Review of Common Fractures PDF

Review of common fractures Lecturer name & title  Shoulder fractures Clavicle Proximal humerus Humeral shaft Clavicle fractures 2.6 % of fractures The medial one-third protects the brachial plexus, the subclavian and axillary vesse...

Review of common fractures Lecturer name & title  Shoulder fractures Clavicle Proximal humerus Humeral shaft Clavicle fractures 2.6 % of fractures The medial one-third protects the brachial plexus, the subclavian and axillary vessels, and the superior lung. Mechanism of injury: fall onto the affected shoulder, direct hit to clavicle or fall on outstretched hand. Clavicle fractures Conservative treatment: Sling immobilization for 4-6 weeks with gentle ROM Sling immobilization to counteract the weight of the arm and neutralize Sternocleidomastoid action Clavicle fractures Surgical treatment: Indications: Open fracture Associated neurovascular compromise Skin tenting Clavicle fractures Surgical treatment: Lateral end fractures have high incidence of non-union open reduction and internal fixation Standard treatment by ORIF using plate and screws  Proximal Humerus fractures 4% of all fractures A proximal humerus fracture in an older individual after a simple fall is considered a fragility fracture Mostly non-displaced The shoulder has four osseous segments: Humeral head Lesser tuberosity Greater tuberosity Humeral shaft  Proximal Humerus fractures Conservative treatment Non-displaced fractures Collar & cuff immobilization (gravity force keeps # alignment) Early shoulder motion at 7 to 10 days consisting of pendulum exercises and passive range of motion Early radiographic follow-up to detect loss of fracture reduction Active range-of-motion exercises are started 6 weeks after injury  Proximal Humerus fractures Surgical treatment ORIF for young patients, with repair of the tuberosities or rotator cuff Hemiarthroplasty for older patients, with repair of the tuberosities or rotator cuff  Humeral shaft fractures Common injury, representing 3% to 5% of all fractures Humeral shaft extends from the pectoralis major insertion to the supracondylar ridge. A careful neurovascular examination is essential, with particular attention to radial nerve function Humeral shaft fractures Radial nerve at risk Distal 1/3 spiral fracture Nerve is immobile as it emerges from lateral intermuscular septum Injury results in wrist and fingers drop  Humeral shaft fractures Conservative treatment: Historically was the standard U shaped Slab Hanging cast Opposite to clavicle fractures, the hanging cast allows gravity to align fracture Healing time 8-12 weeks  Humeral shaft fractures Surgical treatment: Indications: displaced #, Open #, Neuro-vascular injury, Non-union Options: Posterior plating requires identification and dissection of the radial nerve Intra-medullary nailing  Forearm fractures Radial head Combined: Isolated Monteggia ulna or Galeazzi radius shaft Distal radius: Colles’ Smith’s Barton’s Chauffer’s Radial head fracture The radial head plays a role in valgus stability of the elbow Caused by fall onto outstretched hand Treatment: Non-displaced fractures are treated by sling immobilization for 2 weeks followed by early ROM Displaced fractures can be treated with plate / screws or prosthetic replacement Radial head fracture  Isolated Ulna or Radius shaft Fractures Fracture of the radial shaft alone is very rare, and fracture of the ulna alone is uncommon. The forearm acts as a ring; a fracture that shortens either the radius or the ulna results either in a fracture or a dislocation of the other forearm bone at the proximal or distal radioulnar joint. Direct injuries to the ulna are an exception– the ‘nightstick fracture’.  Isolated Ulna or Radius shaft Fractures Non-displaced or minimally displaced fractures may be treated with plaster immobilization Displaced or angulated fractures require fixation with plate and screws  Monteggia Fracture dislocation 2 elements: - Fracture of proximal 1/3 Ulna - Dislocation of radial head Monteggia injuries are easily missed, particularly the radial head dislocation, as the ulnar shaft fracture can be distracting. All Monteggia fractures are considered unstable and require intervention. Closed reduction and cast in children can be attempted, but in adults requires ORIF  Monteggia Fracture dislocation Once the ulnar # is reduced and fixed, the radial head dislocation reduces in position  Galleazi Fracture 2 elements: - Fracture of distal 1/3 of radius - Dislocation of the distal radio-ulnar joint (DRUJ) Three times as common as Monteggia fracture 'Fracture of necessity' as it always requires surgical stabilization