Orthopedic Fracture Management Quiz

Fractures & Dislocations Of The Upper Limb

• Elbow dislocations constitute 10% to 25% of elbow injuries. Among upper extremity injuries in adults, elbow dislocation ranks second only to shoulder dislocation.
• Elbow dislocations are categorized into simple and complex patterns.
• Simple dislocations involve only ligamentous injury without any fractures. They can be anterior or posterior.
• Posterior dislocations are the most common type and are further classified based on the direction of the dislocated ulna (posterior, posteromedial, posterolateral, direct lateral).
• Complex dislocations include associated fractures, such as of the radial head, coronoid process of the ulna, and the olecranon. The "terrible triad" represents a dislocation with injuries to the coronoid process, radial head, and the posterior lateral dislocation of the elbow joint. This may be associated with nerve or vascular injury (e.g., ulnar/median neuropraxia, brachial artery injury). Ulnar collateral ligament tears can also occur.
• In children under 10 years, posterior dislocations (PEDs) are the most common type of joint dislocation, often caused by falling on an outstretched hand.
• Elbow dislocations may lead to dislocations caused by axial compression, valgus stress, arm abduction, and forearm supination. Anterior dislocations originate from direct force to the posterior forearm with the elbow flexed, which is less common.

Treatment

• Simple posterior dislocations are treated via closed reduction under sedation, followed by fixation in a plaster cast or posterior splint with the elbow at 90 degrees for 2-3 weeks. Early active range of motion exercises are crucial.
• Complex or unstable dislocations, severe soft tissue injuries, or bony entrapment require open reduction with or without internal fixation. Ulnar collateral ligament repair is often necessary.

Reduction of Posterior Elbow Dislocation

• The palm-palm technique involves grasping the patient's hand with palms together and fingers interlocked. The examiner's elbow is placed in the patient's antecubital fossa. The examiner then pushes downward on the patient's distal humerus with their elbow, assisting the dislocated elbow back into its anatomical position.

Rehabilitation Considerations

• Extended casting and prolonged immobilization should be avoided to prevent post-traumatic stiffness in simple elbow dislocations.
• Early active range of motion (ROM) is key for successful outcome.
• Elbow splinting for 5-7 days allows for soft tissue rest while compressive dressings and ice help control swelling.
• Starting at day 5-7, a hinged elbow brace (30-90 degrees) is used and active ROM begins.
• Active ROM promotes muscle activation, assists with elbow stability, and increases cross-joint compression. Increasing the brace's range of motion by 10-15 degrees per week is standard.
• The 2 week period following the injury should avoid passive ROM, valgus stress, abduction and external rotation, and forced terminal extension to avoid disrupting MCL healing which could lead to instability or recurrent dislocations.
• Strengthening and resistive exercises are avoided during this time. Training can resume after 6-8 weeks and elbow flexion returns before extension. Full flexion can be expected in 6-12 weeks and extension might take 3-5 months.

Radial Head Fracture

• Radial head fractures often originate from a fall on an outstretched arm (minimal/moderate flexion), which results in a valgus pronation stress that pushes the radius against the capitulum of the humerus. A direct blow to the elbow can less frequently cause this.
• Most common complication is limited ROM (10-15 degrees). Mason classification of radial head and neck fractures, depending on fracture displacement: Type I (undisplaced), Type II (marginally displaced), Type III (comminuted), Type IV (associated with dislocation).
• Treatment depends on the fracture type:
• Type I: immobilization in a cast for 3 weeks
• Type II: ORIF and cast immobilization for 2 weeks
• Type III: ORIF or radial head excision, 2-week cast immobilization
• Type IV: radial head resection or replacement.

Forearm Bone Shaft Fracture

• Monteggia fracture dislocation: Fracture of the upper third of the ulna with anterior displacement of the upper ulnar fragment causing anterior dislocation of the radius and associated superior radio-ulnar joint dislocation. ORIF is necessary, or the dislocation will likely reappear.
• Galeazzi fracture dislocation: Fracture of the distal 1/3rd radius resulting from rotational force and associated inferior radioulnar joint dislocation. Conservative treatment may cause redisplacement and is thus usually followed by ORIF.

Distal Radial Fractures

• Colles' fracture: Extra-articular fracture of the distal radius, typically resulting from a fall onto an outstretched dorsiflexed (extended) hand. It is common in elderly people (osteoporosis), presenting with a 'dinner fork' deformity (dorsal displacement).

• Smith's fracture: Also known as a reverse Colles' fracture, occurs from a fall and palmer-flexed wrist, resulting in palmer displacement. The management is analogous to Colles' fracture, except a focus on regaining wrist flexion.

• Barton's fracture: Intra-articular distal radius fracture with volar (palmer) or dorsal displacement. Managed with ORIF.

• Radial Styloid fracture (Chauffeur fracture): Compression of the scaphoid against the styloid. Non-displaced cases are treated with casting; displaced cases require surgical fixation.

• Carpal bone fractures: The majority are scaphoid fractures (50-80%), often caused by falling on an outstretched hand with a deviated wrist, resulting in an extreme dorsiflexion and radial compression to the hand. Scaphoid fracture of the distal pole heals in 2-3 weeks, while those of the waist and proximal pole may need 8 to 12 weeks of immobilization and the lack of direct blood flow (radial artery) makes the proximal pole vulnerable to necrosis.

• Lunate fractures: Frequently caused by FOOSH mechanism, with the blood supply entering the distal/proximal ends. High risk of avascular necrosis. Treatment: Non-displaced cases typically receive short arm casts; displaced fractures typically require surgical fixation.

• Metacarpal fractures: Type I: Bennett's fracture (oblique base of 1st metacarpal, dislocation/subluxation of the carpometacarpal joint). Sometimes described as a "T" or "Y" shaped fracture, called a Rolando’s fracture requiring surgical fixation if unstable. Type II: Boxer fracture (neck fracture of the 4th or 5th metacarpal, closed fist impact). This type of fracture is typically treated with immobilization (buddy taping, casting, splinting).

Complications

• Malunion: Colles fracture can heal with some malalignment (radius foreshortened and dorsally displaced), leading to limitations in full wrist flexion and ulnar deviation/pronation.
• Avascular necrosis is a complication that can occur after a fracture, especially in the scaphoid and lunate bones. The avascular necrosis arises because there is an interruption in the blood supply.
• Reflex sympathetic dystrophy (RSD): Chronic pain, swelling, vasomotor issues in an extremity, often after injury. Early identification of RSD is crucial and requires prompt medical intervention. Physical therapy that focuses on limiting pain, edema and regaining range of motion is typically part of the treatment.

Treatment and Rehabilitation Protocols

• Treatment and rehabilitation protocols vary based on the specific fracture/dislocation type. Many involve immobilization (e.g., casts, splints) for varying durations, specific exercises, and possible surgical interventions.

General

• Active range of motion exercises are generally encouraged in many protocols.
• Avoiding passive movements for at least 14-21 days, and valgus stress, abduction, and external rotation for certain conditions is generally recommended.
• Maintaining good communication with the treating surgeon about recovery milestones, weight lifting restrictions, and the recovery timeline, throughout the healing process is crucial.