Traumatology of the upper extremity. Object and goal of the seminar Introduce main patological units...
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![Page 1: Traumatology of the upper extremity. Object and goal of the seminar Introduce main patological units Diagnosis and therapy Diseases and injuries of the.](https://reader035.fdocuments.net/reader035/viewer/2022062308/56649d305503460f94a0878a/html5/thumbnails/1.jpg)
Traumatology of the upper extremity
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Object and goal of the seminar
Introduce main patological unitsDiagnosis and therapy
Diseases and injuries of the upper extremity
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Shoulder joint- simple ball joint (arthrodia)
cavitas glenoidalis scapulae – caput humeri
Articulating bones:Humerus, scapula, clavicleArticular surface is covered with cartilageShape of the articular surface determines: range of motion, stability
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Clinical examination - anamnesis
Complicated joint - articulatio glenohumeralis (acromioclavicularis, sternoclavicularis)
Clinical history – pain and its character(direction, sharp or dull pain, permanent or short-term, mechanism of injury, personal clinical history
Acute pain…bursitis subacromialis, rotator cuff rupture, inflammation, fracture, …
Chronic pain– degenerative disease
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Examination of the injured joint – objective status
Aspection – swelling, hematoma, patological shape,damaged skin surface
Palpation– sensitivity, temperature
Examination of stability- dislocation of the joint
Range of the motion
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Physiological range of the motion (degree) – shoulder joint
• Flexion…90 • Extension …50• Abduction…90 • Adduction …25 • Elevation…180• External rotation…90 • Internal rotation….90
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Examination of the injured joint
X-ray evaluation – AP , lateral, comparative images
CTMRI – soft tissueUltrasound – fluid in (around) the joint, RC,
tendons
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Shoulder painfull syndromTenosynovitis capitis longi m. bicipitis brachiiRupture of long tendon of biceps muscleBursitis subacromialisTendinitis m. supraspinatiRupture of rotator cuffImpingement syndrom of shoulderFrozen shoulder syndromArthritis of shoulder jointAC dislocationsInflammation TumorsPains transferred from another place
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Transferred pain
C spineThoracic outlet syndromHeart diseasesLung diseasesNeuralgia, herpes zosterStomach tumor
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Acromioclavicular dislocation indirect violence classification Allman - Tossy I.-III. rupture of ligaments /CC, AC, CA/
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Clinical status
deformation of AC region pain antalgic position of the extremity limitation of motion of the limb
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Examination X-ray • AP• comparative view• traction X-ray
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Treatment
Conservative I. + II. degree
• Scarf bandage, Desault
• orthesis
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Treatment
Surgical - III. degree• suture of ligaments, K-wire osteosynthesis
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Rupture of long tendon of biceps muscle
Treatment:
keep extremity immobileanalgesicstill 40 y. - surgerymore than 40 r. - conservatively
Surgery:key hole fixation to humerus shaftsuture to short tendon of biceps muscle
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Rupture of rotator cuff
• Pushes humeral head into cavitas glenoidalis• Helps to abduction
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Rupture of rotator cuff
Severe painNo abduction
Treatment:ConservativeSurgical• suture• fixation to tuberculum maius using anchor
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Dislocation of humerus• very often injury• indirect mechanism
• anterior• posterior• inferior• (superior)
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Clinical status
• empty cavitas glenoidalis• joint shape• antalgic position of extremity• limitation of range of motion
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Treatment
Conservative • reposition• fixation - orthesis
Surgical … repeated dislocation• repairing joint capsule
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Reposition
• Analgesia
• General Anesthesia
• Fixation to 5 weeks
• Surgical solution
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Complications
• fractures
• nerve injury
– plexus brachialis
– n. axilaris
• vessels injury
X-ray before reposition!!!
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Humeral fractures
1. Proximal humerus2. Shaft3. Distal humerus
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Proximal humeral fractures
occurrence at any age 4. the most common fracture (distal radius, proximal femur, ankle) 2. the most common fracture of upper extremity 4 – 5% of all fracture ratio of male – female till 3 : 1 shoulder joint– greatest range of motion
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Mechanism of proximal humeral fractures
„Low energy trauma“
short-term and older population predominace of women falls from standing at floor level osteoporosis
direct indirect
„High energy trauma“
younger population sport, traffic, men falls from height open fracture polytrauma
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Anatomy greatest range of motion - small stability muscles - important role for the stability joint surface of head is 3-4 times greater than joint surface of cavitas glenoidalis the head forms with the shaft an angle 130 degrees
.
