Applied ER Ortho:Upper Limb Fractures

“Tips and Tricks…”

Matt Petrie

University of CalgaryAcademic Rounds September 26, 2009

Applied ER OrthoA whirlwind tour…

Introduction questions…

Today’s MenuToday’s MenuAppetizers: Appetizers: - OrthopedeseOrthopedese- ReductionsReductions

Main’s:Main’s: - WristWrist- ForearmForearm- Selected Carpal Selected Carpal

BonesBones- ElbowElbow- MetacarpalsMetacarpals- Phalanges/PhalanxPhalanges/Phalanx

SidesSides::- HumerusHumerus- Pediatric ElbowPediatric Elbow

DessertDessert: : - Elbow Dislocation Elbow Dislocation

PearlsPearls- Shoulder Shoulder

Dislocation PearlsDislocation Pearls

DISLAIMER:

‘A note on Eponym’s’

- May be helpful for pattern recognition or older surgeons

- Use anatomical terms

How to speak orthopedese

Case: Mrs. Colles

Describing Fractures: I ABCD2 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.

Describing Fractures: Mrs. Colles

Description Please?

General Management Principles• Analgesia

• Evaluation

• Anesthesia

• Reduction

• Immobilization

• Instruction

• Disposition/Referral

*Note: Anesthesia ≠ Analgesia

General GuidelinesAcceptable angulation of Fractures:

-Adults: 10 degrees

-Pedes: 30 degrees

-Exceptions: 4th, 5th 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 GuidelinesFractures which require a phone call: continued– ++ comminuted fractures– All fracture dislocations– Unstable fractures

Fracture ReductionPrinciples:

- 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?

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 degrees

11

Type of Fracture?

Barton: Subluxation of Carpus

Smith: Flexion FOOSH

Type/Name of Fracture?Monteggia

Type/Name of Fracture?Both Bones Forearm Fracture

- Management?- Reduction as necessary (+- fluoro)- Cast?

Type/Name of Fracture?• Galleazzi

• MUGR

• Monteggia: ulna #

• Galleazzi: Radial #

Diagnosis?Scapho-lunate dissociation, and?

- 1-2mm normal, >3mm abnormal

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

Your Honour…

Lunate Dislocation

• Perilunate

• Lunate:

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

Mid-shaft humerus Fracture90 y.o. female

Management?

40 y.o. male hockey player

Management?

Sugar Tong Splint, ClinicReduction, ST splint, OR

Management?75 y.o. female 14 yo Male

Elbow:• Xray Pearls

• Injury/Fracture Patterns

Elbow: The Lateral is KeyNormal Ant./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: Lateral

Monteggia #

Supracondylar Fracture: Type 1

Supracondylar FracturesType I: minimal/no displacement conservative

Type II: Posterior cortex intact ortho/ORIF

Type III: No cortical contact ORIF

II III

** Beware neurovascular compromise

Adult: Intercondylar Usually ‘T’ type

- Splint: 3 sided*

- Ortho referral

Elbow: ContinuedDiagnosis: Olecranon Fracture

Mechanism: Forced extension in flexion, +- blow

Management: ORIF

Elbow:Radial Head Fracture

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

Metacarpal FracturesReduction and treatment?

Metacarpal FracturesReduction:- Hematoma block or regional technique- MCP and PIP at 90 degrees- ‘upward pressure’ on middle phalange- Traction- Pressure on dorsal aspect of fractureTreatment:- Volar or ulnar splint- In ‘safe’ position- Refer to hand/plastics

Metacarpal FracturesGuidelines: ( i.e. ok for clinic f/u)

Metacarpal Shaft:

- Length: < 5mm shortening

- Rotation: minimal

- *No scissoring

- *No weakness

- Angulation:- 10 degrees at 2nd and 3rd - 20 degrees at 4th

- 30 degrees at 5th

Metacarpal FracturesNeck Fractures:- Tolerate greater angulation- Up to 40 degrees for 4th

and 5th (volar)- Jahss maneuver - Gutter/Volar in safe position- Clinic F/U

Metacarpal FracturesMetacarpal Head Fractures:

- Surgery if >25% articular surface

- > 1mm displacement at joint surface

- Otherwise: splint and refer

Metacarpal FracturesMetacarpal Base Fractures:

- Less tolerance for angulation/displacement- Less able to accommodate at CMC

- 4th and 5th 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 FracturesDistal 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

Phalange Fractures

Phalanges ContinuedSame Fracture?

Same Treatment?A) Consideration for ORIF (>20% articular surface)

B) Avulsion of distal extensor attachment: Mallet Finger: splint

A B

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

DiagnosisOuch!

Structures?.

Elbow ReductionReduction?

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 DislocationTreatment:

- Test and document stability/laxity post reduction

- Splint at 90 degrees

- Refer to Ortho/hand and upper limb

- Physio at 2-3 weeks

Additional Topics:• Proximal humerus fractures

• Shoulder Dislocation

• CRITOE

Questions?

References• www.nysora.com

• www.acep.org

• www.emedicine.com

• Wheeless’ textbook of orthopedics

• www.aafp.com

What view?• Identify the structures please

• Axillary view

Shoulder dislocation and reduction

What is going on here?• Hint?

luxatio erecta

Post reduction film• What is the arrow pointing at?

Hill Sach’s Lesion

What is this?• How did it happen?

Bony Bankart

Anterior Shoulder reductionMechanism?

- External rotation, abduction

Reduction?

1. Stimson: prone, weights on arm

2. Traction/Countertraction

Shoulder Reduction• Traction Counter Traction

– Sheet around both participants

Shoulder Reduction• Spaso technique

• Supine

• Slow flexion to 90 deg.

• Traction

• External rotation at 90 deg.

• * 80% first time reduction

by residents

Shoulder Reduction*Kocher Method:

- Traction

- External rotation

- *Abduction

- Internal rotation as finish

Shoulder ReductionScapular 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

Shoulder ReductionExternal Rotation:

- Verbal anesthesia

- Elbow at 90 deg.

- SLOW external rotation

- + - abduction

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

Diagnosis?

Diagnosis?

Diagnosis?

Normal

Diagnosis?

Diagnosis?• Posterior shoulder Disloc.

• Rim sign: <6mm jt. Space

• Light bulb/Ice cream cone– Internal rotation– Need axillary or scapular

Diagnosis

Reduction: Posterior DislocationMechanism?

- 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.