upper limb fractures (part2)
TRANSCRIPT
• The elbow joint is a modified hinge joint formed by 3 separate articulations,– Ulnotrochlear(hinge)– Radocapitellar(rotation)– Proximal radioulnar(rotation)
Ligaments1- Radial collateral lig.2- Anular lig. Of radius3- Ulnar collateral lig.4- Transverse lig.
Ulnar ligament is also known as the medial collateral ligament. It
prevent abduction of elbow joint. It cosists of 3 bands: Anterior,
posterior, Transverse.
Radial ligament is also called as the lateral collateral ligament.it
prevent adduction of elbow
• The soft tissue restriants can be divided intoStatic stabilizersDynamic stabilizers
• Static stabilizers include:oJoint capsuleoLCL & MCL
• Dynamic stabilizers include Biceps, Brachialis & Triceps
Stability is contributed by:• Antero-posterior:
– Trochlea-olecranon fossa– Coronoid fossa– Radiocapitellar joint– Biceps-triceps-brachialis
• Valgus: – Medial collateral ligament complex – Anterior capsule– Radiocapitellar joint
• Varus:– Lateral collateral ligament is static– Anconeus muscle is dynamic stabilisaer
Two set of movements occur at the elbow:
A)Flexion and extension at the Ulnotrochlear joint
B)Pronation and supination at Superior radio-ulnar joint
Normal range of motion:0 to 150°flexion85° supination & 80° pronation
Functional range of motion:a 100° arc (30 to 130 degrees flexion)50° supination & 50° pronation
Movement of elbow
Dislocation of the elbowDislocation of UlnoHumeral joint
Mechanism of injury:Most commonly injury is caused by fall onto an
outstretched hand or elbow• Posterior dislocation: a combination of elbow
hyperextention, valgus stress, arm abduction and forearm supination
• Anterior dislocation: a direct force strikes the posterior forearm with elbow in flexed position
• Most elow dislocations & fracture dislocations result in injury to all capsulo-ligamentous stabilizers of elbow joint
• The capsuloligamentous injury progresses from lateral to medial (HORI CIRCLE)
Signs and SymptomsPain, Swelling and EcchymosisInstability, Crepitus and Deformity(With the elbow flexed at 90 degrees,the medial &
lateral epicondyles & olecranon process should from isosceles triangle)
A complete peripheral neurological examination for both motor & sensory functions should be done
Radial & ulnar pulses should be compared on both sides
ClassificatonAccording to direction of displacement of ulna relative to the humerus • Posterior• Posterolateral• Posteromedial• Lateral • Medial• Anterior
Treatment principlesRestoration of the inherent bony
stability is goal
Ulnotrochlear and Radiocapitellar contact.The LCL is more important than MCL in setting
of most cases of traumatic elbow instabilityMCL will usually heal properly without any
repair
• Parvin’s method Of Closed reductionPatient lies prone Physician applies gentle downward traction of the wrist for few min, as the olecranon begin to slip distally, the physician lift up gently on the arm
• Meyn and Quigley’s method of reduction:
Only the forearm hangs from the side of the stretcher as gentle downward traction is applied on the wrist, the physican gudies the reduction of olecranon with the opposite hand
Surgical repair (if elbow clinically is unstable post reduction)
Direct repair of the ligaments,capsule and muscles
Static or Hinged external fixator applicationCross pining of the jointTemporary bridge plating of the elbow
• If the elbow remains unstable inspite of repair to lateral structures the medial side of the elbow is approached with care taken to protect the ulnar nerve
• If the elbow is still unstable then an External fixator should be placed
ComplicationsVascular injury of brachial artery may occurNerve injury the medial ulnar nerve may be affected Myositis ossificans which is more common if passive
exercise is inflicted on the patient.Late complications
Stiffness Heterotopic ossification Unreduced dislocation Recurrent dislocation Osteoarthritis after severe fracture dislocation.
RADIAL HEAD FRACTURE
EPIDEMIOLOGY 4% of all fractures and 30% of all elbow
fractures 1/3 patients associated injury to shoulder,
humerus, forearm,wrist or hand.
Rare in children due to cartilagenous nature of radial head
Radial neck fracture more common in children
Anatomy of proximal radius
RadioCapitellar joint transmit 50-60% load across elbow
Radius Head Surgical Anatomy
Important for: Valgus Stability Posterolateral Rotatory
Stability Longitudinal Forearm
Stability (Along With Interossi
Membrane & Druj)
Elbow Stability
MCL & Ulnohumeral Joint: Primary Stabilizer
Radial Head & Capsule: Secondary Stabilizer
Mechanism Of Injury (1) Fall On Outstreched Hand (most Common) Distal Radius
Interossi Membrane(forearm)
Radial Head Impaction Against Capitellum
(2) Valgus Injury To Elbow/Direct Injury
Mcl Rupture/Olecranon Fracture Unstable Elbow
Signs and Symptoms Swelling Ecchmosis Anconeus Triangle Fullness Range Of Motion Restriction Stability Active Finger Extension
Forearm/Interossi Membrane Tenderness Wrist Tenderness
ESSEX LOPRESTI Lesion
Essex Lopresti Lesion
This is defined as longitudinal disruption of forearm
interosseous ligament,usually combined with radial head
fracture and/or dislocationplus distal radioulnar joint injury
Muscle Attachment Around Proximal Radius:
SUPINATOR ATTACHMENT AT PROXIMAL RADIUS. BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.
