COMMON ADULT FRACTURES

1. COMMON ADULT FRACTURES Dr. Munir Saadeddin, FRCSEd Associate Professor Consultant Orthopaedic Surgeon Department of Orthopaedics College of Medicine King Saud University Medical City

2. Original Lecture is by Dr. Sultan Al Dosary

3. Fractures to be discussed • CLAVICLE FRACTURE. • HUMERUS (PROXIMAL& SHAFT). • BOTH BONES FOREARM FRACTURS. • DISTAL RADIUS FRACTURES. • HIP FRACTURES. • FEMUR SHAFT FRACTURE. • TIBIAL SHAFT FRACTURES. • ANKLE FRACTURES.

4. CLAVICLE FRACTURE •  Clavicle is S shape bone. •  It is anchored to scapula via ACJ. •  It is anchored to trunk via SCJ. •  Most of fractures occurs as a result from fall onto shoulder.

5. Fractures are classified into: proximal or medial, middle and lateral third fractures. Most of fractures are of middle third.

6. Clinical findings: Fracture is easily diagnosed, especially if displaced. Injury to brachial plexus and subclavian artery/vein may be present Rarely, Pneumothorax can occur.

7. Plain X-rays: AP chest. Clavicle special view.

8. Treatment Most of clavicle fractures are treated with a sling.

9. Figure of eight Bandage

10. Fracture Clavicle with wide gap

11. Few fractures should be treated surgically with open reduction and internal fixation. Indications: Skin is tented Severe displacement: 100% displacement 2 cm overlap. Treatment by plating.

12. PROXIMAL HUMERUS ANATOMY Proximal humerus has four anatomic parts: Head. Greater tubrosity. Lesser tubrosity. Neck. Anatomic neck vs.Surgical neck

13. PROXIMAL HUMERUS FRACTURE In younger patients: violent trauma In older patients: minor trauma Most fractures are minimally displaced

14. PHYSICAL EXAM • Expose the shoulder very well. • Look for fracture signs • Check the skin. • Peripheral N/V exam. • Axillary nerve: lateral skin patch. • Examine cervical spine

16. X-RAYS AP Lateral Axillary views. CT scan for displaced fractures

17. X-RAYS Fracture is defined by the fragments displaced. Displacement: more than 1 cm.

18. NORMAL AP SHOULDER

20. If fracture is not displaced: • Treatment with sling and NWB of UE for 6-8 weeks. • Early ROM exercises after 2-4 weeks. • Normal function can be resumed after 3-4 months.

21. If the fracture is displaced: Surgery is indicated. ORIF is indicated (plate and screws). Shoulder hemi-arthroplasty is indicated in some cases.

22. HUMERAL SHAFT FRACTURE It can be classified based on location of fracture. (proximal, middle and distal) Fracture symptoms On exam: * Skin * N/V • * Compartment • Watch for radial nerve palsy:

23. X-RAYS

24. Almost all humeral shaft fractures can be treated non-surgically. • Closed reduction. • Functional brace x 4-6 weeks + NWB. • Early ROM of elbow and shoulder.

25. U Shaped slap of POP

26. Surgery is indicated for specific conditions like: Failure to get acceptable reduction. • Segmental fracture • Open fracture( especially with radial N injury) • Obese patient • Bilateral fracture • Floating elbow (forearm and humerus) • Delayed union or non-union Surgery: ORIF with plate and screws

30. Exploration Radial Nerve( Plating done for humeral fracture and radial nerve explored and protected)

31. BOTH BONES OF FOREARM FRACTURES Forearm is complex with two mobile parallel bones. Radius and ulna articulate proximally and distally. It is very unlikely to fracture and displace only one bone without disruption of their proximal or distal articulation: Fractures to be discussed: • Both bones fractures. • Montegia fracture. • Galeazzi fracture.

32. Fractures are often from a fall or direct blow. Both bones fractures: Means radius and ulna are broken. Monteggia fracture: Means proximal or middle third ulna shaft fracture with dislocation of radius proximally (at elbow). Galeazzi fracture: Means distal third shaft radius fracture with disruption of DRUJ.

33. MONTEGGIA: Anterior and Posterior fracture dislocation

34. Montegia fracture dislocation: Lateral

35. GALEAZZI# dislocation

36. GALEAZZI fracture dislocation

37. CLINICAL Symptoms and signs of fracture • Check the skin. • Check the compartments of forearm. • Check ulnar, median and radial nerves . • Check vascularity: color, temperature, capillary refill and pulses.

38. INVESTIGATIONS Plain x-rays: 2 orthogonal views( AP and Lateral) CT scan if fracture extends into joint.

39. TREATMENT Both bones fracture: Reduce and splint at ER/clinic (temporary). Are treated almost always with ORIF: (plate and screws). Montegia fracture: ORIF ulna and closed reduction of radial head. Galeazzi fracture: ORIF radius and close reduction of DRUJ

40. Plating Galeazzi fracture and closed or spontaneous reduction of Distal radio Ulnar Joint( DRUJ )

41. DISTAL RADIUS FRACTURES • Most common fractures of upper extremity. • Most frequently are seen in older women( osteoporosis ) • Young adults fractures are most commonly secondary to high energy trauma.

42. Mechanism of Injury of distal radius

43. Extra-articular: Colles fracture: dorsal angulation, shortening and radial deviation. Smith’s fracture: shortening and volar angulation. (reverse Colles’). Intra-articular: Barton’s fracture: volar or dorsal. Others.

44. Colles Fracture

45. SMITH’S fracture

46. Barton Intra-articular fractures

48. Clinical appearance: garden spade( Smith) /and dinner fork(Colles)

49. X-RAYS Smith’s Colles’

50. Extra-articular fractures: Closed reduction and cast application. Immobilization for 6-8 weeks. ROM exercises after cast removal. Surgery: if reduction is not accepted. Intra-articular fracture: The presence of a step more than 2 mm is an indication for surgery. ORIF with plate and screws. Management of wrist fractures