BONE FRACTURE� MAGNUM OPUS

Issah J. kiswagala

(M.B.B.S)

BONE

• Bone tissue (osseous tissue) is a hard tissue, a type of dense connective tissue.
• The Greek word for bone is Osteon
• Bones protect the various organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, and enable mobility.
• Bone tissue is made up of different types of bone cells. Osteoblasts and osteocytes are involved in the formation and mineralization of bone; osteoclasts are involved in the resorption of bone tissue.

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• In the human body at birth, there are approximately 270 bones present; many of these fuse together during development, leaving a total of 206 separate bones in the adult, not counting numerous small sesamoid bones.
• The largest bone in the body is the femur or thigh-bone, and the smallest is the stapes in the middle ear.

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• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154590/

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PART OF BONES

Cortical bone

• The hard outer layer of bones is composed of cortical bone, which is also called compact bone as it is much denser than cancellous bone.
• It forms the hard exterior (cortex) of bones.
• The cortical bone gives bone its smooth, white, and solid appearance, and accounts for 80% of the total bone mass of an adult human skeleton.
• It facilitates bone's main functions - to support the whole body, to protect organs, to provide levers for movement, and to store and release chemical elements, mainly calcium.

• Cortical bone is covered by a periosteum on its outer surface, and an endosteum on its inner surface.
• The endosteum is the boundary between the cortical bone and the cancellous bone.
• The primary anatomical and functional unit of cortical bone is the osteon.

Cancellous bone

• Cancellous bone, also called trabecular or spongy bone, is the internal tissue of the skeletal bone and is an open cell porous network.
• Cancellous bone is typically found at the ends of long bones, near joints and in the interior of vertebrae.
• Cancellous bone is highly vascular and often contains red bone marrow where hematopoiesis, the production of blood cells, occurs.

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Bone marrow

• Bone marrow, also known as myeloid tissue in red bone marrow, can be found in almost any bone that holds cancellous tissue.
• In adults, red marrow is mostly found in the bone marrow of the femur, the ribs, the vertebrae and pelvic bones.

CROSS-SECTION OF BONE

Bone cells

TYPES OF BONES

Bone can be classified based on both anatomy and structure

1. Anatomic
• Long bones
• Flat bones
2. Structure
• Macroscopic level
• cortical
• cancellous
• Microscopic level
• lamellar
• woven bone

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ANATOMIC CLASSIFICATION

• Long bones e.g. femur, humerus, tibia, forearm bones
• Three anatomic regions in long bones
• Diaphysis
• thick cortical bone surrounding a central canal of cancellous bone
• outer region covered by periosteum
• Metaphysis
• thin cortical bone surrounding loose trabecular bone
• Epiphysis
• end of bone that forms the articular surface
• contains the physis and the subchondral region under the articular cartilage

• Flat bones e.g. skull, pelvis, scapula
• varied structure of either purely cortical bone or cortical bone with a thin central trabecular region

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INTRODUCTION

• Fracture is a partial or complete break in the continuity of the bone.
• In more severe cases, the bone may be broken into several pieces.
• bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

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CLASSIFICATION

• Fractures are classified in various ways
• Stability
• Stable fracture and
• Unstable fracture
• Aetilogical/mechanism
• Traumatic fracture – a fracture due to sustained trauma. e.g. fractures caused by a fall, road traffic accident, fight, etc.
• Pathologic fracture – a fracture due to some underlying diseases that weaken a bone e.g. Osteoporosis, metastatic tumour to the bone, etc.

3. Soft-tissue involvement
• Closed fractures are those in which the overlying skin is intact
• Open fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed
4. Displacement
• Non-displaced fracture and
• Displaced fracture e.g. angulated, rotated, shortned

Open fracture

FRACTURE PATTERN

• Transverse fracture: a fracture that is at a right angle to the bone's long axis
• Oblique fracture: a fracture that is diagonal to a bone's long axis (more than 30°)
• Spiral fracture: a fracture where at least one part of the bone has been twisted
• Segmental fracture: is a fracture composed of at least two fracture lines that together isolate a segment of bone
• Comminuted fracture: are fractures where more than 2 bone components are created

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Fracture patterns

• Impacted fracture: a fracture caused when bone fragments are driven into each other
• Avulsion fracture: a fracture where a fragment of bone is separated from the main mass
• Compression fracture/wedge fracture: usually occurs in the vertebrae, e.g. when the front portion of a vertebra in the spine collapses due to osteoporosis

Compression fracture

• Linear fracture: a fracture that is parallel to the bone's long axis
• Greenstick fracture: occurs when a bone bends and cracks, instead of breaking completely into separate pieces.

