Applied ER Ortho: Upper Limb Fractures “Tips and Tricks”

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Applied ER Ortho: Upper Limb Fractures “Tips and Tricks…”. University of Calgary Academic Rounds September 26, 2009. Matt Petrie. Applied ER Ortho. A whirlwind tour…. Introduction questions…. Today’s Menu. Appetizers: Orthopedese Reductions Main’s: Wrist Forearm - PowerPoint PPT Presentation

Transcript of Applied ER Ortho: Upper Limb Fractures “Tips and Tricks”

  • Applied ER Ortho:Upper Limb Fractures

    Tips and TricksMatt PetrieUniversity of CalgaryAcademic Rounds September 26, 2009

  • Applied ER OrthoA whirlwind tourIntroduction questions

  • Todays MenuAppetizers: OrthopedeseReductionsMains: WristForearmSelected Carpal BonesElbowMetacarpalsPhalanges/PhalanxSides:HumerusPediatric Elbow

    Dessert: Elbow Dislocation PearlsShoulder Dislocation Pearls

  • DISLAIMER: A note on Eponyms

    May be helpful for pattern recognition or older surgeons

    Use anatomical terms

  • How to speak orthopedese

  • Case: Mrs. Colles

  • Describing Fractures: I ABCD2 OI) Intro:

    A) AreaB) BoneC) CharacterD) Displacement (where)

    A) Angle/ApexB) Bone LengthC) ClosedD) Dysfunction

    O) Other injuries/info

    56yo RHD female pianist

    Right, DistalRadiusComminuted20% displaced (radial)And which fragment

    30 degrees, apex volarShortened (1cm)ClosedNeurovascular statusUlnar styloid fractureSurgical pertinent factsRotationIntra-articular: gap/stepMortise, DRUJ, etc.

  • Describing Fractures: Mrs. Colles

  • Description Please?

  • General Management PrinciplesAnalgesiaEvaluationAnesthesiaReductionImmobilizationInstructionDisposition/Referral

    *Note: Anesthesia Analgesia

  • General GuidelinesAcceptable angulation of Fractures: -Adults: 10 degrees-Pedes: 30 degrees -Exceptions: 4th, 5th MCImmobilization Time: 6-8 weeks-Exceptions: Tibia, Scaphoid, ElderlyChoice of Material: -Displaced/Reduced: plaster -Undisplaced: dealers choice

  • General GuidelinesFractures that dont need ortho (but still need follow up)

    non-displaced buckle fracture (non salter harris)Minimally displaced phalangeal/phalanxSmall avulsion fractures (most)Minimally displaced clavicle fractureDistal phalanx

  • General GuidelinesFractures which require a phone call*Open*Neurovascular compromise (esp. post reduction)*Intra-articular with step/gap of >1mmAll Salter Harris II and upAngulation >10 deg in adults 30 deg. In pedes (post reduction)> 50% Displaced long bone fractureMidshaft forearm, humerus

  • General GuidelinesFractures which require a phone call: continued++ comminuted fracturesAll fracture dislocationsUnstable fractures

  • Fracture ReductionPrinciples:Think about the mechanismAdequate analgesiaProlonged traction (muscle tension)Accentuate deformityCorrect deformityMaintain tractionSplint/Cast to correct deformityThree 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 degrees11

  • Type of Fracture?

  • Barton: Subluxation of Carpus

  • Smith: Flexion FOOSH

  • Type/Name of Fracture?Monteggia

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

  • Type/Name of Fracture?GalleazziMUGRMonteggia: ulna #Galleazzi: Radial #

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

  • Dont miss this onePeri-lunate dislocation

  • Your Honour

  • Lunate Dislocation

  • Perilunate

    Lunate:

  • Diagnosis?ScaphoidSnuffbox tendernessBlood supply distal to proximalZones: waistRisk of AVNProlonged casting: SPICA10 days x-ray vs bone scan MRI/CT

  • Mid-shaft humerus Fracture90 y.o. femaleManagement?40 y.o. male hockey playerManagement?Sugar Tong Splint, ClinicReduction, ST splint, OR

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

  • Elbow:Xray PearlsInjury/Fracture Patterns

  • Elbow: The Lateral is KeyNormalAnt./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: LateralMonteggia #

  • Supracondylar Fracture: Type 1

  • Supracondylar FracturesType I: minimal/no displacement conservativeType II: Posterior cortex intact ortho/ORIFType III: No cortical contact ORIFIIIII** Beware neurovascular compromise

  • Adult: Intercondylar Usually T typeSplint: 3 sided*Ortho referral

  • Elbow: ContinuedDiagnosis: Olecranon FractureMechanism: Forced extension in flexion, +- blowManagement: ORIF

  • Elbow:Radial Head FractureMinimal displacement (
  • Metacarpal FracturesReduction and treatment?

