upper & lower extremity trauma

UPPER & LOWER EXTREMITY TRAUMA

Çağatay Uluçay

Yeditepe University Faculty of MedicineDepartment of Orthopaedics & Traumatology

Topics

Clavicle Shoulder DislocationHumerusElbowForearmDistal RadiusSchaphoidMetacarpPhalanx

Clavicle Fractures

Clavicle Fractures

MechanismFall onto shoulder (87%)Direct blow (7%)Fall onto outstretched hand

(6%)

Clavicle Fractures

Clinical Evaluation 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 TreatmentSling or 8 bandage immobilization for usually 3-4 weeks with early ROM encouraged

Operative interventionFractures with neurovascular injuryFractures with severe associated chest injuriesOpen fracturesGroup II, type II fracturesCosmetic reasons, uncontrolled deformityNonunion

Associated InjuriesBrachial Plexus Injuries

Contusions most common, penetrating (rare)Vascular InjuryRib Fractures Scapula FracturesPneumothorax

Clavicle Fractures

Proximal Humerus Fractures

Proximal Humerus Fractures

EpidemiologyMost common fracture of the humerusHigher incidence in the elderly, thought to be related to

osteoporosisFemales 2:1 greater incidence than males

Mechanism of InjuryMost commonly a fall onto an outstretched arm from

standing heightYounger patient typically present after high energy trauma

such as MVA

Proximal Humerus Fractures

Clinical EvaluationPatients 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

TreatmentMinimally displaced fractures- Sling immobilization, early motionTwo-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 fracturesDue 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 InjuryDirect trauma is the most common especially MVAIndirect trauma such as fall on an outstretched handFracture pattern depends on stress applied

Compressive- proximal or distal humerusBending- transverse fracture of the shaftTorsional- spiral fracture of the shaftTorsion and bending- oblique fracture usually associated with a

butterfly fragment

Humeral Shaft Fractures

Clinical evaluationThorough history and

physicalPatients 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 evaluationAP 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 FracturesConservative Treatment

Goal of treatment is to establish union with acceptable alignment

>90% of humeral shaft fractures heal with nonsurgical management20 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

TreatmentOperative 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 FracturesDistal 1/3 fracturesMay entrap or lacerate radial nerve as the fracture passes

through the intermuscular septum

Supracondylar humerus fracture

Forearm Fractures

Forearm Fractures

EpidemiologyHighest ratio of open to closed than any other

fracture except the tibiaMore common in males than females, most likely

secondary mva, contact sports, altercations, and falls

Mechanism of InjuryCommonly associated with mva, direct trauma

missile projectiles, and falls

Forearm Fractures

Clinical EvaluationPatients 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 EvaluationAP and lateral radiographs of the forearmDon’t forget to examine and x-ray the elbow and wrist

Distal Radius Fractures

Distal Radius Fractures

EpidemiologyMost common fractures of the upper extremityCommon in younger and older patients. Usually a result of

direct trauma such as fall on out stretched handIncreasing incidence due to aging population

Mechanism of InjuryMost commonly a fall on an outstretched extremity with

the wrist in dorsiflexionHigh energy injuries may result in significantly displaced,

highly unstable fractures

Distal Radius Fractures

Clinical EvaluationPatients 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 examinedNV exam including specifically median nerve for

acute carpal tunnel compression syndrome

Radiographic Evaluation

3 view of the wrist including AP, Lat, and ObliqueNormal Relationships

23 Deg

11 mm

11 Deg

Distal Radius Fractures

EponymsColles 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 handSmith Fracture (Reverse Colles)

Fracture with volar angulation (apex dorsal) from a fall on a flexed wristBarton Fracture

Fracture with dorsal or volar rim displaced with the hand and carpusRadial Styloid Fracture (Chauffeur Fracture)

Avulsion fracture with extrinsic ligaments attached to the fragmentMechanism of injury is compression of the scaphoid against the styloid

Colles fracture

Smith fracture

Barton fracture

Galeazzi fracture

Montegia fracture

Distal Radius Fractures

TreatmentDisplaced 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 weightReproduce the fracture mechanism and reduce the fracturePlace in sugar tong splint

Operative ManagementFor 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 fractureII-Rolando’s fracturesIII-IV Extra articuler

fractures

Bennett’s Fracture

Rolando Fracture

Phalanx Fractures

Mallet Finger

Hip fractures

High energy forces falls car accidents pelvic (side impacts)

high mortality rates Femoral neck fractures

> 250,000women 3 times likely to get

fracture

Hip fractures

Young people: high energy impacts

Mechanismdirect impact lateral rotation of leg

Stress fractures femurDynamic models of falls

impact forces 3-10 kN

INTERTROCHANTERIC FRACTURE

POST OPERATIVE X-Ray

CT SCAN PELVIS

ACETABULAR FRACTURE

Thigh injuries

Three muscular compartments anterior medial posterior

Quadriceps contusion blunt trauma extensive hematoma swelling increase muscle weight loss of strength

Myositis Ossificans

Ant.

Post.

Medial

Femoral fractures

High energy trauma car & motorcycle and or

pedestrian accidents (78%) Classified by location,

configuration and level of comminution

Dangerous near epiphyseal plates

AP LAT

FRACTURED LT. FEMUR

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 muscleeccentric action

Predisposing factors: fatigue muscle imbalance lack of flexibility lack of warm up

Biarticular musclesbicep femorisMTJ

PATELLA FRACTURE

NORMAL

QUADRACEPS TENDON INJURY

Patella tendon injury

NORMAL

ANTERIOR CRUCIATE LIGAMENT INJURY

Normal

POST OPERATIVE LIGAMENT REPAIR

POSTERIOR CRUCIATE LIGAMENT INJURY

normal

AP TIBIA & FIBULA (LOWER LEG)

Lower Leg Injuries Four muscle compartments

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

fracturesBaseball bats

Foot & Ankle injuries

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 forces = 10 times BW

Injuries peritenitis bursitis multifactorial etiology

trainingmalaligments trauma footwear

Foot & Ankle injuries

Tendon rupture 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 & stabilityplantar flexion: unstable

Involve ankle and subtalar joint 85% inversion sprain

(supination sprains) ATFL-CFL-PTFL Sometime deltoid (taut in

plantar flexion)

Fractures through the medialand lateral malleoli

Foot & Ankle injuries

Eversion sprains (pronation) less common

Fractures malleolus Deltoid ligament Tibia and fibula separation

(high forces)

Foot & Ankle injuries

Lisfranc 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

PATIENT FELL OFF OF A LADDER

CALCANEAL FRACTURE

Metatarsal Fractures and Dislocation