UPPER & LOWER EXTREMITY TRAUMA Çağatay Uluçay Yeditepe University Faculty of Medicine Department of Orthopaedics & Traumatology

Topics Clavicle Shoulder Dislocation Humerus Elbow Forearm Distal Radius Schaphoid Metacarp Phalanx

Clavicle Fractures

Clavicle Fractures Mechanism Fall onto shoulder (87%) Direct blow (7%) Fall onto outstretched hand (6%)

Clavicle Fractures Clinical Evaluation Radiographic Exam Inspect and palpate for deformity/abnormal motion Thorough distal neurovascular exam Auscultate the chest for the possibility of lung injury or pneumothorax Radiographic Exam AP chest radiographs. Clavicular 45deg A/P oblique X-rays Traction pictures may be used as well

Clavicle Fracture Closed Treatment Operative intervention Sling or 8 bandage immobilization for usually 3-4 weeks with early ROM encouraged Operative intervention Fractures with neurovascular injury Fractures with severe associated chest injuries Open fractures Group II, type II fractures Cosmetic reasons, uncontrolled deformity Nonunion

Clavicle Fractures Associated Injuries Brachial Plexus Injuries Contusions most common, penetrating (rare) Vascular Injury Rib Fractures Scapula Fractures Pneumothorax

Proximal Humerus Fractures

Proximal Humerus Fractures Epidemiology Most common fracture of the humerus Higher incidence in the elderly, thought to be related to osteoporosis Females 2:1 greater incidence than males Mechanism of Injury Most commonly a fall onto an outstretched arm from standing height Younger patient typically present after high energy trauma such as MVA

Proximal Humerus Fractures Clinical Evaluation Patients typically present with arm held close to chest by contralateral hand. Pain and crepitus detected on palpation Careful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury

Proximal Humerus Fractures Treatment Minimally displaced fractures- Sling immobilization, early motion Two-part fractures- Anatomic neck fractures likely require ORIF. High incidence of osteonecrosis Surgical neck fractures that are minimally displaced can be treated conservatively. Displacement usually requires ORIF Three-part fractures Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement requires ORIF. Four-part fractures In general for displacement or unstable injuries ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%)

Humeral Shaft Fractures

Humeral Shaft Fractures Mechanism of Injury Direct trauma is the most common especially MVA Indirect trauma such as fall on an outstretched hand Fracture pattern depends on stress applied Compressive- proximal or distal humerus Bending- transverse fracture of the shaft Torsional- spiral fracture of the shaft Torsion and bending- oblique fracture usually associated with a butterfly fragment

Humeral Shaft Fractures Clinical evaluation Thorough history and physical Patients typically present with pain, swelling, and deformity of the upper arm Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured

Humeral Shaft Fractures Radiographic evaluation AP and lateral views of the humerus Traction radiographs may be indicated for hard to classify secondary to severe displacement or a lot of comminution

Humeral Shaft Fractures Conservative Treatment Goal of treatment is to establish union with acceptable alignment >90% of humeral shaft fractures heal with nonsurgical management 20 degrees of anterior angulation, 30 degrees of varus angulation and up to 3 cm of shortening are acceptable Most treatment begins with application of a coaptation spint or a hanging arm cast followed by placement of a fracture brace

Humeral Shaft Fractures Treatment Operative Treatment Indications for operative treatment include inadequate reduction, nonunion, associated injuries, open fractures, segmental fractures, associated vascular or nerve injuries Most commonly treated with plates and screws but also IM nails

Humeral Shaft Fractures Holstein-Lewis Fractures Distal 1/3 fractures May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum

Supracondylar humerus fracture

Forearm Fractures

Forearm Fractures Epidemiology Mechanism of Injury Highest ratio of open to closed than any other fracture except the tibia More common in males than females, most likely secondary mva, contact sports, altercations, and falls Mechanism of Injury Commonly associated with mva, direct trauma missile projectiles, and falls

Forearm Fractures Clinical Evaluation Radiographic Evaluation Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of function at the hand Careful exam is essential, with specific assessment of radial, ulnar, and median nerves and radial and ulnar pulses Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for compartment syndrome Radiographic Evaluation AP and lateral radiographs of the forearm Don’t forget to examine and x-ray the elbow and wrist

Distal Radius Fractures

Distal Radius Fractures Epidemiology Most common fractures of the upper extremity Common in younger and older patients. Usually a result of direct trauma such as fall on out stretched hand Increasing incidence due to aging population Mechanism of Injury Most commonly a fall on an outstretched extremity with the wrist in dorsiflexion High energy injuries may result in significantly displaced, highly unstable fractures

Distal Radius Fractures Clinical Evaluation Patients typically present with gross deformity of the wrist with variable displacement of the hand in relation to the wrist. Typically swollen with painful ROM Ipsilateral shoulder and elbow must be examined NV exam including specifically median nerve for acute carpal tunnel compression syndrome

Radiographic Evaluation 3 view of the wrist including AP, Lat, and Oblique Normal Relationships 23 Deg 11 Deg 11 mm

Distal Radius Fractures Eponyms Colles Fracture Combination of intra and extra articular fractures of the distal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortenting Most common distal radius fracture caused by fall on outstretched hand Smith Fracture (Reverse Colles) Fracture with volar angulation (apex dorsal) from a fall on a flexed wrist Barton Fracture Fracture with dorsal or volar rim displaced with the hand and carpus Radial Styloid Fracture (Chauffeur Fracture) Avulsion fracture with extrinsic ligaments attached to the fragment Mechanism of injury is compression of the scaphoid against the styloid

Colles fracture

Smith fracture

Barton fracture

Galeazzi fracture

Montegia fracture

Distal Radius Fractures Treatment Displaced fractures require and attempt at reduction. Hematoma block-10ccs of lidocaine or a mix of lidocaine and marcaine in the fracture site Hang the wrist in fingertraps with a traction weight Reproduce the fracture mechanism and reduce the fracture Place in sugar tong splint Operative Management For the treatment of intraarticular, unstable, malreduced fractures. As always, open fractures must go to the OR.