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Muscles around shoulder
Superficial level: m. deltoideus Deep level: muscles of RC– m. supraspinatus m.infraspinatus m. teres minor m.subscapularis
Peripheral muscles: m.pectoralis maior (crista tuberculi maioris)m. latissimus dorsi, m. teres maior (crista tuberculi minoris)m. corachobrachialis, m. bicipitis brachii- caput breve (proc coracoideus)
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Retroversion of the hole– 9 degrees dorsallybody of the scapula is placed 30 degrees from frontal
levelhole facing ventrolaterally
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Surgical anatomy
Collum anatomicum humeri - inclination - 115-130 degrees - retroversion of the head - 15-30 degrees dorsallyCollum chirurgicum humeri
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Morfology of proximal humeral fractures
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Anatomy – blood supplay a. circumflexa humeri anterior – a. arcuata (Laing artery) metafyseal-epifyseal supplay (injured in dislocated fractures of surgical neck) Branches of ACHP – postero-inferior part of the head via RC in tubercles
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Clinical examinationswellinghematoma (elbow, forearm, chest wall)damage to the skin cover, open fracturepaincrepitationfunctional deficitvascular and neurological deficit!!! (suspicion for vascular injury - angiography)
Examination of the whole limb – current forearm and hand injuries
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AP
Lateral
Axillar
(thoracal)
X - ray3 standard projection(Neer)
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CT scan
more than two fragments dislocation of fragments – particullary of the humeral head assessment of the size of fragments articular fractures fractures of cavitas glenoidalis postoperative complications
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Indication criteria for treatment of proximal humeral
fractures
Objective examination: age, the internal status, the ability of active rehabilitationSkin condition of injured extremityType of the fracture: X-ray examinationPersonal and technical equipment
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Treatment of proximal humeral fractures
Conservative
Surgical
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Conservative treatment - indication
Individual approache Internal complications
75 – 80% small dislocation – conservative treatment15 – 20% great dislocation- surgical treatment
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Indications for surgical treatment
Instable fractures with dislocation Intraarticular fractures with joint dislocations Failure of conservative treatment Neurovascular injuries Open fractures Patological fractures Polytrauma
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Surgical or conservative?
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4-frg lux.
3-frg2-frg
patol.
2-frg
4-frg
Fracture of proximal humerus
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Osteosynthesis or primary replacement?
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Surgical methods
1) Conventional implants
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Percutaneous stabilization - K-wires
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Osteosynthesis – screw and wires
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Osteosynthesis -T-plates
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Conventional implants
Disadvantages:
Problematic bone fixation in porotic bone -
instability Frequent failure of osteosynthesis Sometimes the need for accessory fixation (brace, orthesis)
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2) Modern surgical methods:
angle stable implants
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Failure prevention( osteoporotic bone, comminuted) Head of the screw – locked in the hole
Principle of angular stable implant
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Surgical technique-position of the patient- beach chair position
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Surgical approache - deltoideopectoral
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Surgical approache - transdeltoideal
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Surgical technique - reduction K wires – joystick bone hook
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Surgical technique – entry point
Two X-ray projections Entry point
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Nail insertion
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Angle stable plate
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ArthroplastyCCEP
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Surface replacement
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TSA
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Reverse replacement
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Rehabilitation
long term phase of the exercise
• passive
• assisted
• active and physical
exercise
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Complications of surgical treatment
General
Impaired wound healing. HematomaInflammation
SpecificRestriction of motionHead necrosisFailure of OSNonunionFracturesHeterotopic ossificationNerv and vessels injuries
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Nail cutting
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Screw cutting
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Periimplants fracture
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Nonunion
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Fractures of scapula
infrequent mostly direct mechanism
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fr. of body fr. of neck fr. of glenoid fr. of acromion fr. of coracoid process fr. of spine
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Treatment
Conservative• hinge• Desault• orthesis
Surgical• Intraarticular fractures
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Clavicle fracture
