fractures and dislocations of the upper limb33333

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    PREPARE- M. ALISAWEPREPARE- M. ALISAWE

    FRACTURE OF UPPERFRACTURE OF UPPER

    LIMBLIMB

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    Upper Limb includeUpper Limb include

    Clavicle

    Scapula

    Shoulder Joint

    Humerus

    Elbow Joint

    Forearm Bones

    Wrist Joint Scaphoid Bone

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    FRACTUREFRACTURE

    Definition : is a structural break in thenormal continuity of a bone

    It is caused by trauma

    It may be complete or incomplete or

    fissure fracture

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    ContCont

    Dislocation is total disruption of a joint with

    no intact between the articular surfaces

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    Aetiology of fractureAetiology of fracture

    1. Traumatic fracture :

    a. Direct trauma : The bone breaks

    transversely at the site of trauma,double bone break at the same level .

    b. Indirect trauma : the bone breaks

    obliquely at the weakness point.c. Avulsion fracture [muscle violence] :

    due to muscle contraction

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    ContCont

    2.pathological fracture :

    a. By minor trauma[ which would not

    fracture normal bone]due to generalized

    or localized bone disease .

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    Types of fractureTypes of fracture

    1. Simple : without an external wound

    2. Compound : with an external wound

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    Shape of fractureShape of fracture

    1. Transverse[ direct trauma]

    2. Oblique [indirect]

    3. spiral[ [indirect]4. Comminuted [sever compression]

    5. Green stick [in children]

    6. Wedge [vertebral fracture]

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    Clinical features and diagnosis ofClinical features and diagnosis of

    fracturefracture

    1. History of trauma.

    2. Loss of function [loss of movement.

    3. Pain due to friction between bone ends .4. Swelling due to fracture bone , oedema,

    haematoma .

    5. Deformity;described according to theposition distal fragment

    6. Tenderness ; maximum over the fracture line

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    ContCont

    7.abnormal mobility .

    8. x-ray :

    a. At the time of fracture : for diagnosisb. after fixation :to know good or bad

    reduction

    C. at the end of treatment : before removingthe plaster cast to know the type of union [

    good or bad union]

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    Mechanism of injuryMechanism of injury

    MostlyIndirect :

    Commonly described as a fall onoutstretched hand

    Type of injury depends onposition of theupper limb at the time of impact : Flexed,

    Extended, adducted, abducted, pronatedor supinated

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    Fracture of clavicleFracture of clavicle

    Fracture of the middle third [shaft ] (80%)

    This is the commonest fracture in the whole body

    Trauma and morbid anatomy :

    Clavicular shaft fracture is usually due to a fall on theoutstretched hand and less commonly due to direct

    blow or to a fall on the point of the shoulder .

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    ContCont

    The fracture almost always occurs in the

    middle third because it is the thinnest part

    of the bone which is further weakened by

    the junction of the two main curves of theshaft .

    The potential deforming forces are the

    weight of the arm that lead downward andinward displacement of the outer fragment-

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    ContCont

    -And the pull of the sternomastoid muscle

    that lead to upward displacement of the

    proximal fragment

    In children the fracture is often of the

    greenstick varity .

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    Clinical featuresClinical features

    The shoulder is dropped and deformity

    and the pt support the elbow with the

    opposite hand and bend his head to the

    affected side to relax the sternomastoid

    muscle .

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    DiagnosisDiagnosis

    history of injury

    clinical features

    symptoms : pain with the motion of shoulderjoint , swelling, ecchymosis,

    sign: deformity , tenderness , bony crepitus

    x-ray

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    CCC fracture of middle third of clavicleCCC fracture of middle third of clavicle

    .

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    TreatmentTreatment

    Conservative by an broad arm sling for 3

    weeks and analgesics or figure of eight

    bandage.

    Internal fixation is rarely needed .

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    Figure of eight BandageFigure of eight Bandage

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    IIndications of open reduction andndications of open reduction and

    internal fixationinternal fixation

    Nonunion: the most frequent indication.

    Neurovascular involvement . A persistent wide separation of the

    .fragments with interposition of soft tissue.

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    Fracture of the distal end with torn of

    coracoclavicular ligaments in an adult .

