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

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

3. Clavicle Fractures

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

5. 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

6. 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

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

8. Proximal Humerus Fractures

9. 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

10. 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

11. 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%)

12. Humeral Shaft Fractures

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. Supracondylar humerus fracture

20. Forearm Fractures

21. 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

22. 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

23. Distal Radius Fractures

24. 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

25. 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

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

27. 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

28. Colles fracture

29. Smith fracture

30. Barton fracture

31. Galeazzi fracture

32. Montegia fracture

33. 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.

35. Schaphoid Fracture

36. Metacarpal Fractures

37. Boxers Fracture

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

39. Bennett’s Fracture

40. Rolando Fracture

41. Phalanx Fractures

42. Mallet Finger

43. 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

44. 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

45. INTERTROCHANTERIC FRACTURE

46. 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

47. ACETABULAR
FRACTURE
CT SCAN PELVIS

48. 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.

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

50. FRACTURED LT. FEMUR
LAT AP

51. 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)

52. 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

53. PATELLA FRACTURE
Patella fracture
NORMAL

54. QUADRACEPS TENDON INJURY
NORMAL
Patella tendon injury

55. 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

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

57. 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

58. AP TIBIA & FIBULA
(LOWER LEG)

59. 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

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

61. 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

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

63. 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

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

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

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

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

68. 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)

69. Fractures through the medial
and lateral malleoli
Fractures through the medial and lateral malleoli

70. 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

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

72. 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

73. CALCANEAL FRACTURE
PATIENT FELL OFF OF A LADDER

74. Metatarsal Fractures and Dislocation