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ANATOMICAL FRACTURE LOCATION

1. Skull fracture
• Basilar skull fracture
• Blowout fracture – a fracture of the walls or floor of the orbit
• Mandibular fracture
• Nasal fracture
• Le Fort fracture of skull – i.e. facial fractures involving the maxillary bone and surrounding structures
2. Fracture of upper limbs
3. Fracture of lower limbs

4. Spinal fracture
• Cervical fracture
• Fracture of C1, including Jefferson fracture
• Fracture of C2, including Hangman's fracture
• Flexion teardrop fracture – a fracture of the anteroinferior aspect of a cervical vertebral
• Clay-shoveler fracture – fracture through the spinous process of a vertebra occurring at any of the lower cervical or upper thoracic vertebrae
• Burst fracture – in which a vertebra breaks from a high-energy axial load

• Compression fracture – a collapse of a vertebra, often in the form of wedge fractures due to larger compression anteriorly
• Chance fracture – compression injury to the anterior portion of a vertebral body with concomitant distraction injury to posterior elements
• Holdsworth fracture – an unstable fracture dislocation of the thoracolumbar junction of the spine

COMPLICATIONS

• Complications of fractures may be classified into three broad groups, depending upon their time of occurrence.
• Immediate complications – occurs at the time of the fracture.
• Early complications – occurring in the initial few days after the fracture.
• Late complications – occurring a long time after the fracture.

CASTS

• Casting involves circumferential application of plaster or fiberglass to an extremity. Casts provide superior immobilization, but have higher complication rates.
• A cast holds a broken bone (fracture) in place and prevents the area around it from moving as it heals.
• Casts also help prevent or decrease muscle contractions and help keep the injured area immobile, especially after surgery, which can also help decrease pain.
• Spica – includes truck and one or more limbs eg. Hip Spica cast

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SPLINTS

• Splints/Slabs are non-circumferential immobilizers and they allow for swelling in the acute phase. E.g. back-slab
• Splinting is useful for a variety of acute orthopedic conditions such as fractures, reduced joint dislocations, sprains, severe soft tissue injuries, and post-laceration repairs
• The purpose of splinting acutely is to immobilize and protect the injured extremity, aid in healing, and lessen pain.
• Brace – splinting which can allow motion at adjacent joint

CAST MATERIALS

• The hard, outer layer of a cast is made of either
• Plaster e.g. Plaster Of Paris (P.O.P) or
• Fiberglass
• Cotton and other synthetic materials are used to line the inside of the cast to make it soft and provide padding around bony areas. This also pads nerves and blood vessels.
• Plaster casts can be molded into arm or leg. They come in one color, white.
• Fiberglass casts are more durable and lightweight than plaster casts. They come in a variety of colors and designs.

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CAST/SPLINT APPLICATION

• Casting and splinting both begin by placing the injured extremity in its position of function.
• Casting continues with application of stockinette, then circumferential application of two or three layers of cotton padding, and finally circumferential application of plaster or fiber-glass.
• In general, 2-inch padding is used for the hands, 2- to 4-inch padding for the upper extremities, 3-inch padding for the feet, and 4- to 6-inch padding for the lower extremities.

• Splinting may be accomplished in a variety of ways
• Begin as if creating a cast and, with the extremity in its position of function, apply stockinette, then a layer of overlapping circumferential cotton padding.
• The wet splint is then placed over the padding and molded to the contours of the extremity, and the stockinette and padding are folded back to create a smooth edge
• The dried splint is secured in place by wrapping an elastic bandage in a distal to proximal direction.
• For an average-size adult, upper extremities should be splinted with six to 10 sheets of casting material, whereas lower extremities may require 12 to 15 sheets.

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�CASTS FOR UPPER EXTREMITIES

• Short Arm Cast
• Common Uses. Non-displaced or minimally displaced fractures of the distal wrist, such as Colles and Smith fractures or greenstick, buckle, and physeal fractures in children; carpal bone fractures other than scaphoid or trapezium.
• Application. The cast extends from the proximal one third of the forearm to the distal palmar crease volarly and just proximal to the MCP joints dorsally
• Position of Function. The wrist is in a neutral position and slightly extended; the MCP joints are free.