    Floating shoulder: Fractures of both theclavicle and the surgical neck of the scapula

    A patient that cannot endure the suffer of

    figure-of-eight bandage fixation .

    Redisplacement after reduction that cannotbe accepted by the patient.

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    ComplicationComplication

    1. Malunion is common (union is bad time

    and position).

    2. Non union is uncommon .

    3. Injury of subclavian vessels and brachial

    plexus.

    4. Tear in muscle .5. Stiffness of shoulder joint .

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    Fracture of the outer third (15%)Fracture of the outer third (15%)

    Usually no displacement occurs because

    both fragment are attached to the scapula

    by ligament .

    When the coraco clavicular ligament is

    ruptured the outer segment displaces

    forward and inward .

    If no displacememt , no treatment is

    required (but analgesics)

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    ContCont

    When there is displacement , the fracture

    is treated by internal fixation.

    Fracture of inner third are rare

    (5%).

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    Fracture of the scapulaFracture of the scapula

    The commonest fracture of the

    scapula involve is either the neck or the

    body of bone .

    Fracture of the neck of scapula:

    the fracture result from direct violenceand the fracture line usually run from .

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    ContCont

    The suprascapular notch to below the

    coracoids process .

    Treatment : broad arm sling and early

    active shoulder movement .

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    Fracture of the body of the scapula:Fracture of the body of the scapula:

    The fracture result from direct violence .

    The fracture is stellate .

    Treatment is board arm sling and activeshoulder movement .

    Important to look for and exclude an

    associated chest injury.

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    Fractures of the scapula

    1-Neck 2-body

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    Dislocation of the ShoulderDislocation of the Shoulder

    MostlyAnterior> 95 % of dislocations

    PosteriorDislocation occurs < 5 %

    True Inferiordislocation (luxatio erecta) occurs < 1%

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    Anterior dislocationAnterior dislocation

    The head of the humerus usually

    dislocates forward to assume one of

    the following position :

    1. subcoracoid (commonest).

    2.Subclavicular.

    3.Subglenoid.

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    1.subcoracoid(commonest).

    2.Subclavicular.

    3.Subglenoid.

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    Mechanism of anterior shoulderMechanism of anterior shoulder

    dislocationdislocation

    1. UsuallyIndirectfall on Abducted and

    extended and external rotation

    shoulder.

    2. May be direct when there is a blow on the

    shoulder from behind

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    Anterior Shoulder dislocationAnterior Shoulder dislocation

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    Clinical PictureClinical Picture

    1. Flatten of theshoulder: Loss of

    the contour of the

    shoulder may appear

    as a step .

    2. Swelling: Anterior

    bulge of head ofhumerus may be

    visible or palpable.

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    4- A gap can be palpated above the dislocated

    head of the humerus.

    5-Deformit y: abduction + external rotation.

    6-Change in the length of the arm .

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    Diaganosis:

    clinical picture+ x-ray (AP views).

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    X Ray anterior Dislocation ofX Ray anterior Dislocation of

    ShoulderShoulder

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    ComplicationComplication

    1. Axillary nerve injuny.

    2. Avulusion of the supraspinatus tendon is discovered by inability of the

    pt to initiate abduction .

    3. associated of greater tuberosity or humeral neck fracture .

    4. Recurrent dislocation .

    5. rupture of the inferior part of the capsule.

    Avascular necrosis of the head of the Humerus (high risk with

    delayed reduction)

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    Axillary Nerve InjuryAxillary Nerve Injury

    Also called circumflex nerve

    It is a branch from posteriorcord of Brachial plexus

    It hooks close round neck of

    humerus from posterior to

    anterior

    It pierces the deep surface of

    deltoid and supply it and the

    part of skin over it

    M t f A t i

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    Management of AnteriorManagement of Anterior

    Shoulder DislocationShoulder Dislocation

    Is an Emergency.

    It should be reduced in less than 24hours

    or there may be Avascular Necrosis ofhead of humerus.

    Following reduction the shoulder should

    be immobilised strapped to the trunk for 3-4 weeks and rested in a collar and cuff.

