Transcript Applied ER Ortho: Upper Limb Fractures University of Calgary Academic Rounds

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
- Selected Carpal Bones
- Elbow
- Metacarpals
- Phalanges/Phalanx
Sides:
- Humerus
- Pediatric Elbow
Dessert:
- Elbow Dislocation Pearls
- Shoulder Dislocation 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:
• 56yo RHD female pianist
•
•
•
•
•
•
•
•
A) Area
B) Bone
C) Character
D) Displacement (where)
Right, Distal
Radius
Comminuted
20% displaced (radial)
– And which fragment
•
•
•
•
A) Angle/Apex
B) Bone Length
C) Closed
D) Dysfunction
• O) Other injuries/info
•
•
•
•
•
•
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 Guidelines
Acceptable 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 Guidelines
Fractures which require a phone call: continued
– ++ comminuted fractures
– All fracture dislocations
– Unstable fractures
Fracture Reduction
Principles:
- 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 Principles
A) Length (wrt ulna)
B) Volar Tilt Angle
Wrist Normals
Radial Inclincation: 23 deg.
Volar Tilt:
Volar Angle: 11 deg.
11
Normal:11 degrees
90
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 Fracture
90 y.o. female
Management?
40 y.o. male hockey player
Management?
Sugar Tong Splint, Clinic
Reduction, ST splint, OR
Management?
75 y.o. female
14 yo Male
Elbow:
• Xray Pearls
• Injury/Fracture Patterns
Elbow: The Lateral is Key
Normal
Ant./Post. Fat pad
Elbow: The Lateral is Key
Elbow: The Lateral is Key
Radiocapitellar Line (Dot on the i)
Anterior Humeral Line
Middle 1/3 Capitellum
Elbow: Lateral
Monteggia #
Supracondylar Fracture: Type 1
Supracondylar Fractures
Type 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: Continued
Diagnosis: Olecranon Fracture
Mechanism: Forced extension in flexion, +- blow
Management: ORIF
Elbow:
Radial Head Fracture
- Minimal displacement (<1mm):
- Sling, ROM, Fracture Clinic (arm immobilizer)
Metacarpal Fractures
Reduction and treatment?
Metacarpal Fractures
Reduction:
- Hematoma block or regional technique
- MCP and PIP at 90 degrees
- ‘upward pressure’ on middle phalange
- Traction
- Pressure on dorsal aspect of fracture
Treatment:
- Volar or ulnar splint
- In ‘safe’ position
- Refer to hand/plastics
Metacarpal Fractures
Guidelines: ( 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 Fractures
Neck Fractures:
- Tolerate greater angulation
- Up to 40 degrees for 4th
and 5th (volar)
- Jahss maneuver
- Gutter/Volar in safe position
- Clinic F/U
Metacarpal Fractures
Metacarpal Head Fractures:
- Surgery if >25% articular surface
- > 1mm displacement at joint surface
- Otherwise: splint and refer
Metacarpal Fractures
Metacarpal 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 Fractures
Distal 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 Continued
Same Fracture?
Same Treatment?
A)
B)
A
Consideration for ORIF (>20% articular surface)
Avulsion of distal extensor attachment: Mallet Finger: splint
B
Same Again?
• Dorsal extension splint, followed by buddy tape
Diagnosis
Ouch!
Structures?
.
Elbow Reduction
Reduction?
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 Dislocation
Treatment:
- 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 reduction
Mechanism?
- 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 Reduction
Scapular 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 Reduction
External 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 Dislocation
Mechanism?
- 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.