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• Long Arm Cast
• Common Uses: Acute and definitive management of elbow, proximal and mid-shaft forearm, and wrist injuries; acute management of distal radial (non-buckle) and/or ulnar fractures in children.
• Application: The splint extends from the axilla over the posterior surface of the 90-degree flexed elbow, and along the ulna to the proximal palmar crease
• Not recommended: The posterior splint is not recommended for complex or unstable distal forearm fractures.

• Shoulder Spica Cast
• Common uses: Used for shoulder dislocations, or after surgery on the shoulder area
• Application: Applied around the trunk of the body, the shoulder, arm, and hand

• Single Sugar-Tong Splint

Common Uses:

• Acute management of distal radial and ulnar fractures.

Application:

• The splint extends from the proximal palmar crease, along the volar forearm, around the elbow to the dorsum of the MCP joints

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• Long Arm Posterior Splint
• Common Uses: Acute and definitive management of elbow, proximal and mid-shaft forearm, and wrist injuries; acute management of distal radial (non-buckle) and/or ulnar fractures in children.
• Application: The splint extends from the axilla over the posterior surface of the 90-degree flexed elbow, and along the ulna to the proximal palmar crease
• Not recommended: The posterior splint is not recommended for complex or unstable distal forearm fractures.

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• Double Sugar-Tong Splint
• Common Uses: Acute management of elbow and forearm injuries, including Colles fractures.
• Application: Physicians should start by placing a single sugar-tong splint and a second sugar-tong splint is then applied, extending from the deltoid insertion distally around the 90-degree flexed elbow, and proximally to 3 inches short of the axilla
• Advantage: The splint provides superior pronation and supination control, and is preferable with complex or unstable fractures of the distal forearm and elbow.

CASTS FOR THE LOWER EXTREMITIES

• Short Leg Cast
• Common Uses:
• Definitive treatment of injuries for lower leg fractures (ankle and foot), ankle fractures, and severe ankle sprains and strains
• Also used to hold the leg or foot muscles and tendons in place after surgery to allow for healing. May be walked on once the fracture is stable enough to bear weight without becoming re-injured
• Application: applied to the area below the knee down to the foot
• Position of Function: The ankle is flexed to 90 degrees (neutral).
• Not recommended: not appropriate for most children under the age of 3, who may kick off the short leg cast

• Leg cylinder cast/long leg cast
• Common uses: used for knee or lower leg fractures, knee dislocations, or after surgery on the leg or knee
• Application: applied from the upper thigh to the ankle or foot
• Position: usually applied with the knee bent to prevent walking on the cast

• Unilateral hip spica cast (also known as single hip spica)
• Common uses: used for thigh (femur) fractures, also used to hold the hip or thigh muscles and tendons in place after surgery
• Application: applied from below the chest to the foot of the affected leg
• Position: slightly flexed knee and hip joint

• One-and-one-half spica cast
• Common uses: used for thigh (femur) fractures, also used to hold the hip or thigh muscles and tendons in place after surgery
• Application: applied from the chest to the foot on one leg, and to the knee on the other leg, with a bar placed between both legs to keep the hips and legs immobile

• Bilateral hip spica cast (also known as double hip spica)
• Common uses: used for pelvis, hip, or thigh (femur) fractures, also used to hold the hip or thigh muscles and tendons in place after surgery
• Application:
• Long leg: applied from the chest to the feet, with a bar between both legs to keep the hips and legs immobile
• Short leg: applied from the chest to the thighs or knees

• Clubfoot cast
• Common uses: used to treat clubfoot
• Application: applied from upper thigh to toes, usually changed every 5-7 days

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FRACTURE OF UPPER LIMBS

CLAVICLE

CLAVICLE FRACTURES

CLASSIFICATION

Allman Classification

1. Group 1
• Middle 1/3 fractures
• 80% of clavicle fractures
2. Group 2
• Distal 1/3 fractures
• 15% of clavicle fractures
3. Group 3
• Proximal 1/3 fractures
• 5% of clavicle fractures

MECHANISMS OF INJURY

1. Birth trauma
• Clavicle compressed against maternal symphysis in a cephalic presentation or direct traction in a breech delivery
• 5/1000 live births
• Associated with : birth weight, forceps delivery, prolonged 2nd stage in primipara
• Right is more than Left, due to LOA position
2. Trauma
• Fall on outstretched hand (FOSH) or on point of shoulder
• Direct blow
• Seizures
3. Non-traumatic fracture
• Pathological : tumour, infection, AV malformation