    M th d f R d ti fM th d f R d ti f

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    Methods of Reduction ofMethods of Reduction of

    anterior shoulder Dislocationanterior shoulder Dislocation

    1. Hippocrates Method( A form of anesthesiaor pain abolishing is required).

    2. Stimpsons technique ( some sedation andanalgesia are used but No anesthesia isrequired ).

    3. Kochers technique : is the method usedin hospitals under general anesthesia andmuscle relaxation .

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    Hippocrates MethodHippocrates Method

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    Stimpsons techniqueStimpsons technique

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    Kochers TechniqueKochers Technique

    o under general anesthesia , the operator externally

    rotates the arm to relax the subscapularis muscle while

    pulling down on the am to disengage the head .

    o The humerus is adducted and internally rotated

    bringing the elbow across the chest .

    o Fixation in a sling and bandage for 3 weeks .

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    Kochers TechniqueKochers Technique

    T t t f tTreatment of recurrent

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    Treatment of recurrentTreatment of recurrent

    dislocationdislocation

    1. putti-platt operation . The idea is to limit

    external rotation of the shoulder by

    capsulorraphy and shorten of the

    subscapsularis muscle by overlapping .

    2. bankart operation . The glenoidal

    labrum is displayed and is repaired by

    reattaching the labrum by suturing it tothe bony rim of the glenoid .

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    Posterior dislocationPosterior dislocation

    Should always be suspected after an

    epileptic fit or an electric shock.

    Caused by direct blow on the front of the

    shoulder

    The head slide backward to the lie below

    the acromion ( subacromial dis ) or

    infraspinous fossa of thescapula(subspinous dis )

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    Fractures of The HumerusFractures of The Humerus

    1. ProximalHumerus (includes surgical

    and anatomical neck ).

    2. Shaftof Humerus.

    3. Distalhumerus ( includes SupraCondylar fracture in children ).

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    Fracture Proximal HumerusFracture Proximal Humerus

    more common in the elderly and usually

    Associated with osteoporosis.

    classification : 1-Articular surface or itsanatomical neck .

    2- Greater T .

    3- lesser T .

    4-surgical neck.

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    ContCont

    The above classification then identify each one

    according to :

    - one part # no displacement .

    two part # one segment isdisplaced .

    three part # two segment is

    displaced.

    Four part # three segmentare dis.

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    Mechanism of injuryMechanism of injury

    Surgical neck :- fall on out stretched hand

    in abduction and external rotation.

    Anatomical neck :- fall on the shoulder

    directly against the glenoid cavity.

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    Clinical pictureClinical picture

    1. pain in the shoulder and inability to

    move the joint.

    2. in minor impacted fracture of surgical

    neck , limited movement may be

    possible.

    3. the diagnosis is made radiologically .

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    Fracture Proximal HumerusFracture Proximal Humerus

    Fracture Proximal Humerus :Fracture Proximal Humerus :

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    Fracture Proximal Humerus :Fracture Proximal Humerus :

    Plating or Rush Nail insertionPlating or Rush Nail insertion

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    TreatmentTreatment

    one part ( 80% of fracture are un displaced ):-External immobilization into a sling until pain has subsided.

    two part fracture :- open reduction + internal fixation by

    screw and wire then arm to neck sling for 3 weeks.

    surgical neck :- closed reduction + collar and cuff sling for

    3 weeks.

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    ContCont

    Three part # :- open reduction + internal fixation

    +repair of the rotator cuff.

    four part # :- usually associated with avascular

    necrosis of the humeral head ___ so replacedby prosthetic head + repair of rotator cuff.

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    Intra-medullary K wire fixationIntra-medullary K wire fixation

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    ComplicationComplication

    1. shoulder stiffness.

    2. axillary nerve injury.

    3. Avascular necrosis of the humeral head .

    4. Dislocation of the shoulder .

    5. Malunion .

    6. nonunion .

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    Fractures Shaft of the HumerusFractures Shaft of the Humerus

    Mechanism of injury:-

    CommonlyIndirectinjury

    Indirect injury results twisting injury of the

    arm and /or fall on outstretched hand .

    Direct injuries like bit stick.

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    Clinical pictureClinical picture

    As general principles + deformity

    Displacement:- this depends on the level

    P. Fragment Distal fragment

    bove the insertion of

    deltoid .

    Adducted by pectoralis or

    latisums dorsi.

    Abduction by deltoid muscle.

