FRACTURES AND FRACTURES AND DISLOCATIONS OF DISLOCATIONS OF

HAND AND FOREARMHAND AND FOREARM

K.MOZAFARIAN K.MOZAFARIAN

COMMON TERMINOLOGYCOMMON TERMINOLOGY

DEFINITION OF FX;DEFINITION OF FX;SITE OF FX: side, bone anatomic locationSITE OF FX: side, bone anatomic locationType of fx: trans, short oblique, spiral, Type of fx: trans, short oblique, spiral, comminuted, segmental, buterflycomminuted, segmental, buterflyAngulationAngulationTranslation or displacementTranslation or displacementOverridingOverridingRotation Rotation

Radial head fracturesRadial head fractures

Type 1: nondisplacedType 1: nondisplaced

Type 2: partial displacedType 2: partial displaced

displacement < 2mmdisplacement < 2mm

displacement >2mmdisplacement >2mm

Type 3: total comminuted Type 3: total comminuted

TreatmentTreatment

All type one and most type 2 fractures : All type one and most type 2 fractures : sling , immediate motionsling , immediate motion

Some type 2 fractures that blocs rotation, Some type 2 fractures that blocs rotation, some partial fx c displacement >2mm and some partial fx c displacement >2mm and repairable c fracture dislocations of repairable c fracture dislocations of forearm and elbow : ORIFforearm and elbow : ORIF

Comminuted fx : excision , prosthesis in Comminuted fx : excision , prosthesis in case of elbow or forearm instability or in case of elbow or forearm instability or in most young pt most young pt

Deforming forcesDeforming forces

Pronator quadratus Pronator quadratus

Pronator teres Pronator teres

Supinator Supinator

Biceps Biceps

FX OF RADIUS AND ULNAR FX OF RADIUS AND ULNAR SHAFTSHAFT

Anatomic reduction is Anatomic reduction is mandatory (no mandatory (no rotation ,no rotation ,no angulation)angulation)

Otherwise it results in Otherwise it results in severe loss of severe loss of functionfunction

Open reduction and Open reduction and internal fixation is internal fixation is always indicatedalways indicated

Treatment planTreatment plan

ORIF by plate and screwsORIF by plate and screws

ORIF by intra medulary rodORIF by intra medulary rod

Forearm shaft fracture in Forearm shaft fracture in childrenchildren

Long arm cast except for stable distal third Long arm cast except for stable distal third fractures in >4y/o child which is treated by fractures in >4y/o child which is treated by short arm castshort arm cast

Duration: 6-8 wks, more time in bayonet Duration: 6-8 wks, more time in bayonet positionposition

Few more weeks of splinting until the Few more weeks of splinting until the transverse lucent sign disappear and all 4 transverse lucent sign disappear and all 4 cotices has unioncotices has union

Acceptable reductionAcceptable reduction

Angulation: Distal 3Angulation: Distal 3rdrd : 20 degree : 20 degree

Middle 3Middle 3rdrd : 15 degree : 15 degree

Proximal 3Proximal 3rdrd: 10 degree: 10 degree

Provided that 2 y of growth remainingProvided that 2 y of growth remainingo Translation 100 percent if shortening is <1 Translation 100 percent if shortening is <1

cmcmo Rotation: up to 45 degreeRotation: up to 45 degree

Complications: Complications: 1- Redisplacement : the most common, occure 1- Redisplacement : the most common, occure

in 10%in 10%

2-forearm stiffness:18-72% show at least mild 2-forearm stiffness:18-72% show at least mild deficits, mostly pronation contracture, deficits, mostly pronation contracture,

3- Refracture: more than any other fracture, 4-3- Refracture: more than any other fracture, 4-8%, average at 6 m, male 3times than 8%, average at 6 m, male 3times than female, older children ( 12 y/o), diaphyseal, female, older children ( 12 y/o), diaphyseal,

Treatment is ORIF by some authors but others Treatment is ORIF by some authors but others are ifo closed reduction are ifo closed reduction