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ASSOCIATED INJURIES

• Acromio-Clavicular and Sterno- Clavicular dislocations
• Head and neck injuries
• Fracture of 1st rib
• Scapulo-thoracic dissociation
• Lung and pleura
• Pneumothorax
• Hemothorax
• Neurovascular injury i.e. Brachial Plexus (mostly Ulnar nerve),

CLINICAL PRESENTION

• Anterior shoulder pain
• May have deformity with skin tenting (impending open fracture)

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INVESTIGATIONS

1. X-RAY Radiographs
• recommended views
• upright AP of bilateral shoulders
• 15° cephalic tilt (zanca view)
• helps to determine superior/inferior displacement
2. CT scan
• may help evaluate displacement, shortening, comminution, articular extension, vascular injury, and nonunion

TREATMENT

• NON-OPERATIVE
• Children
• Sling until comfortable
• Adults
• Non-operative management: sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks or with the figure-of-eight bandage/brace for 6 weeks.

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• OPERATIVE
• Surgical Indications:
• NV injury that fails to reverse with nonoperative management
• Open fracture
• Multiple trauma
• A floating shoulder with a displaced clavicular fracture and an unstable scapular fracture
• Posterior fracture-dislocation of proximal clavicle
• Segmental fractures
• Operative technique for Midshaft Fractures (closed reduction and intramedullary fixation vs. open reduction internal fixation)
• Plates and Intramedullary fixation
• Operative technique for Distal 1/3 Fractures
• Plates

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Clavicular plate

Intramedullary fixation

COMPLICATIONS

• Nonunion
• Malunion
• Post-traumatic Arthritis
• Infraclavicular numbness secondary to iatrogenic supraclavicular nerve branch injury

HUMERUS

HUMERUS

• The humerus is the longest and largest bone of the upper limb.
• It is located between the elbow joint and the shoulder.
• There is
• Shoulder dislocation and
• Humeral fracture

SHOULDER JOINT

• The shoulder joint (glenohumeral joint) is a ball and socket joint between the scapula and the humerus.
• It is the major joint connecting the upper limb to the trunk.
• It is one of the most mobile joints in the human body, at the cost of joint stability.
• The shoulder joint is formed by the articulation of the head of the humerus with the glenoid cavity (or fossa) of the scapula. This gives rise to the alternate name for the shoulder joint – the glenohumeral joint.

GLENOHUMERAL STABILITY

• Static restraints
• Glenohumeral ligaments (below)
• Glenoid labrum (below)
• Articular congruity and version
• Negative intraarticular pressure
• if release head will sublux inferiorly
• Dynamic restraints
• Rotator cuff muscles
• Rotator interval
• Biceps long head
• Periscapular muscles

SHOULDER DISLOCATION

• The shoulder dislocation (more accurately termed a glenohumeral joint dislocation) involves separation of the humerus from the glenoid of the scapula at the glenohumeral joint.
• Types dislocation
• Anterior shoulder dislocation (95% of shoulder dislocations)
• Posterior shoulder dislocation 2-4%
• Inferior shoulder dislocation (Luxatio erecta) <1%

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ANTERIOR SHOULDER DISLOCATION

Epidemiology:

• Incidence
• One of most common shoulder injuries
• 1.7% annual rate in general population
• Demographics
• Have a high recurrence rate that correlates with age at dislocation
• Up to 80-90% in teenagers (90% chance for recurrence in age <20)
• Mechanism: anteriorly directed force on the arm when the shoulder is abducted and externally rotated

CLINICAL PRESENTATION

• Traumatic event causing dislocation
• Feeling of instability
• Shoulder pain complaints caused by subluxation and excessive translation of the humeral head on the glenoid
• Patients present with severe pain and restriction of movement of the shoulder.

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INVESTIGATIONS

• X-RAY Radiographs : True AP, Scapular Y and axillary view
• CT scan : helpful for evaluation of bony injuries
• MRI : best for visualization of labral tear

MANAGEMENT

• Non-operative : acute reduction, ± immobilization, followed by therapy
• Reduction
• simple traction-countertraction is most commonly used
• relaxation of patient with sedation or intraarticular lidocaine is essential
• Immobilization not shown any benefit
• Physical therapy strengthening of dynamic stabilizers (rotator cuff and peri-scapular musculature)
• Operative : If there is fracture of glenoid or other parts

COMPLICATIONS

• Nerve injury : musculocutaneous (most common) and axillary nerve
• Stiffness : especially in external rotation
• Recurrence : often due to unrecognized glenoid bone loss
• Shoulder pain

