Applied ER Ortho: Upper Limb Fractures “Tips and Tricks…”

1. Applied ER Ortho:Upper Limb Fractures“Tips and Tricks…” University of Calgary Academic Rounds September 26, 2009 Matt Petrie

2. Applied ER Ortho A whirlwind tour… Introduction questions…

3. Today’s Menu Appetizers: Orthopedese Reductions Main’s: Wrist Forearm Selected Carpal Bones Elbow Metacarpals Phalanges/Phalanx Sides: Humerus Pediatric Elbow Dessert: Elbow Dislocation Pearls Shoulder Dislocation Pearls

4. DISLAIMER: ‘A note on Eponym’s’ • May be helpful for pattern recognition or older surgeons • Use anatomical terms

5. How to speak orthopedese

6. Case: Mrs. Colles

7. Describing Fractures: I ABCD2 O I) Intro: A) Area B) Bone C) Character D) Displacement (where) A) Angle/Apex B) Bone Length C) Closed D) Dysfunction O) Other injuries/info 56yo RHD female pianist Right, Distal Radius Comminuted 20% displaced (radial) And which fragment 30 degrees, apex volar Shortened (1cm) Closed Neurovascular status Ulnar styloid fracture Surgical pertinent facts Rotation Intra-articular: gap/step Mortise, DRUJ, etc.

8. Describing Fractures: Mrs. Colles

9. Description Please?

10. General Management Principles • Analgesia • Evaluation • Anesthesia • Reduction • Immobilization • Instruction • Disposition/Referral *Note: Anesthesia ≠ Analgesia

11. General Guidelines Acceptable angulation of Fractures: -Adults: 10 degrees -Pedes: 30 degrees -Exceptions: 4th, 5th MC Immobilization Time: 6-8 weeks -Exceptions: Tibia, Scaphoid, Elderly Choice of Material: -Displaced/Reduced: plaster -Undisplaced: dealer’s choice

12. General Guidelines Fractures that don’t need ortho (but still need follow up) • non-displaced buckle fracture (non salter harris) • Minimally displaced phalangeal/phalanx • Small avulsion fractures (most) • Minimally displaced clavicle fracture • Distal phalanx

13. General Guidelines • Fractures which require a phone call • *Open* • Neurovascular compromise (esp. post reduction)* • Intra-articular with step/gap of >1mm • All Salter Harris II and up • Angulation >10 deg in adults • 30 deg. In pedes (post reduction) • > 50% Displaced long bone fracture • Midshaft forearm, humerus

14. General Guidelines Fractures which require a phone call: continued • ++ comminuted fractures • All fracture dislocations • Unstable fractures

15. Fracture Reduction Principles: • Think about the mechanism • Adequate analgesia • Prolonged traction (muscle tension) • Accentuate deformity • Correct deformity • Maintain traction • Splint/Cast to correct deformity • Three point molding

16. Analgesia and Treatment? Reduction Technique? Casting position?

17. Distal Radius Fracture Principles A) Length (wrt ulna) B) Volar Tilt Angle

18. Wrist Normals

19. Radial Inclincation: 23 deg.

20. Volar Tilt:

21. Volar Angle: 11 deg. 11 Normal:11 degrees 90

22. Type of Fracture?

23. Barton: Subluxation of Carpus

24. Smith: Flexion FOOSH

25. Type/Name of Fracture? Monteggia

26. Type/Name of Fracture? Both Bones Forearm Fracture • Management? • Reduction as necessary (+- fluoro) • Cast?

27. Type/Name of Fracture? • Galleazzi • MUGR • Monteggia: ulna # • Galleazzi: Radial #

28. Diagnosis? Scapho-lunate dissociation, and? - 1-2mm normal, >3mm abnormal

29. Don’t miss this one… • Peri-lunate dislocation

31. Your Honour…

32. Lunate Dislocation

33. Perilunate • Lunate:

34. Diagnosis? Scaphoid • Snuffbox tenderness • Blood supply distal to proximal • Zones: waist • Risk of AVN • Prolonged casting: SPICA • 10 days x-ray vs bone scan MRI/CT

35. Mid-shaft humerus Fracture 90 y.o. female Management? 40 y.o. male hockey player Management? Sugar Tong Splint, Clinic Reduction, ST splint, OR

36. Management? 14 yo Male 75 y.o. female

37. Elbow: • Xray Pearls • Injury/Fracture Patterns

38. Elbow: The Lateral is Key Normal Ant./Post. Fat pad

39. Elbow: The Lateral is Key

40. Elbow: The Lateral is Key Anterior Humeral Line Middle 1/3 Capitellum Radiocapitellar Line (Dot on the i)

41. Elbow: Lateral Monteggia #

42. Supracondylar Fracture: Type 1

43. Supracondylar Fractures Type I: minimal/no displacement  conservative Type II: Posterior cortex intact  ortho/ORIF Type III: No cortical contact  ORIF II III ** Beware neurovascular compromise

44. Adult: Intercondylar Usually ‘T’ type • Splint: 3 sided* • Ortho referral

45. Elbow: Continued Diagnosis: Olecranon Fracture Mechanism: Forced extension in flexion, +- blow Management: ORIF

46. Elbow: Radial Head Fracture • Minimal displacement (<1mm): • Sling, ROM, Fracture Clinic (arm immobilizer)

47. Metacarpal Fractures Reduction and treatment?

48. Metacarpal Fractures Reduction: • Hematoma block or regional technique • MCP and PIP at 90 degrees • ‘upward pressure’ on middle phalange • Traction • Pressure on dorsal aspect of fracture Treatment: • Volar or ulnar splint • In ‘safe’ position • Refer to hand/plastics

49. Metacarpal Fractures Guidelines: ( i.e. ok for clinic f/u) Metacarpal Shaft: • Length: < 5mm shortening • Rotation: minimal • *No scissoring • *No weakness • Angulation: • 10 degrees at 2nd and 3rd • 20 degrees at 4th • 30 degrees at 5th

50. Metacarpal Fractures Neck Fractures: • Tolerate greater angulation • Up to 40 degrees for 4th and 5th (volar) • Jahss maneuver • Gutter/Volar in safe position • Clinic F/U