Posterior Interossei Nerve At Risk:
Posterior Interosseous Nerve Traverses From Anterior To Posterior Through Supinator Muscle.
Always Check Pre Operative Active Finger Extension
Radiographic Findings STANDARD AP AND LATERAL X RAY of elbow OBLIQUE(GREEN SPAN)VIEW FOREARM AND WRIST X RAY IF REQUIRED
X RAY FINDINGS
Classification Of Radial Head FracturesMason classification
Type IMinimally displaced, no
mechanical block to rotation,intraarticular displacement <2mm
Type II Displaced fx >2mm or angulated, possible mechanical block to
forearm rotation
Type III Comminuted and displaced fx, mechanical block to motion
Type IV Radial head fracture with elbow dislocation
MORREY MODIFIED MASON CLASSIFICATION BY QUANTIFYING DISPLACEMENT AREA >30% AND DISPLACEMENT OF >2 MM
TreatmentGoal
Correction Of Any Block To Forearm Rotation
Early Mobilisation Of Elbow And Forearm
Stability Of Elbow And Forearm
Prevention Of Secondary Osteoarthrosis Of Elbow
Non Operative Treatment
Indication: Isolated Radial Head Fracture With Mason Type 1
(Undisplaced <2mm) Plaster Slab For 3 Weeks Early Active Mobilization Of Elbow Persistant Pain.Inflammation,contracture
Suspect Capitellar Fracture
Operative Management(Open Reduction & Internal Fixation)
INDICATION FOR ORIF: Mason type II with mechanical block(displaced) Large fragment >2 mm Mason type III where ORIF feasible(>3 FRAGMENT POOR
OUTCOME) Mechanical block to motion (lignocaine inj in elbow joint) Presence of other complex ipsilateral elbow
injuries(without metaphyseal bone loss)
FRAGMENT EXCISION LEADS TO INSTABILITY
TRY TO PRESERVE SMALLEST FRAGMENT
PRONATE FOREARM WHILE FIXATION
Which implant to use? Mini fragment screw(2.4 or 2.7 mm)
(counter sink must) Headless compression compression
screw/Herbert screw Low profile plate/mini t plate(in safe
zone/postero lateral) K WIRE
COMPLICATION OF ORIF
PIN INJURY
HARDWARE FAILURE
HARDWARE IMPINGEMENT
STIFFNESS OF ELBOW
RESTRICTION OF SUPINATIONPRONATION
Radial Head Replacement To prevent proximal migration of the radius Silicon implant poor outcome : SILICON
SYNOVITIS Titanium/vitallium metallic implant of choice
RADIAL HEAD EXCISION
INDICATION: Low demand, sedentary patients In a delayed setting for continued pain of an isolated
radial head fracture
CONTRAINDICATION: In children Presence of destabilizing injuries (Essex-lopresti
lesion,fracture dislocation elbow(mason type 4),monteggia)
Terrible triad of elbow(coronoid fracture,MCL deficiency)
Distal Radius Fractures
Common injury
Potential for functional impairment and frequent complications
HISTORY First surgeon to recognize these injuries
was Pouteau 1783. His work was not widely publicized.
Later Abraham Colles 1814 gave the classic description of “Colles fracture”
Advent of X rays at the end of nineteenth century contributed much to the understanding of different patterns of injury.
Incidence
One sixth of all fractures treated in the Emergency Room (16%)
Bimodal distribution less than 30 years (70% men) over 50 years (85% women) Males age 35 or older - 90 per 100,000
population
Introduction Occurs through the distal metaphysis of
the radius May involve articular surface. Mechanism of injury
forced extension of the carpus, impact loading of the distal radius.
Diagnosis: History and Physical Findings
History Wrist is typically swolen with ecchymosis and
tender Visible deformity of the wrist, with the hand
most commonly displaced in the dorsal direction less comonly in volar direction
Movement of the hand and wrist are painful. Adequate and accurate assessment of the
neurovascular status of the hand is performed, before any treatment is carried out.