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REDUCTION TECHNIQUES

• Kocher maneuver
• The patient lies in supine position with his arm adducted to the thorax and his elbow flexed in 90°
• Then provides external rotation in the shoulder until resistance is felt, the arm is flexed (lifted), retaining the external rotation in the shoulder, and adducted.
• The arm is then internally rotated, initiating the reduction
• After the reduction the arm should be rested on the patient in extended position of the shoulder and flexed position of the elbow

• Hippocratic method
• The patient lies in supine position
• holds the affected limb by the forearm and hand then place a heel in the axilla of the affected shoulder, acting as a fulcrum while the arm is adducted, this initiate reduction

• Stimson's maneuver
• The patient lies in prone position with his arm hanging aside the examining table
• A downward traction to the arm is applied for 10–20 min by the practitioner or by attaching weights to the wrist of the patient.
• Then, the weights are released allowing the humerus to fall back into its position, thus reducing the glenohumeral joint

• Matsen's traction-countertraction maneuver
• The patient lies in supine position with a sheet around his thorax and also around the waist of the assistant standing at the contralateral side of the affected shoulder.
• Another sheet is wrapped around the waist and forearm of the practitioner standing on the side of the dislocated shoulder near the waist of the patient, while holding the elbow of the patient in 90° flexion and the shoulder in 90° abduction.
• Applies traction to the affected arm by leaning back while the assistant provides counter-traction

• Scapular manipulation technique
• The patient is lying in prone position with his shoulder flexed to 90° and his arm hanging in external rotated position from an examining table.
• A downward traction is applied by hanging weights on the wrist of the patient or by having an assistant apply traction.
• Thereafter push the tip of the inferolateral scapular edge medially rotating upward, initiating the reduction.

• FARES method
• The patient lies in supine position with the practitioner standing at the side of the dislocated shoulder.
• The practitioner holds the wrist of the patient with both arms keeping the elbow of the patient extended and the forearm in neutral position. Then, the arm is slowly abducted in an oscillating movement (approximately 5 cm up- and downward movement) while constant longitudinal traction is applied.
• The arm is externally rotated when abducted beyond 90°. Reduction usually takes place at approximately 120°

• Eskimo technique
• The patient lies on the side of the unaffected shoulder.
• Two practitioners lift the patient by the dislocated arm, while the arm is abducted. By doing this, they elevate the patient slightly above the ground for a short time, initiating the reduction
• If no reduction occurs, the practitioner can place his hand in the axilla and apply pressure on the humeral head to reposition it in the glenoid rim

• Milch maneuver
• The patient lies in a supine vertical position, with his shoulders slightly higher than his pelvic position.
• The practitioner holds the patient's arm at the wrist, abducting it to an overhead position and external rotating it to 90°. Subsequently, the practitioner pushes the humeral head into a superior and lateral direction
• Traditionally this technique is performed without traction, but it can be modified by applying traction.

• Spaso technique
• The patient lies in a supine position with his shoulder flexed at 90° and the elbow in extended position .
• The practitioner should first initiate longitudinal traction until the patient is comfortable enough to tolerate the scapula touching the examination table.
• Then, the practitioner should provide external rotation to the shoulder to facilitate reduction
• After the reduction the arm should be rested on the patient in extended position of the shoulder and flexed position of the elbow.

• Sitting method
• The patient is seated while facing the practitioner.
• The practitioner holds the forearm of the affected limb and flexes the shoulder to 90° while having the elbow of the patient slightly flexed.
• Then, the practitioner places his other arm on the anterior chest wall at the side of the affected limb, to control the glenoid tilt by manipulating a part of the scapula such as the acromion or coracoid process.
• Finally, the practitioner applies longitudinal traction to initiate the reduction.
• If this fails, the practitioner can additionally rotate the affected limb internally or externally.

• Sitting method
• The patient is seated while facing the practitioner. The practitioner holds the forearm of the affected limb and flexes the shoulder to 90° while having the elbow of the patient slightly flexed.
• Then, the practitioner places his other arm on the anterior chest wall at the side of the affected limb, to control the glenoid tilt by manipulating a part of the scapula such as the acromion or coracoid process.
• Finally, the practitioner applies longitudinal traction to initiate the reduction. If this fails, the practitioner can additionally rotate the affected limb internally or externally.

