Common fractures and dislocations

1. Filip Gilic CCFP-EM Common fractures and dislocations

2. A word on terminology

3. Relations of fragments • Undisplaced/displaced: in anatomical alignment/not in alignment • Translated: expressed either in mm or % of the thickness of the bone (eg translated 50% of the thickness of the radius) • Angulated. Measured in degrees off the long axis of the bone, described in terms of where the apex points • Distracted- separated by a gap • Shortened- shorter then anatomic alignment • Intraarticular: going into the joint

8. Hand anatomy

9. Hand exam (for fractures) • Look, Feel, Move, NVS • Palpate all phalanxes/metacarpals/carpals/distal radius and ulna • Axially load all fingers • Look for scissoring (proximal phalanx/metacarpal) • Check grip strength (proximal phalanx/metacarpal) • NVS (median, ulnar, radial)

10. Hand fractures Distal/middle phalanx: generally buddy tape/gutter. If significant joint involvement (>1/3 surface) send to ortho for possible pinning Proximal phalanx: potentially very disabling. Gutter/buddy tape if ZERO displacement or scissoring. Any angulation/translation scissoring: send to ortho Metacarpals:The closer to the thumb, the more potentially disabling. Acceptable angulation in dorsal plane: 40 deg 5th 20 deg 4th 15 deg 3rd/2nd If more- reduce Can’t reduce/scissoring- ortho

11. Thumbcommonest fracture is intraarticular # of the metacarpal base Radial displacement Cousin Bennett Cousin Rollando (the comminuted guy)

12. Skier’s/Gamekeeper’s Thumb Opening of the MCP >40 deg considered a full rupture- ortho

14. Carpals • Scaphoid: commonest carpal # • hard to see # sometimes, high risk of non union/AVN • Signs of scaphoid # • Snuff box tender (test in ulnar deviation) • Axial load of thumb • Tender scaphoid tubercle • 2 out of 3= thumb spica + ortho in 2 w for re-x-ray or bone scan

15. Scaphoid #

16. Lunate injuries • Rarer then scaphoid injuries but easily overlooked as everyone is only looking at the scaphoid • Most important carpal bone as it presents 2/3 of articular surface with radius • Fractures here present risk of AVN as well • Lives right next to scaphoid tubercle-little dimple distal to radius at the base of 3rd finger line

17. Scaphlunate dislocation:ortho for ligamentous repair

18. Lunate dislocation:commonest carpal dislocations3 C’s disrupted (line up of radius/lunate/capitate)ortho

19. Perilunate dislocation

20. Colle’s/Smith’sColles (points down) Smiths (points up) Ortho after you reduce it

21. Harmless Torus fracture of Distal radius-splint

22. Elbow Slight anterior fat pad Radial head Capitellum Ocelranon

25. Elbow Adults: commonest is radial head fracture Can be subtle 2 clues Abnormal fat pad sign Displacement of the radiocapitellar line Remember: Posterior fat pad is ALWAYS pathological Anterior is likely pathological if wide Rx: sling if undisplaced, ortho if displaced

26. In children, supracndylar (ie distal humerus fractures) are commonest • Also can be subtle • Also offer 2 clues • Abnormal fat pad • Displacement of the anterior humeral line • Undisplaced- full arm flaster with elbow flexed for 4 weeks. DO NOT keep them in it longer as they will contracture • Displaced- ortho • High Risk of NV compromise if displaced

28. Intraarticular olceranon fractures: need ORIF

29. Pulled elbow! • Fun to reduce • Suppination/flexion +/- hyperpronation • Pronation flexion • If unsuccessful, put them in flexion spint, it will generally self reduce in a day or two.

30. Humerus • Proximal humerus and SURGICAL neck of humerus generally not a big deal • Cast and send to ortho in a week or two • ANATOMICAL neck (above the surgical neck) -surgery CAST ORTHO

31. BREAK!!!!

32. Shoulder

33. Shoulder exam • ROM- active/passive • Impigement • AC joint • Supraspinatus – ABducts • Subscapularis- Internally rotates • Infraspinatus/Teres Minor- Externally rotates • Biceps tendon

34. Shoulder X rays

35. AC joint injury Type I: N x ray Type II: acromion/clavicle overlap by 50% or more Type III and above- complete elevation of clavicle Type I + II: RICE + sling Type III –ortho (controversy of surgery vs conservative)

36. Dislocations • Most are anterior. • Posterior in EEE (epileptics, electricity, EtoH)

37. Anterior Normal Dislocated

38. Posterior Posterior Normal Anterior

39. Reduction method • SEDATE, SEDATE, SEDATE • Arm ADDucted, flexed at elbow 90 deg • Externally rotate while adducted • If fully rotated and no reduction (pop), elevate the arm overhead.

40. Hip • #: Shortened, Adducted, externally rotated- ortho • Dislocation: Shortened, Adducted, INTERNALY rotated • Dislocation- a true ortho emergency. Delay in reduction increases chances of AVN. • Mostly see in MVAs when a flexed knee is forced backward (ie not belted, flies out of the seat into the dashboard) • 90% are posterior

41. Reduction • Allis manouver • SEDATE • Flex the hip and the knee. • Get up on the gurney • Lift the flexed leg • Assistant stabilizes the pelvis and thus provides countertraction • Internal/external rotation

42. Kiddie hips Overweight pubertal boys 4-10 y.o. kids Legg Calves Perthe (AVN) SCFE

43. Femur • Bleeds. A lot. • High possibility of NV injury • Traction splint (if you have one), unless its open.

44. Knee • Most injuries are ligamentous or meniscal • Make sure you don’t miss tibial plateau fractures- they generally need an operation- usually axial load injuries • Their X ray can be very subtle- use CT

45. Osgood Shclahter (teens)essentially avulsion fracture/tear of the tibial tuberosity

46. Ankle X rays

47. Ankle The higher the fracture site, The higher the energies involved And higher chance of needing ortho If bimaleolar, generaly displaced- ortho operation

48. Trimaleolarbimaleolar + posterior tibia= operation

49. Maissoneuvein high energy ankle fractures make sure you don’t miss a Maissoneuve

50. Bones of the foot