Complication rate around 40% (non-union, instability, stiffness..) Radius is fixed with plate and DRUJ is pinned with K-wires if unstable Distal radius fractures Colles’ #: Dorsally displaced, extra- articular Smith’s #: Volarly displaced, extra- articular Barton #: Fracture-dislocation of radiocarpal joint with intra-articular # involving the volar or dorsal lip (volar Barton or dorsal Barton #) Chauffeur’s #: Radial styloid # Colles’ Fracture The most common fracture encountered in orthopedic practice Distal radius fracture with dorsal angulation 'Dinner fork' deformity clinically Mechanism of injury is fall onto outstretched hand with wrist extended Can result in Median nerve compression Colles’ Fracture Treatment options: Closed reduction under haematoma block and casting Closed reduction & percutaneous K-wire fixation Open reduction & internal fixation with plate Smith’s fracture Distal radius fracture with volar angulation 'Garden spade' deformity clinically Mechanism of injury is fall onto flexed wrist This is an unstable fracture that requires ORIF  Hand fractures Boxer’s # Bennett’s # Scaphoid #  Scaphoid Fractures Scaphoid fractures are the most common carpal bone fractures If patient has normal radiographs but there is a high level of suspicion can immobilize in thumb spica and re- evaluate in 12 to 21 days CT or MRI may be needed to confirm diagnosis Total healing time of 10-12 weeks  Scaphoid Fractures Scaphoid has retrograde blood flow Blood supply: - major blood supply is dorsal carpal branch (branch of the radial artery) - minor blood supply from superficial palmar arch (branch of volar radial artery) creates vascular watershed and poor fracture healing environment The more proximal the fracture, the higher risk of non-union  Scaphoid Fractures Clinical provocative tests: anatomic snuffbox tenderness dorsally scaphoid tubercle tenderness volarly scaphoid compression test  Scaphoid Fractures Treatment Thumb spica cast: stable undisplaced #s 8-12 weeks ORIF: Displaced #s Gap > 1mm Headless screw Boxer’s Fracture Fifth metacarpal neck fracture resulting from direct trauma to the clenched fist. Conservative treatment: ulnar gutter splint and buddy taping is standard treatment the wrist extended at 20 degrees, 60-70 degree of flexion at the metacarpophalangeal (MCP), and interphalangeal joints in extension (Edinburgh position) Boxer’s Fracture Surgical treatment: for open fractures, significant angulation, rotational deformity or intra- articular extension K wiring ORIF with plate & screws Bennett’s Fracture the most common fracture involving the base of the thumb Intraarticular fracture that separates the palmar ulnar aspect of the first metacarpal base from the remaining first metacarpal typically caused by axial loading on a partially flexed metacarpal Requires reduction and fixation with K-wires  Hip fractures Inter- trochanteric Femoral neck fractures fractures Sub- trochanteric fractures Femoral neck fractures Occur in the region between the head of femur and inter- trochanteric region These fractures are prone to non-union because of: - Being intracapsular, hip synovial fluid impedes the healing process - Loss of blood supply to femoral head and neck Femoral neck fractures Blood supply to the femoral head: Fracture disrupts the lateral ascending cervical branches of the medial femoral circumflex artery. This increases the risk for avascular necrosis of femoral head Femoral neck fractures Fracture neck of femur in a young adult is a rare occurrence and signifies a high energy trauma. The principle of treatment is anatomic reduction and fixation, as early as possible, to reduce the chances of avascular necrosis and non- union Fracture is usually treated with closed reduction and fixed with cannulated screws Femoral neck fractures The geriatric patients account for majority of the cases. high mortality in geriatric age group (20–35% within the first year of injury) Joint replacement is the preferred modality of treatment in old patients Hemiarthroplasty for the less active patients or total hip replacement for the active and fit patient  Inter-trochanteric fractures occur in the area between the greater and lesser trochanter and may involve these two structures. Inter trochanteric fractures make up 45% of all hip fractures This region consists of weight bearing trabeculae and has a good amount of cancellous bone and vascularity thus minimizing the risk of avascular necrosis and non- union  Inter-trochanteric fractures Inter trochanteric fractures are usually managed by surgical fixation. The choice of implants depends upon the fracture pattern Dynamic Hip Screw (DHS) has