• Chair method
• The patient sits sideways on a chair with the backrest of the chair in his axilla.
• The practitioner holds the hand of the patient in one hand and the elbow of the patient in the other while he ensures that the elbow of the patient is gently flexed.
• After calming the patient, downward traction is applied by the practitioner or by an attached sling with weights, facilitating reduction. A slight amount of external rotation in combination with gentle forward flexion can be applied by the right hand of the physician.
• The same technique can be performed using an Oxford Chair, from which the front rest could be positioned in a 45° angle, permitting the patient to lean to the back rest

• Bokor-Billmann's shoulder reduction technique
• The patients sits upright with his back against a firm surface to minimize movements of the upper body. The practitioner holds the wrist of the patient in one hand and the elbow in the other maintaining 90° flexion of the elbow and 90° flexion of the shoulder.
• The arm is then adducted until it reaches the midline of the thorax. Maintaining the arm in midline position the shoulder is internally rotated. At 25°–30° a resistance is felt, the practitioner should maintain constant pressure to overcome this resistance, inducing reduction.

• Cunningham technique
• The patient sits in a chair with his back straight and his arm adducted to the body with his arm in neutral position and his elbow in 90° flexion. The practitioner kneels on the side of the affected arm facing the opposite direction.
• The practitioner then slides his hand between the patients forearm and body having the hand of the patient resting on the upper arm of the practitioner.
• The practitioner applies gentle downward traction and massages the trapezius, deltoid and biceps muscle sequentially with his other hand initiating the reduction.

• Legg maneuver
• The patient is seated in a straight-backed chair to minimize movement while the assistant stabilizes the unaffected shoulder by applying downward pressure.
• The patient actively abducts his affected arm to 90°. Subsequently, the arm is externally rotated until the palm faces forward.
• The practitioner then flexes the elbow to 90° and stabilizes the affected arm behind the patient's head. (A) Then, the arm is adducted to the patients side while fully flexing the elbow. (B) The patient is then asked to internally rotate his arm across the chest. (C).
• The actual reduction occurs during the adduction and internal rotation.

• Manes' method
• The patient is seated in a chair while the practitioner stands behind him and places his flexed forearm in the axilla of the affected shoulder of the patient.
• Thereafter, the practitioner presses the forearm in the axilla in a super lateral direction while applying gentle traction on the flexed forearm of the affected arm of the patient with his other hand.

• Walz method
• The patient sits straight-backed on a chair while the practitioner stands behind him. The practitioner then places one hand in the axilla making a fist and having his thumb facing upward, making contact with the humeral head.
• With the other hand, the practitioner holds the forearm of the patient and applies downward traction, usually initiating the reduction. (A) If no reduction occurs, the practitioner can rotate his hand externally in the axilla, pushing the humeral head laterally in the glenoid fossa.(B)

• Boss-Holzach-Matter method
• During the reduction the patient sits on the examination table with his leg straight while his wrists are protected by cotton wool and bound together.
• The knee on the same side of the dislocated arm is then flexed to 90° and the patient places his forearms around this knee.
• The head of the examination table is then lowered slowly and the patient is asked to lean back hyperextending his neck, providing anterior axial traction to the dislocated shoulder, and pushing the shoulders anteriorly, thus creating a rotational movement of the scapula in the vertical axis

POSTERIOR SHOULDER DISLOCATION

• Acute posterior shoulder dislocations are less common than anterior dislocations, but more commonly missed.

Epidemiology

• Incidence
• 2% to 5% of all unstable shoulders
• Risk factors
• bony abnormality
• glenoid retroversion or hypoplasia
• ligamentous laxity

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Mechanism:

• Trauma (50%) or microtrauma with the arm in a flexed, adducted, and internally rotated Position
• Posterior instability: due to posterior labrum tear, avulsion or erosion
• Seizures and electric shock: tetanic muscle contraction pulls the humeral head out

CLINICAL PRESENTATION

• Pain with flexion, adduction, and internal rotation of the arm
• Prominent posterior shoulder and coracoid
• Limited external rotation
• Shoulder locked in an internally rotated position common in undiagnosed posterior dislocations

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INVESTIGATIONS

• X-RAY Radiographs
• Recommended views
• AP - may show a 'lightbulb' sign
• Axillary lateral - best view to demonstrate a dislocation
• CT : analyze the extent and location of bone loss in a chronic dislocation (>2 to 3 weeks)
• MRI : chronic posterior instability without history of acute posterior dislocation, evaluate for suspected posterior labral tear, rotator cuff tear etc.

