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
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