Schaphoid Fracture

Metacarpal Fractures

Boxers Fracture

First Metacarpal Fractures I- Bennett’s fracture II-Rolando’s fractures III-IV Extra articuler fractures

Bennett’s Fracture

Rolando Fracture

Phalanx Fractures

Mallet Finger

Hip fractures High energy forces Femoral neck fractures > 250,000 falls car accidents pelvic (side impacts) high mortality rates Femoral neck fractures > 250,000 women 3 times likely to get fracture

Hip fractures Young people: high energy impacts Mechanism direct impact lateral rotation of leg Stress fractures femur Dynamic models of falls impact forces 3-10 kN

INTERTROCHANTERIC FRACTURE

This is showing the repair done here This is showing the repair done here. This is an IM rod that they drill and hammer into your bone to fix the fracture. POST OPERATIVE X-Ray

ACETABULAR FRACTURE CT SCAN PELVIS

Thigh injuries Ant. Medial Post. Three muscular compartments anterior medial posterior Quadriceps contusion blunt trauma extensive hematoma swelling increase muscle weight loss of strength Myositis Ossificans Ant. Medial Post.

Femoral fractures High energy trauma car & motorcycle and or pedestrian accidents (78%) Classified by location, configuration and level of comminution Dangerous near epiphyseal plates

FRACTURED LT. FEMUR LAT AP

Femoral fractures Gunshot fractures affected by bullet diameter, velocity, weight, shape, and tumbling Low-velocity splintering High velocity or close range shotgun blasts More soft tissue damage Torsional loading young skiers high skill level (risk)

Hamstring Excessive tension applied to the muscle eccentric action Predisposing factors: fatigue muscle imbalance lack of flexibility lack of warm up Biarticular muscles bicep femoris MTJ

PATELLA FRACTURE Patella fracture NORMAL

QUADRACEPS TENDON INJURY NORMAL Patella tendon injury

ANTERIOR CRUCIATE LIGAMENT INJURY A test to see if this is still intact is the anterior draw sign where you pull the tibia anterior to the femur. If the ACL is ruptured there will be nothing to prevent the tibia from coming really far forward and you will not feel an end feel. Normal

POST OPERATIVE LIGAMENT REPAIR They take a piece of you… and drill it in with these screws

POSTERIOR CRUCIATE LIGAMENT INJURY Posterior draw sign. Push the tibia posterior to the relative to the femur and if it is ruptured there will be no end feel and the tibia will go really far posterior normal

AP TIBIA & FIBULA (LOWER LEG)

Lower Leg Injuries Four muscle compartments Compartment Syndrome Anterior lateral sup and deep posterior Compartment Syndrome fluid accumulation as a result of acute or chronic exertion can affect vascular and neural function Ischemia Fascia adaptations Fasciotomy

Lower Leg Injuries Tibial stress syndrome: Inflammatory reaction of the deep fascia Mechanism chronic overload can lead to periostitis common in runners multifactor

Lower leg injuries Stress reaction: bone with evidence of remodeling but without actual fracture Stress fracture 50% occur on the tibia runners: middle and distal third jumpers: proximal fractures dancers midshaft

Lower leg injuries High energy fractures car accidents: direct impact skiing: torsional and boot fractures Baseball bats

Foot & Ankle injuries 26 bones Achilles tendon Most complex areas in the human body due to large number of muscle, ligaments and bones Ligaments deltoid: eversion ATFL: restrict inversion CFL PTFL 26 bones Achilles tendon

Foot & Ankle injuries Arches Longitudinal medial lateral Transverse Absorb and distribute loads during weight bearing Supported by bones, muscles, plantar ligaments and plantar fascia

Foot & Ankle injuries Achilles tendon: largest and stronger Injuries forces = 10 times BW Injuries peritenitis bursitis multifactorial etiology training malaligments trauma footwear

Foot & Ankle injuries Tendon rupture Mechanism degeneration Men 30-40 years Blood type (O) Mechanism sudden dorsiflexion rapid change in direction excess tension on taut tendon taut tendon struck by object

Foot & Ankle injuries Plantar Fasciitis: inflammation of the plantar fascia involving microtears of partial rupture of the fascia Repetitive loading compressing the plantar fascia (1.3- 2.9 BW) Factors lack of flexibility lack of ankle strength overtraining poor mechanics leg length discrepancies over pronation

Foot & Ankle injuries Ankle sprains: most common injuries Irregular talus & stability plantar flexion: unstable Involve ankle and subtalar joint 85% inversion sprain (supination sprains) ATFL-CFL-PTFL Sometime deltoid (taut in plantar flexion)

Fractures through the medial and lateral malleoli Fractures through the medial and lateral malleoli

This is a CT scan showing you the fractures through the medial and lateral maleoli CT scans with sagittal reconstructions and 3-D volumn imaging

Foot & Ankle injuries Eversion sprains (pronation) less common Fractures malleolus Deltoid ligament Tibia and fibula separation (high forces)

Foot & Ankle injuries Lisfranc Turf toe Low energy: tripping or bumping High: falls, crashes, object drop Axial loading foot in extreme plantar flexion or dorsiflexion Violent twisting Turf toe damage to capsule and ligaments of 1st MP joint

CALCANEAL FRACTURE PATIENT FELL OFF OF A LADDER

Metatarsal Fractures and Dislocation