TREATMENT

Non-operative: Acute reduction and immobilization in external rotation for 4 to 6 weeks

• Technique
• immobilize in 10-20 degrees of external rotation with elbow at side
• after 6 weeks advance to physical therapy (rotator cuff strengthening and peri-scapular stabilization) and activity modification (avoid activities that place arm in high-risk position)
• Physical therapy may be a first line treatment for chronic posterior instability
• Operative: For recurrent posterior shoulder instability despite appropriate course of physical therapy

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COMPLICATIONS

• Stiffness: most common complication after labral repair
• Recurrence: 2nd most common (7% to 50%)
• Degenerative joint disease: 3rd most common
• Adhesive capsulitis
• Nerve injury : axillary or suprascapular

• DePalma's method for posterior shoulder dislocation
• The affected arm is adducted and internally rotated. Then, caudal traction is performed while the medial side of the upper arm is pushed laterally.
• This method can be modified by applying longitudinal traction instead of caudal traction (lever principle

• Reduction of posterior dislocation by forward pressure of the humeral head
• This method is performed under general anesthesia while the affected arm is flexed, adducted and internally rotated.
• The humeral head is gently pressed anteriorly while an assistant provides cross-body traction to the arm. Reduction is then achieved by external rotation of the arm

• Caudal traction for Posterior dislocation
• A posterior shoulder dislocation is reduced while pulling the affected arm caudally to perform a swimmer's view radiograph

PLAIN RADIOGRAPHS

• Anterior and inferior dislocations are usually simple diagnoses, with the humeral head and outline of the glenoid being incongruent
• All dislocations should be easily identified on trans-scapular Y views. When the humeral head is normally aligned, it will project centered over the center of the Y formed by the coracoid, blade of the scapula and spine of the scapula (acromion).
• Where the humeral head is displaced medially and overlies the glenoid, the dislocation is anterior.
• Posterior dislocations show a 'lightbulb' sign

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INFERIOR SHOULDER JOINT DISLOCATION

• Luxatio Erecta (Inferior Glenohumeral Joint Dislocation)
• Specific term for inferior dislocation of the glenohumeral joint trapped underneath the coracoid and glenoid
• Epidemiology
• Incidence - very rare, only 0.5% of all shoulder dislocations
• Mechanism: hyper-abduction force (a high-energy injury) applied to arm, levering the proximal humerus onto the acromion, injuring inferior capsule/labrum

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CLINICAL PRESENTATION

• Inability to move shoulder - arm is in fixed, abducted, overhead position
• Shoulder pain
• Patient presents with the arm in a fixed, abducted position
• Neurovascular injury: neurologic injury up to 60%, vascular injury up to 39%

INVESTIGATIONS

• X- RAY Radiographs
• recommended views: complete shoulder series
• Findings: inferior glenohumeral dislocation with arm fully abducted
• MRI
• should be obtained after shoulder is relocated

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TREATMENT

• Non-operative: inactive elderly patients
• closed reduction and immobilization
• Technique
• Traction-countertraction - similar technique as for anterior shoulder dislocations
• post-reduction - brief period of immobilizer
• Operative: For active younger patients

PROXIMAL HUMERUS FRACTURES

INTRODUCTION

• Proximal humerus fractures are common fractures often seen in older patients with osteoporotic bone following a simple ground-level fall on an outstretched arm.
• Sling immobilization is the treatment for the majority of these fractures.
• Surgical treatment may be indicated in more complex and displaced fractures

RELEVANT ANATOMY

• Osteology :
• anatomic neck - represents the old epiphyseal plate
• surgical neck - represents the weakened area below head and more often involved in fractures than anatomic neck
• Muscles:
• pectoralis major displaces shaft anteriorly and medially
• supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity
• subscapularis interally rotates articular segment or lesser tuberosity
• Blood Supply : anterior humeral circumflex artery and posterior humeral circumflex artery

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EPIDEMIOLOGY

• Incidence : 4-6% of all fractures
• Third most common non-vertebral fracture pattern seen in the elderly (>65 years old)
• Two-part surgical neck fractures are most common
• 2:1 female to male ratio
• Location : may occur at the surgical neck, anatomic neck, greater tuberosity, and lesser tuberosity

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RISK FACTORS

• Osteoporosis
• Diabetes
• Epilepsy
• Female gender

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MECHANISM

• Low-energy falls : elderly with osteoporotic bone
• High-energy trauma : young individuals, it associates with soft tissue and neurovascular injuries

