually require free flap for coverage
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Tibial Shaft Fractures
Treatment Options IM Nail ORIF with Plates External Fixation Cast or Cast-Brace
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Tibial Shaft Fractures
Advantages of IM nailing Lower non-union rate Smaller incisions Earlier weightbearing and function Single surgery
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Tibial Shaft Fractures
IM nailing of distal and proximal fx Can be done but requires additional planning, special nails, and advanced techniques
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Tibial Pilon Fractures
Fractures involving distal tibia metaphysis and into the ankle joint Soft tissue management is key! Often occurs from fall from height or high energy injuries in MVA “Excellent” results are rare, “Fair to Good” is the norm outcome Multiple potential complications
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Tibial Pilon Fractures
Initial Evaluation Plain films, CT scan Spanning External Fixator Delayed Definitive Care to protect soft tissues and allow for soft tissue swelling to resolve
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Tibial Pilon Fractures
Treatment Goals Restore Articular Surface Minimize Soft Tissue Injury Establish Length Avoid Varus Collapse Treatment Options IM nail with limited ORIF ORIF External Fixator
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Tibial Pilon Fractures
Complications Mal or Non-union (Varus) Soft Tissue Complications Infection Potential Amputation
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Ankle Fractures Most common weight-bearing skeletal injury
Incidence of ankle fractures has doubled since the 1960’s Highest incidence in elderly women Unimalleolar 68% Bimalleolar 25% Trimalleolar 7% Open 2%
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Osseous Anatomy
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Lateral Ligamentous Anatomy
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Medial Ligamentous Anatomy
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Syndesmosis Anatomy
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Ankle Fractures History Mechanism of injury
Time elapsed since the injury Soft-tissue injury Has the patient ambulated on the ankle? Patient’s age / bone quality Associated injuries Comorbidities (DM, smoking)
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Ankle Fractures Physical Exam Neurovascular exam
Note obvious deformities Pain over the medial or lateral malleoli Palpation of ligaments about the ankle Palpation of proximal fibula, lateral process of talus, base of 5th MT Examine the hindfoot and forefoot
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Ankle Fractures AP Ankle Tibiofibular overlap Tibiofibular clear space
<10mm is abnormal and implies syndesmotic injury Tibiofibular clear space >5mm is abnormal - implies syndesmotic injury Talar tilt >2mm is considered abnormal
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Ankle Fractures Ankle Mortise View
Foot is internally rotated and AP projection is performed Abnormal findings: Medial joint space widening Talocural angle <8 or >15 degrees (compare to normal side) Tibia/fibula overlap <1mm
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Ankle Fractures Lateral View Posterior malleolar fractures
Anterior/posterior subluxation of the talus under the tibia Displacement/Shortening of distal fibula Associated injuries
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Ankle Fractures Classification Systems (Lauge-Hansen)
Based on cadaveric study First word refers to position of foot at time of injury Second word refers to force applied to foot relative to tibia at time of injury
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Ankle Fractures Classification Systems (Weber-Danis)
A: Fibula Fracture distal to mortise B: Fibula Fracture at the level of the mortise C: Fibula Fracture proximal to mortise
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Ankle Fractures Initial Management
Closed reduction (conscious sedation may be necessary) Splint Delayed fixation until soft tissues stable Pain control Monitor for possible compartment syndrome in high energy injuries
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Ankle Fractures Indications for non-operative care: Management:
Nondisplaced fracture with intact syndesmosis and stable mortise Less than 3 mm displacement of the isolated fibula fracture with no medial injury Patient whose overall condition is unstable and would not tolerate an operative procedure Management: WBAT in short leg cast or CAM boot for 4-6 weeks Repeat x-ray at 7–10 days to r/o interval displacement
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Ankle Fractures Indications for operative care: Bimalleolar fractures
Trimalleolar fractures Talar subluxation Articular impaction injury Syndesmotic injury
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Ankle Fractures ORIF: Fibula Medial Malleolus Posterior Malleolus
Lag Screw if possible + Plate Confirm length/rotation Medial Malleolus Open reduce 4-0 cancellous screws vs. tension band Posterior Malleolus Fix if >30% of articular surface Syndesmosis Stress after fixation Fix with 3 or 4 cortex screws
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Hindfoot Fractures: Talus Calcaneus
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Talar fractures: Rare Poor blood supply high incidence of AVN
Can be major or minor
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Major Talar fractures:
Neck, head, body (& lat process) Talar neck fractures = 50% Hawkins type1= non displaced + no joint inv. Type II = displaced with subluxation or dislocation of the subtalar joint BUT ankle joint is OK Type III = Type II +dislocation of ankle joint Type IV = Type III + talar head dislocation
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Talar Neck #
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R calcaneus x-ray:
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Bohler’s angle (30-40 deg)
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Treatment: * Intraarticular= post facet involved
Extraarticular= 25-35% Anterior process, tuberosity, medial process, sustenaculum tali, and body If not displaced nor involving subtalar jt may treat with compressive dressings/casting * Intraarticular= post facet involved - well padded post splint or surgery
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Calcaneal fractures: More than 50% are associated with other extremity or spinal fractures