    Below the insertion of deltoid .Abduction by deltoid. Adducted and pulled up wardby the coracobrachialis .

    Fracture shaft of the HumerusFracture shaft of the Humerus

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    Fracture shaft of the HumerusFracture shaft of the Humerus

    (diagnosis)(diagnosis)

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    TreatmentTreatment

    Closed reduction + external fixation :-

    Reduction : with gentle traction on the elbow.

    fixation : u-shaped plaster slab for 8 weeks +

    collar and cuff sling . if it is not possible to reduction by method used

    ___open reduction + plate and screws fixation or

    bone graft

    If the # is transverse or near the mid shaft ,

    intramedullary nail is used

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    U Shaped slabU Shaped slab

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    Plating fracture Shaft of humerusPlating fracture Shaft of humerus

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    ComplicationComplication

    1. Radial nerve injury.

    2. Delayed union.

    3. Nonunion.

    4. Joint stiffness.

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    Radial Nerve InjuryRadial Nerve Injury

    Results in Wrist drop

    Associated with fracturehumerus in up to 12%

    of fractures

    2/3 ( 8%) of Radial injury are Neuropraxia

    1/3 ( 4%) are nerve lacerations or transection

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    Supra-condylar Fracture of HumerusSupra-condylar Fracture of Humerus

    Mechanism of trauma:-caused bya fall onto the outstretched hands ( its a

    frequent in children )

    Types:-1-extension types 99%

    2-flexion types 1%

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    Clinical pictureClinical picture

    As general + deformity

    Extension types 99% flexion types 1%

    Distal fragment . Displaced backward and upward .

    Displaced forward and upward .

    Treatment of supra-condylarTreatment of supra-condylar

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    Treatment of supra-condylarTreatment of supra condylar

    FractureFracture

    Absolute Emergency.

    Should de done under G A by experienceddoctor as soon as possible.

    In the past the arm was held in flexed elbowposition in back-slab pop after reduction.

    At present time Percutaneous K wire fixationis ALWAYScarried out after reduction.

    C

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    ContCont

    After care : hospitalization and monitoring

    of radial pulse for 48 hours.

    Open reduction + internal fixation by wires

    , when closed methods failed to reduction

    S d l f tS d l f t

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    Supra-condylar fracture.Supra-condylar fracture.

    Complications Supra-CondylarComplications Supra-Condylar

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    Complications Supra CondylarComplications Supra Condylar

    FracturesFractures

    Early= Compartment syndrome

    Brachial Artery injury ( Acute

    Volkmann's Ischemia )

    Nerve Injury : Median, Ulnar or Radial

    Late= Stiffness

    Volkmann's Ischemic contracture

    Heterotopic CalcificationMal-Union ( Cubitus Valgus or varus)

    C

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    Volkmann's Ischemic ContractureVolkmann's Ischemic Contracture

    Massive infarction of the

    muscles of forearm in the

    case of s-p humerus

    especially flexion type frominjury of brachia l artery.

    Di l ti f th lb j i tDi l ti f th lb j i t

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    Dislocation of the elbow jointDislocation of the elbow joint

    It more common in adults.

    Mechanism of trauma:

    1-P-dislocation : fall on the outstretch hand

    while the limb is extended .

    2-A-dislocation : fall on the tip of the elbow .

    Cli i l i tCli i l i t

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    Clinical pictureClinical picture

    As general + 1-pain and tenderness

    2-SWELLING

    3-no movement at the elbow

    T t tT t t

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    TreatmentTreatment

    P-DISLOCATION : Reduction bydownward traction and forward push on

    the upper end of the ulna, fixation is done

    90 flexion for 3 weeks .