Diagnosis: Diagnostic Tests and Examination
General physical exam of the patient, including an evaluation of the injured joint, and a joint above and below
Radiographs of the injured wrist-pa and lat view , oblique view
CT scan of the distal radius to know extent of intrarticular involvement
Osseous Anatomy
Distal radius – 80% of axial load Scaphoid fossa Lunate fossa Sigmoid notch – DRUJ
Distal ulna
Anatomy Scaphoid and lunate
fossa Ridge normally exists
between these two
Sigmoid notch: second important articular surface
Triangular fibrocartilage complex(TFCC): distal edge of radius to base of ulnar styloid
Anatomy Articular Surface
Scaphoid facet
Lunate facet
Sigmoid notch
Normal range of movement
RADIOLOGY
Ulnar inclination (avg 23°)
Volar tilt (avg 11 to 12°)
Radial Height (avg 11 mm)
Ulnar variance (+/- 1 mm)
Measurement of Radial Length and Inclination
Inclination = 23 degrees
Computed TomographyIndications:
Intra-articular fxs with multiple fragments
centrally impacted fragments
DRUJ incongruity
Common Classifications
Column theory
Gartland/Werley Frykman Weber (AO/ASIF) Melone Fernandez (mechanism)
Frykman ClassificationExtra-articular
Radio-carpal joint
Radio-ulnar joint
Both joints
{Same pattern as odd numbers, except ulnar styloid also fractured
AO/ OTA Classification
Group A: Extra-articular
Group B: Partial Intra-articular
Group C: Complete Intra-articular
COONEY (1990) UNIVERSAL CLASSIFICATION
Type I Extraarticular, undisplaced Type 2 Extraarticular, displaced Type 3 Intraarticular, undisplaced Type 4 Intraarticular, displaced
MODIFIED AO
Type A Extraarticular Type B Partial articular B1–radial styloid fracture B2–dorsal rim fracture B3–volar rim fracture B4–die-punch fracture Type C Complete articular
Column Theory
Rikli & Regazzoni, 1996
3 Columns: Radial, Intermediate, Medial
Three Column Theory
Radial ColumnLateral side of radius
Intermediate ColumnUlnar side of
radius Ulnar Column
distal ulna
Radial column
Intermediate column
Ulnar column
Classification – Fernandez (1997)
I. Bending-metaphysis bending with loss of palmar tilt and radial shortening ,DRUJ injury(Colles, Smith)
II. Shearing-fractures of joint surface (Barton, radial styloid)
Classification – Fernandez (1997)
III. Compression-intraarticular fracture with impaction of subchondral and metaphyseal bone (die-punch)
IV. Avulsion-fractures of ligament attachments (ulna, radial styloid)
V. Combined/complex - high velocity injuries
Assessment of X-rays Assess involvement of dorsal or volar
rim Is comminution mainly volar or dorsal? is one of four cortices intact?
Look for “die-punch” lesions of the scaphoid or lunate fossa.
Assess amount of shortening
Look for DRUJ involvement
EPONYMS COLLES #-extra articular or intra articular distal radius -
clinicaly described as dinner fork deformity-mechanism---fall on to an hyper
extended ,radialy deviated wrist with the forearm in pronation
SMITH #(REVERSE COLLES #) # distal radius with volar
angulation or volar displacement of the hand and distal radius
mechanism—fall on to a flexed wrist with the forearm fixed in supination
unstable pattern often requires ORIF because of difficulty in maintaining closed reduction
BARTON #
# disdlocation or subluxation of wrist in which the dorsal or volar rim of distal radius is displaced
mechanism-fall on to a dorsiflexed wrist with the forearm fixed in pronation
unstable # requires ORIF
RADIAL STYLOID #(CHAUFFEUR’S #, BACKFIRE #,HUTCHINSON #)
Avulsion # with extrinsic ligaments remaining attached to styloid fragment
Mechanism-compression of scaphoid against styloid with the wrist in dorsiflexion and ulnar deviation
Often associated with intercarpal ligament injury
Requires ORIF
ASSESSMENT OF STABILITYfive factors indicative of instability (1)initial dorsal angulation of more than 20
degrees (volar tilt),(2) dorsal metaphyseal comminution,(3) intraarticular involvement, (4) an associated ulnar fracture, and(5) patient age older than 60 years
Treatment Goals Preserve hand and wrist function
Realign normal osseous anatomy
Promote bone healing
Avoid complications
Allow early finger and elbow ROM
Options for Treatment Casting
Long arm vs short arm Sugar-tong splint
External Fixation Joint-spanning Non bridging
Percutaneous pinning Internal Fixation
Dorsal plating Volar plating Combined dorsal/volar plating focal (fracture specific) plating
Indications for Closed Treatment
Low-energy fracture
Medical co-morbidities
Minimal displacement- acceptable alignment
Closed Treatment of Distal Radial Fractures
Obtaining and then maintaining an acceptable reduction.
Immobilization: long arm short arm adequate for elderly patients
Frequent follow-up necessary in order to diagnose redisplacement.