been, for long, the standard implant of choice for stable fractures Proximal Femoral Nail (PFN) has recently become the treatment of choice specially for unstable fractures  Sub-trochanteric fractures proximal femur fractures located within 5 cm of the lesser trochanter. Subtrochanteric fractures constitute 10–30% of all hip fractures Can be difficult to reduce intra- operatively due to muscle forces Risk of non-union or mal-union Sub-trochanteric fractures Surgical fixation with intra-medullary nail is the treatment of choice  Knee fractures Patella # Tibial plateau # Patella Fractures Caused by direct trauma or rapid contracture of the quadriceps with a flexed knee Diagnosed clinically with the inability to perform a straight leg raise and sometimes palpable fracture gap Displacement of the fracture is caused by pull of Quadriceps tendon superiorly and patellar tendon inferiorly Patella Fractures Undisplaced fractures with intact extensor mechanism (patient able to perform straight leg raise) can be treated conservatively in a cylinder cast or knee immobilizer with full weight bearing Patella Fractures Displaced fractures are treated surgically with tension band wiring Tension band biomechanically transforms tension forces into compression forces across the fracture thus promotes healing Tibial Plateau Fractures Intra-articular fractures The main mechanism of injury is a varus or valgus load along with or without an axial load Tibial plateau fractures may be lateral, medial, or bicondylar. Can be associated with: - Compartment syndrome - Vascular injury - ligament injury - Significant soft tissue injury Tibial Plateau Fractures Non-displaced fractures can be treated conservatively with hinged knee brace and non-weight bearing mobilization Displaced fractures need ORIF with plate and screws In case of severe soft tissue compromise, a temporary external fixator can be applied until soft tissues resolve, followed by delayed fixation with plate and screws  Foot & ankle fractures Ankle # Calcaneus # 5th Metatarsal base # Ankle Fractures Ankle joint is a modified hinge joint consisting of tibia, fibula, and talus 3 ligamenotus complex stabilize ankle: - Deltoid ligament - Lateral ligament complex (ATFL, CFL, PTFL) - Syndesmosis Ankle Fractures Anatomical ankle fracture patterns: Isolated medial malleolus # Isolated lateral malleolus # Bimalleolar ankle # (medial and lateral malleoli) Trimalleolar ankle # (medial, lateral & posterior) Ankle Fractures Undisplaced or minimally displaced stable fractures can be treated in a cast or walking boot Displaced fractures require ORIF Temporary external fixation may be needed if soft tissues are swollen until the swelling subsides  Calcaneus Fractures Calcaneus fractures are the most common tarsal bone fractures and are associated with a high degree of morbidity and disability most commonly occur due to to axial loading (e.g. fall from height) hence the name (Lover’s #) CT scan is essential to determine the extent of the fracture and for pre- operative planning Calcaneus Fractures Extraarticular fractures account for 25 % of calcaneal fractures. These typically are avulsion injuries of either the calcaneal tuberosity from the Achilles tendon, the anterior process from the bifurcate ligament, or the sustentaculum tali. Intraarticular Fractures account for the remaining 75%. The talus acts as a hammer or wedge compressing the calcaneus at the subtalar joint causing the fracture. Calcaneus Fractures Treatment options: Treatment is nonoperative versus operative based on fracture displacement and alignment, associated soft tissue injury, and patient risk factors Cast immobilization ORIF (displaced #s)  5th metatarsal base fractures 5th Metatarsal Base Fractures are among the most common fractures of the foot Predisposed to poor healing due to the limited blood supply to the specific areas of the 5th metatarsal base 5th Metatarsal base is divided into 3 zones:  5th metatarsal base fractures Zone 1: Avulsion # / Dancer’s # / Pseudo-Jones # Proximal tubercle avulsion Due to contraction of the peroneus brevis Zone 2: Jones # Metaphyseal-diaphyseal junction Vascular watershed area Increased risk of nonunion  5th metatarsal base fractures Zone 3: Proximal diaphyseal fracture Distal to the 4th-5th metatarsal articulation Stress fracture in athletes  5th metatarsal base fractures Treatment Restricted weight-bearing and immobilization in cast or walking boot for 6 to 8 weeks. Operative management should be considered in scenarios of professional athletes or cases of delayed fracture healing beyond 10 weeks ORIF with intra-medullary screw or tension band wiring Questions?