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Nonunion
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Humeral shaft fractures
direct mechanism dislocation depend on fracture level
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Humeral shaft fractures
Humeral shaft fractures account for approximately 1–3% of all fractures
High and low energy trauma
Fracture displacement is the result of muscular forces
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Fracture patterns of the humeral shaft
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Examination
X - ray• AP • lateral view
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TreatmentNon-operative: Operative:
• Compression plating
• IM nailing
Antegrade
Retrograde
• External fixation
• MIPO technique
• Nondislocated fxt
• Hanging Arm Cast
• Velpeau
• Abduction Brace
• Functional Brace
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Anterolateral approach
Be careful about traction of the nerve
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• Open fractures with extensivesoft tissue injuries
• Severe contamination
External Fixation
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OS by plating
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HackethalHackethal
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Nailing
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Complication of humeral fractures
Radial nerve injury from accident or iatrogenic –distal third of humerus
Delayed union and nonunion
Failure of internal fixation
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Distal humeral fractures2% of all fractures1/3 of the humeral fracturesMostly intraarticular
MechanismLow energy trauma – middle aged and elderly
(ground-level falls), associated with osteoporosisHigh energy trauma – younger patients (sports,
vehicle accidents), open injuries
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Anatomy – triangular structure• MEDIAL & LATERAL column and connecting arch distally
Distally – intraarticular portion• Laterally: capitellum humeri• Medially: medial epicondyle with trochlea (tie arch)• Forward angulation 30-45°• Trochlea valgus angle 4-8°• Trochlea externally rotated 3-8°2-3cm proximally to the
olecranon fossa – termination of the intramedullary canal
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Functional anatomy
Trochlea is center of the joint
Hinged joint with single axis of rotation (trochlear axis)
45°
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• Physical examination• Soft-tissue envelope• Vascular status
– Radial and ulnar pulses
Evaluation• Neurovascular status
– Radial nerve (most commonly injured, 14cm prox. to lat. epicondyle)
– Ulnar and Median nerves (rarely injured)
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X -ray- AP and lateral view- CT
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Principles of treatment
- Restoration of axial alignment
- Anatomical reduction of the articular surfaces
- Stable fixation of the articular segment to the
metaphysis and diaphysis
- Goal: early range of motion of the elbow
- Prevention of posttraumatic arthritis
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New implants - LCP
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Posterior approache
Isolate and gently retract the ulnar nerve
Olecranon intraarticular osteotomy (if needed)
Open reduction and internal fixation
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Surgical approach—skin incision
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Ulnar nerve identification and mobilization
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Olecranon osteotomy
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Reduction and fixation
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Early rehabilitation
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Elbow joint- Composed joint- Humeroulnar……..hinge- Humeroradial……..ball- Prox.radioulnar…..cylindrical
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Range of motion in elbow
Flexion – 140-160 extension-10Pronation 80-90 supination 80-90SFTR: S 10-0-160 R 90-0-90
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EnthesopathyPathological changes in the tendons, ligaments,insertions to the bone
Causes:• Acute or chronic overload• Repeated small injury• Repetitive movements
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Epicondylitis radialis humeriSyndrome of tennis elbow
• Pain when extensors are functional• Palpation pain on the radial epicondyle• Painfull supination of the forearm• Handgrip pain
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Epicondylitis radialisConservative treatment:• Not burdening, NSAD locally and generally• Stretching, special orthesis• Corticoids locally• Rehabilitation• Immobilization
Surgical treatment:• Op. sec. Hohman• Op. sec. Boyd- Mc Leod
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Epicondylitis ulnaris humeri
• Enthezopathy of common flexor insertion• Pain on the ulnar epicondyle• Pain when flexors are functional
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Dislocation of the elbow
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Fracture of the radial head
• small abruption• large abruption• comminuted fractures• fractures of the neck
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Fracture of the radial head - OS
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Olecranon fracture
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Olecranon + proc. coronoideus
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Fractures of the both forearm bones
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Galeazzi fracture
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Monteggia fracture
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Fractures of distal radius
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Introduction
1/6 of all the fractures
most cases between 6 – 10 year a 60 – 69 year
75 % of the forearm fractures