    A-DISLOCATION: reduction by posterior

    push on the ulna and fixation in extenionposition in posterior slap

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    FRACTURES OFFRACTURES OF

    SHAFT OF RADIUSSHAFT OF RADIUSAND ULNAAND ULNA

    A tAnatomy

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    AnatomyAnatomy

    radius & ulna lie parallel to eachother when forearm is supinated

    interosseous membrane:joinradius and ulna, which is directedobliquely downward from radius

    to ulna and is relaxant at theneutral position of forearm

    http://www.ortho-u.net/orthoo/131.htmhttp://www.ortho-u.net/orthoo/131.htm
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    special typespecial type

    Monteggia fracture-dislocation

    fractures of proximal third of ulna with

    dislocation of radial head

    Galeazzi fracture-dislocation

    fracture of distal third of radius withdislocation of distal radioulnar joint

    MONTEGGIA FRACTURE DISLOCATIONMONTEGGIA FRACTURE DISLOCATION

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    MONTEGGIA FRACTURE-DISLOCATIONMONTEGGIA FRACTURE-DISLOCATION

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    Monteggia fracture-dislocationMonteggia fracture-dislocation

    M t i f t di l tiMonteggia fract re dislocation

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    Monteggia fracture dislocationMonteggia fracture dislocation

    Def: fracture of the upper 1/3 ulna anddislocation of the head of the radius from

    superior radio-ulnar joint.

    Types :

    a. Extension type 85% ; the ulna is broken

    and angulated anteriorly, and the head of

    radiaus is displaced foreword.

    t t ttreatment

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    treatmenttreatment 1. close reduction and external fixation for 3

    months.

    2. open reduction and internal fixation by plate and

    screws.

    b. Flextion type; 15% the ulna is angulated and brokenbackward and the radius is dislocated backward.

    Treatment: close reduction and external fixation 2-3

    months.

    G l i f t di l tiGaleazzi fracture dislocation

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    Galeazzi fracture-dislocationGaleazzi fracture-dislocation

    Glia i fract re dislocationGliazi fracture dislocation

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    Gliazi fracture dislocationGliazi fracture dislocation

    Fracture lower1/3 of the radius+ dislocation 1/3 of the ulna

    Treatment ; open reduction and internal

    fixation as it is unstable fracture by platesand screws.

    DiagnosisDiagnosis

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    DiagnosisDiagnosis

    history of injury

    clinical features: swelling, pain ,

    subcutaneous ecchymosis, limitation ofupper extremity motion, deformity,tenderness, bony crepitus ,

    normal postelbow triangle x-ray

    T t tT t t

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    TreatmentTreatment

    Fractures of the forearm bones may resultin severe loss of function unless

    adequately treated

    Open reduction and internal fixation fordisplaced diaphyseal fractures in the adult

    are generally accepted as the best methodof treatment.

    I l fi i

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    Internal fixationInternal fixation

    A satisfactory device for internal fixation

    must hold the fracture rigidly, eliminating

    as completely as possible angular as well asrotary motions

    method: intramedullary nail or the AO

    compression plate

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    FRACTURES OFFRACTURES OF

    DISTAL RADIUSDISTAL RADIUS

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    ClassificationClassification extension type Colles fracture flexion type

    Smith fracture

    colles fracturecolles fracture

    http://www.ortho-u.net/orthoo/93.htmhttp://www.ortho-u.net/orthoo/94.htmhttp://www.ortho-u.net/orthoo/94.htmhttp://www.ortho-u.net/orthoo/94.htmhttp://www.ortho-u.net/orthoo/93.htm
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    colles fracturecolle s fracture

    Def :fracture of distal inch of radius which iscommonly comminuted and impacted.

    Trauma:fall on the outstrech hand.

    Common associated injury:1.Styloid fracture of the ulna and radius or both.

    2.Tear in the triangular fibro-cartilage between

    the lower end of radius and ulna with loss ospronation and supination.

    Diagnosis of CollesDiagnosis of Colles

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    g fg f

    fracturefracture history of injury:fall on outstretched hand

    clinical features: swelling,subcutaneous ecchymosis,pain ,limitation of wrist joint,tenderness,fork deformity

    x-ray

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    TreatmentTreatmentMost distal radial fractures can

    be successfully treated

    nonoperativelyManualreduction

    ComplicationsComplications

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    Malunion

    Sundecks' atrophy

    Tear of the extensor pollicis loungustendon

    Stuffiness of finger & shoulder

    Loss of movement

    C ll f tColles fracture

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    Colles fractureColles fracture

    Smith fractureSmith fracture

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    Smith fractureSmith fracture

    Due to fall on the dorsum of the

    hand

    The distal fragment of radius isdisplaced forward

    S i h fS ith f t

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    Smith fractureSmith fracture