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Midfoot Fractures: Navicular Cuboid Lisfranc
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Navicular fractures: -Most common midfoot fracture but still rare -treatment= non-displaced=short-leg walking cast x6 wks displaced : surgery
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Cuboid Fractures: Treat as per navicular fractures r/o Lisfranc injury
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Lisfranc Joint: Formed by the articulations of metatarsals 1-3 with the cuneiforms and metatarsals 4 & 5 with the cuboid The metatarsal bases of digits 2-5 are joined by strong ligaments
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What to look for on x-ray:
Normally, medial aspect of metatarsals 1-3 should align with medial borders of cuneiforms Metatarsals should be aligned dorsally with tarsals on lateral view Medial 4th metatarsal should align with medial cuboid Any fracture or dislocation of the navicular or cuneiforms or widening between metatarsals 1-3 Proximal 2nd metatarsal # is pathogpneumonic
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Normal Lisfranc joint
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Treatment: May try closed reduction with traction but post reduction displacement of >2mm or tarso-metatarsal angle> 15 degrees requires surgery
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Forefoot fractures: Metatarsal Phalangeal
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Treatment: Nondisplaced or min displaced fractures of metatarsal 2-4 stiff shoe, casting, or fracture brace. Non displaced 1st metatarsal NWB BK walking cast Displaced 1st or 5th metatarsal Attempt closed reduction if >3mm displacement or 10 degrees angulation
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Treatment cont. Metatarsal base # r/o LF injury
Jones Fracture=5th metatarsal base fracture. Tx=non displaced NWB BK cast x6-8 wks = displaced surgery
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Jones #
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Dislocations of the Upper Limb
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Dislocation of the Shoulder
Mostly Anterior > 95 % of dislocations Posterior Dislocation occurs < 5 % True Inferior dislocation (luxatio erecta) occurs < 1% Habitual Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless
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Mechanism of anterior shoulder dislocation
Usually Indirect fall on Abducted and extended shoulder May be direct when there is a blow on the shoulder from behind
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Anterior Shoulder dislocation
Usually also inferior Bankart’s Lesion
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Clinical Picture Patient is in pain
Holds the injured limb with other hand close to the trunk The shoulder is abducted and the elbow is kept flexed There is loss of the normal contour of the shoulder
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Clinical Picture Loss of the contour of the shoulder may appear as a step Anterior bulge of head of humerus may be visible or palpable A gap can be palpated above the dislocated head of the humerus
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X Ray anterior Dislocation of Shoulder
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Associated injuries of anterior Shoulder Dislocation
Injury to the neuro vascular bundle in axilla ( rare ) Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) Associated fracture
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Axillary Nerve Injury Also called circumflex nerve
It is a branch from posterior cord of Brachial plexus It hooks close round neck of humerus from posterior to anterior It pierces the deep surface of deltoid and supply it and the part of skin over it
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Axillary nerve injury
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Management of Anterior Shoulder Dislocation
Is an Emergency It should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerus Following reduction the shoulder should be immobilised strapped to the trunk for 3-4 weeks and rested in a collar and cuff
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Methods of Reduction of anterior shoulder Dislocation
Hippocrates Method ( A form of anesthesia or pain abolishing is required ) Stimpson’s technique ( some sedation and analgesia are used but No anesthesia is required ) Kocher’s technique is the method used in hospitals under general anesthesia and muscle relaxation
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Hippocrates Method
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Stimpson’s technique
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Kocher’s Technique
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SHOULDER REDUCTION Sedation Apply traction and counter traction
Lift humeral head into the glenoid
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Complications of anterior Shoulder Dislocation : Early
Neuro vascular injury ( rare ) Axillary nerve injury Associated Fracture of neck of humerus or greater or lesser tuberosities
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Elbow Dislocation incidence
elbow dislocations are the most common major joint dislocation posterolateral is the most common type of dislocation (80%) demographics predominantly affects patients between age years old
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Simple no associated fracture account for 50-60% of elbow dislocations complex associated fracture present may take form of terrible triad injury involves a disruption of the LUCL, a radial head fracture, a coronoid tip fracture and a dislocation of the elbow
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Fracture dislocation
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complications Varus Posteromedial instability Loss of motion
Neurovascular injuries (ulnar/median nerves) Compartment syndrome Damage to articular surface Chronic instability Heterotopic ossification Contracture/stiffness correlated with immobilization beyond 3 weeks
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MONTEGGIA FRACTURE-DISLOCATION
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MONTEGGIA FRACTURE-DISLOCATION
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GALEAZZI FRACTURE-DISLOCATION
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