  • Metacarpal FracturesReduction:Hematoma block or regional techniqueMCP and PIP at 90 degreesupward pressure on middle phalangeTractionPressure on dorsal aspect of fractureTreatment:Volar or ulnar splintIn safe positionRefer to hand/plastics

  • Metacarpal FracturesGuidelines: ( i.e. ok for clinic f/u)Metacarpal Shaft:Length: < 5mm shorteningRotation: minimal*No scissoring*No weaknessAngulation:10 degrees at 2nd and 3rd 20 degrees at 4th30 degrees at 5th

  • Metacarpal FracturesNeck Fractures:Tolerate greater angulationUp to 40 degrees for 4th and 5th (volar)Jahss maneuver Gutter/Volar in safe positionClinic F/U

  • Metacarpal FracturesMetacarpal Head Fractures:Surgery if >25% articular surface> 1mm displacement at joint surfaceOtherwise: splint and refer

  • Metacarpal FracturesMetacarpal Base Fractures:Less tolerance for angulation/displacementLess able to accommodate at CMC4th and 5th tend to be unstableReduce, splint, refer

  • Metacarpal Fracture:Fracture?Bennet FractureFracture dislocation CMCUnstable: Ad.P.LongusIntra-articularReduce, spica, callNeeds surgery if large fragment

  • Metacarpal Fracture:Same thing?Rolandos Fracture3 part intra-articularComminutedSimilar to BennetNeeds ORIF

  • Phalanx FracturesDistal Phalanx: stable, good reduction- Splint and follow upProximal Phalanx: reduce, splint -usually ORIF transverse/unstable - splint hand and wristMiddle Phalanx: VariableIntra-Articular: > 20% Splint and ORIFCondylar, Fracture/dislocation, Spiral = ORIF

  • Phalange Fractures

  • Phalanges ContinuedSame Fracture?Same Treatment?Consideration for ORIF (>20% articular surface)Avulsion of distal extensor attachment: Mallet Finger: splintAB

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

  • DiagnosisOuch!

    Structures?.

  • Elbow ReductionReduction?Parvin MethodPt. supine, arm at 90Humerus on table with padTraction to pronated hand/wrist

    2. Traction/Counter-tractionElbow at 90, traction to humerus (prox/post.)Traction to forearm

  • Elbow DislocationTreatment:Test and document stability/laxity post reductionSplint at 90 degrees Refer to Ortho/hand and upper limbPhysio at 2-3 weeks

  • Additional Topics:Proximal humerus fracturesShoulder DislocationCRITOE

  • Questions?

  • Referenceswww.nysora.comwww.acep.orgwww.emedicine.comWheeless textbook of orthopedicswww.aafp.com

  • What view?Identify the structures please

  • Axillary view

  • Shoulder dislocation and reduction

  • What is going on here?Hint?luxatio erecta

  • Post reduction filmWhat is the arrow pointing at?Hill Sachs Lesion

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

  • Anterior Shoulder reductionMechanism?External rotation, abductionReduction?Stimson: prone, weights on armTraction/Countertraction

  • Shoulder ReductionTraction Counter TractionSheet around both participants

  • Shoulder ReductionSpaso techniqueSupineSlow flexion to 90 deg.TractionExternal rotation at 90 deg.* 80% first time reduction by residents

  • Shoulder Reduction*Kocher Method:TractionExternal rotation*AbductionInternal rotation as finish

  • Shoulder ReductionScapular Rotation:ProneTraction/weight to armTip of scapula medialSuperior aspect lateralTrying to move glenoid to humeral headAtraumatic: successful in experienced hands

  • Shoulder ReductionExternal Rotation:Verbal anesthesiaElbow at 90 deg.SLOW external rotation+ - abduction

  • Dislocation TreatmentNo consensus on immobilisationStandard is sling for 2-3 weeks with pendulum/elbow ROMNo evidence to show it makes a differenceMust delay return to sport/activityNew small (n=40) trial of splinting in external rotation (not definitive)Itoi et al. , 2003, J Shoulder Elbow SurgDecreased rate of dislocation, no other differences

  • Dislocation TreatmentEvidence in US and Canada to show early surgical intervention decreases re-dislocation rate in young patients Consider early ortho referral for this subgroupCochrane Review

  • Diagnosis?

  • Diagnosis?

  • Diagnosis?Normal

  • Diagnosis?

  • Diagnosis?Posterior shoulder Disloc.Rim sign:
  • Diagnosis

  • Reduction: Posterior DislocationMechanism?- Internal rotation and adduction

    Reduction:Prolonged traction? Lateral tractionAnterior pressure on humeral head (gentle)Gentle, mild external rotation

  • Pitfall Dont miss thisLisfranc FractureNormal

  • LisFranc FractureDr. LisFranc in Napoleans armyQuick amputation through the jointFracture dislocation at TMTHyperflexion +- vertical loading +- torsionHints: large, swollen, bruised footFall from heightCar accident, Stirrup fallLook at alignmentLook for small fractures at base of MTsIf in doubt CT

  • Pitfall Dont miss thisLateral margin of the 1st metatarsal lines up with the