ratio of women and men 4 : 1 (osteoporosis)
children: ratio of boys and girls 3 : 1 (physical activity)
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History
Abraham Colles - 1814: clinical description of this fracture in English speaking countries - described it before discovery of X-ray (1898) - extraarticular fracture with dorsal dislocation - „Colles fracture“ – incorrectly used name for all fractures of distal radius
R.W. Smith - 1847 volar dislocation of distal fragment
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Anatomy
JOINTS: radio-carpal medio-karpal carpo-metacarpal distal radio-ulnar
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Mechanism of injury
Dorsal angulation – wrist in extension, pronation, ulnar duction - 90 % of fractures (Colles type)Volar angulation - wrist in volar flection - 10 % of fractures (Smith type)
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Clinical picture
swelling hematoma typical dislocation restriction of range of
motion blisters, visible
fragments under skin vessels, nerves
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Distal radius fractures
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Distal radius fractures
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X – ray evaluationNormal Anatomy 1. Volar Angulation 11º (1 – 21)2. Radial Inclination 22º(13 – 30)3. Radial Length 11º4. Ulnar Variance 0±2mm(comparison with intact side)
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CT
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Associated Injuries
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Another diagnostics method
MRI - diagnosis of post-traumatic and chronic states - displaying of soft tissue(tendon, capsule, muscles) - patological states(osteomyelitis, AVN)
Artroscopy – optical evaluation of articular structures
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Treatment goals
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• Non-operative treatment
• Short arm cast
• Check X-ray at week
Undisplaced fractures
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Displaced fractures
• Dorsal Comminution beyond midaxial plane of the radius
• Intra-articular Involvement• Associated Ulnar Fracture• Volar
Angulation/Displacement
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Closed reduction- Anaesthesia – Haematoma/Bier’s block, GA
- X - ray control
- Manipulation technique
- Longitudinal traction- Pronation or neutral position of hand- Ulnar tilt- No big wrist flexion - Plaster cast
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Unstable extra-articular Supplementary fixation with exfix
• 1.6mm K-wires• X - ray control• Additional cast
immobilisation• Removal in 5-6 weeks• Poor wire fixation in
osteoporotic bone
Percutaneous K-wiring
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Bridging external fixation
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Non-bridging external fixator• Comminuted extra-articular
• Limited indications
• Allows early mobilisation
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Surgical treatment – transfixation with K - wires
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Surgical treatment – external fixation
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Surgical treatment – plate and screws
Locked volar plate
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Surgical procedure
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Surgical treatment– nailing
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Surgical treatment– combination of methods
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Volar approache
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Dorsal approache
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Malunion DRUJ problems CRPS – overdistraction Tendon rupture Carpal Tunnel syndrome Arthritis Failure of osteosynthesis
Complications
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Scaphoid fractures
swelling pain - (fossa tabatiére) limitation of motion
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Diagnostics• X-ray - AP
- lateral view- ulnar duction
• CT
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Treatment Conservative
• reduction, plaster cast (12-16 weeks!)
Surgical • osteosynthesis (Herbert screw), • tranfixation
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Herbert screw
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Complications
nonunion – bone grafting carpal instability necrosis
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Luxatio perilunatis
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Hand
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Open or closed fracture skin damage and fracture in the same place of limb a wide range of local findings o
!!! Decision affects treatment!!!
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Clinical status
skin damage, swelling of soft tissue, hematoma bleeding (artery, vein, capillary) pathological movement, crepitations, changed shape prominence of bone fragments from the wound oppression skin with impending perforation contamination of the wound neurovascular lesion
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General Principles
• Protecting open wounds• Positioning the limb• Immobilizing the injury• Checking neurovascular function
• Pulse• Palpate• Utilize pulse oximetry
• Motor• Sensation
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Treatment at operating room
mechanical cleaning of the wound with steril brush removing dirt, foreign bodies, devitalized tissue repeated washings with disinfectans cultivation debridement osteosynthesis antibiotics
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External fixation Advantages
• No foreign body in the wound
• Fracture site vascularity not compromised
• Applied distant to injury
• Overbridging joints
Disadvantages• Pin tract infections• Fracture malalignment• Patient tolerence• Adjacent joint stiffness• Transfixation of muscles• Interfere with flap
design and vascular acces