ComplicationsComplications

4- Malunion4- Malunion

5- Delayed and nonunion5- Delayed and nonunion

6- Cross union 6- Cross union

MONTEGGIA FX-DISLOCATIONMONTEGGIA FX-DISLOCATION

FX of the proximal or FX of the proximal or middle third of the middle third of the ulna with dislocation ulna with dislocation of the radial headof the radial head

Types of the Monteggia fx- Types of the Monteggia fx- dislocationdislocation

Treatment Treatment

Ulnar fx : open reduction and internal Ulnar fx : open reduction and internal fixation by plate and screws or by tension fixation by plate and screws or by tension band wiringband wiring

Radial head dislocation: open reduction Radial head dislocation: open reduction when it can not be reduced by reduction of when it can not be reduced by reduction of the ulnar fxthe ulnar fx

Galeazzi fx- dislocationGaleazzi fx- dislocation

Fx of the distal radius with dislocation of Fx of the distal radius with dislocation of the ulnar headthe ulnar head

It should be treated by open redution and It should be treated by open redution and internal fixation as the ruleinternal fixation as the rule

Fx of distal radiusFx of distal radius

A- Extraarticular fx:A- Extraarticular fx:

COLLES FX: dorsal displacement and COLLES FX: dorsal displacement and

volar angulationvolar angulation

SMITH FX: dorsal angulation and volar SMITH FX: dorsal angulation and volar

displacementdisplacement

Colles fractureColles fracture

Dorsal displacement Dorsal displacement and volar angulationand volar angulation

Treatment of extraarticular fx Treatment of extraarticular fx

Extra articular fx can usually be treated by Extra articular fx can usually be treated by closed redution and castingclosed redution and casting

If the reduction can not be obtained by If the reduction can not be obtained by closed methods open reduction and closed methods open reduction and internal fixation by pins or plate is internal fixation by pins or plate is indicatedindicated

If reduction is obtained but is unstable If reduction is obtained but is unstable PCP or external fixator is the Rx of choicePCP or external fixator is the Rx of choice

Acceptable reduction of the distal Acceptable reduction of the distal radiusradius

Acceptable reductionAcceptable reduction

Intra articular fracturesIntra articular fractures

Intraarticular fx should usually be treated Intraarticular fx should usually be treated by PCP or external fixatorby PCP or external fixator

Anatomical reduction of the articular Anatomical reduction of the articular surface is mandatory for good resultssurface is mandatory for good results

Carpal bone fracturesCarpal bone fractures

Scaphoid fx is the most common fracture Scaphoid fx is the most common fracture of the carpusof the carpus

Circulation of the scaphoid is from distal Circulation of the scaphoid is from distal to proximalto proximal

Chance of avascular necrosis and Chance of avascular necrosis and nonunion is higher nonunion is higher

Scaphoid fracture Scaphoid fracture

Diagnosis of the fractureDiagnosis of the fracture

Radiographic examination: PA- LAT-AP Radiographic examination: PA- LAT-AP with 30 degree supination and ulnar with 30 degree supination and ulnar deviation(scaphoid view)deviation(scaphoid view)

Fx displacement can be demonstrated by Fx displacement can be demonstrated by motion seriesmotion series

Types of fractureTypes of fracture

Treatment of scaphoid fractureTreatment of scaphoid fracture

Undisplaced fractures: thumb spica cast for 12 Undisplaced fractures: thumb spica cast for 12 weeksweeks

Displaced fractures : step>1mmDisplaced fractures : step>1mm

S-L angle>60S-L angle>60

lunocapitate>15lunocapitate>15

-closed reduction and thumb spica -closed reduction and thumb spica

-otherwise : open reduction and pin or screw -otherwise : open reduction and pin or screw fixationfixation

LUNATE FRACTURE ; LUNATE FRACTURE ; KIENBOCK DISEASEKIENBOCK DISEASE

Lunate fracture: Kienboch Lunate fracture: Kienboch diseasedisease

Hand fracturesHand fractures

Fx of metacarpal bones Fx of metacarpal bones

Fx of proximal phalanxFx of proximal phalanx

Fx of distal phalanxFx of distal phalanx

Fx of middle phalanxFx of middle phalanx

Multiple fxMultiple fx

Open fxOpen fx

Hand fxHand fx