Technique of Closed Reduction Anesthesia
Hematoma block Intravenous sedation Bier block
Traction: finger traps and weights Reduction Maneuver (dorsally angulated
fracture): hyperextension of the distal fragment, Maintain weighted traction and reduce the
distal to the proximal fragment with pressure applied to the distal radius.
Apply well-molded “sugar-tong” splint or cast, with wrist in neutral to slight flexion.
Avoid Extreme Positions!
Acceptable Reduction Criteria Radial length: within 2-3 mm of the
contralateral wrist Palmar tilt: neutral tilt Intrarticular step-off or gap< 2mm Radial inclination <5° loss Carpal malalignment: absent Ulnar variance: no more than 2 mm of
shortening compare to ulnar head
Indications for Immediate Surgical Treatment
High-energy injury Open injury Secondary loss of reduction Articular comminution, step-off, or gap Metaphyseal comminution or bone loss Loss of volar buttress with
displacement DRUJ incongruity
Operative Management of Distal Radius Fractures
External fixation: The treatment of choice for distal radius fractures
in the 1980’s
Spanning ( Ligamentotaxis)
A spanning fixator is one which fixes distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals
Use for comminuted fracture
Complications
Mal-unionPin track infectionFinger stiffness Loss of reduction; early vs lateTendon rupture
Non-spanning External Fixator
External Fixation- Disadvantages -
Bulky
Poor screw hold in porosis and comminution
Screws do not buttress
Cutaneous radial nerve injury
Pin tract infection
Reflex sympathetic dystrophy
Percutaneous Pins
Percutaneous Pinning-Kapandji
intrafocal pinning through fracture site
buttress against displacement
Drawback-tendency to translate distal fragment in opposite direction
Internal Fixation of Distal Radius Fractures
Useful for elevation of depressed articular fragments and bone grafting of metaphyseal defects
required if articular fragments can not be adequately reduced with percutaneous methods
Selection of Approach Based on location of comminution. Dorsal approach for dorsally angulated
fractures. Volar approach for volar rim fractures Radial styloid approach for buttressing of
styloid Combined approaches needed for high-
energy fractures with significant axial impaction.
Classical Henry approach(chung)
Extended carpal tunnel approach
VOLAR
Volar –Henry Approach
Freer elevator is used to elevate pronator quadratus
from radius
Fracture line is exposed
Volar plate positioned, insertion of first screw
Reduction and placement of Kirschner wires for provisional fixation
Courtesy J. Orbay, MD
-
DORSAL APPROACH
3rd DC –EPL(extensile)1-2nd DC
Dorsal Plating, PCP and Ex Fix
Generally not prefere because of high rate of complication like
- tendon dysfunction and rupture - tenosynovitis of extensor tendons indicated for- dorsal die-punch fractures or
fractures with displaced dorsal lunate facet fragments
DISTRACTION PLATE FIXATION
-less tendon irritation than dorsal
Volar Plating for Dorsal Fractures
Fixed angle locked screws ,,variable angle
Fragment Specific System
Five potential fracture fragments
radial column, dorsal cortical
wall, dorsal ulnar split, volar rim, and the central
intraarticular fragment
Radial pin-plate For stabilization of radial column
Ulnar pin-plate for stabilization of dorsal ulnar split fragment
Dorsal cortical wall fragment stabilized by small fragment
clamp
simultaneously stabilization of dorsal wall fragment and intraarticular component
Volar approach, application buttress plate
Dorsal approach, application of 2 “L” buttress plates
EPL Tendon
Extensor retinaculum repaired beneath EPL to prevent erosion against plate- EPL left transposed
Advanced TechniquesArthroscopic-Assisted
reduce articular incongruities also diagnose associated soft tissue
lesions minimally invasive
Complications After Fracture of Distal Radius
Arthritis/arthrosis Loss of motion Hardware complications Nerve compression/neuritis Osteomyelitis Persistent pain/pain syndromes (CRPS) Tendon (rupture, lag, trigger, tenosynovitis) Delayed union/nonunion/malunion Radioulnar (synostosis, disturbance)
Conclusions External fixators still have a role in the
treatment of distal radius fractures
Spanning ex fix does not completely correct fracture deformity by itself
Should usually combined with percutaneous pins (augmented fixation)
Conclusions new plating techniques allow for
accurate and rigid fixation of fragments
Plating allows early wrist ROM
Volar, smaller and more anatomic plates are better tolerated
combination treatment is often needed
Olecranon Fracture Forearm Fractures (including Galleazi and
Monteggia)
Commonly asked questions: Volkmann’s Ischaemic Contracture Reflex Symathetic Dystrophy (Sudeck’s
Osteodystrophy)
Important topics (must read): Bennet’s and Rolando’s Fractures Scaphoid Fractures