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• Associated conditions
• Nerve injury - axillary nerve injury most common
• Arterial injury - most often occur at level of surgical neck or with subcoracoid dislocation of the head

CLASSIFICATION

• Can be classified in either AO/OTA or Neer classification
• Neer classification classifies proximal fractures based on anatomic relationship of 4 segments i.e.
• Greater tuberosity
• Lesser tuberosity
• Articular surface
• Shaft

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NEER CLASSIFICATION

CLINICAL PRESENTATION

• Pain and swelling
• Decreased motion
• Extensive ecchymosis of chest, arm, and forearm on Inspection

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INVESTIGATIONS

• X-RAY Radiographs
• recommended views is complete trauma series i.e
• True AP (Grashey)
• Scapular Y
• Axillary
• CT scan
• MRI rarely indicated

TREATMENT

• NON-OPERATIVE
• sling immobilization followed by progressive rehabilitation
• Technique : sling for comfort x2-3wks, immediate physical therapy for early ROM
• Indications : most proximal humerus fractures can be treated non-operatively including minimally displaced surgical and anatomic neck fractures, fractures in patients who are not surgical candidates, elderly age
• Outcomes : Immediate physical therapy results in faster recover

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• OPERATIVE
• CRPP (closed reduction percutaneous pinning) - 2-part surgical neck fractures and 3-part and valgus-impacted 4-part fractures
• ORIF - 2-, 3-, and 4-part fractures in younger patients
• Intramedullary nailing - surgical neck fractures or 3-part greater tuberosity fractures in younger patients or combined proximal humerus and humeral shaft fractures
• Arthroplasty

COMPLICATIONS

• Avascular necrosis
• Malunion
• Nonunion
• Adhesive capsulitis and scar tissue
• Posttraumatic arthritis

HUMERAL SHAFT FRACTURES

RELEVANT ANATOMY

• Osteology
• humeral shaft is cylindrical
• distally humerus becomes triangular
• intramedullary canal terminates 2 to 3 cm proximal to the olecranon fossa
• Muscles
• insertion for pectoralis major, deltoid and coracobrachialis
• origin for brachialis, triceps and brachioradialis
• Nerves
• radial nerve courses along spiral groove

EPIDEMIOLOGY

• Incidence : 3-5% of all fractures
• Bimodal age distribution
• young patients with high-energy trauma
• elderly, osteopenic patients with low-energy injuries

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CLASSIFICATION

• DESCRIPTIVE
• Fracture location:
• Proximal third of shaft of femur
• Middle third of shaft of femur
• Distal third of shaft of femur
• Fracture pattern:
• Spiral,
• Transverse,
• Comminuted etc.

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CLINICAL PRESENTATION

• Pain
• Extremity weakness
• Loss of function
• Deformity
• Examine overall limb alignment will often present with shortening and in varus

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INVESTIGATIONS

• X-RAY Radiographs
• views
• AP and lateral be sure to include joint above and below the site of injury
• Other views are traction views and transthoracic lateral

​

​

TREATMENT

• NONOPERATIVE
• Coaptation splint followed by functional brace
• Indications : Indicated in vast majority of humeral shaft fractures
• absolute contraindications
• severe soft tissue injury or bone loss
• vascular injury requiring repair
• brachial plexus injury
• Hanging cast

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• OPERATIVE
• Open reduction and internal fixation (ORIF)
• indications
• open fracture
• vascular injury requiring repair
• brachial plexus injury
• compartment syndrome

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COMPLICATIONS

• Malunion
• Nonunion
• Radial nerve palsy

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Dx:

Spiral fracture of mid-third shaft of left humerus medially displaced

DISTAL HUMERUS FRACTURES�

INTRODUCTION

• Distal humerus fractures are traumatic injuries that include
• supracondylar fractures
• single column (condyle) fractures
• bicolumn fractures
• coronal shear fractures

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RELEVANT ANATOMY

• Osteology
• Elbow is a hinged joint
• Trochlea
• articulates with sigmoid notch
• allows for flexion and extension
• Capitellum
• articulates with proximal radius
• allows for forearm rotation
• Muscles
• common flexors (originate from medial epicondyle)
• common extensors (originate from lateral epicondyle)

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EPIDEMIOLOGY

• Accounts for 0.5-7% of all fractures and 30% of elbow fractures
• Most common in young males and older females
• Location : distal intercondylar fractures are the most common fracture pattern

​

​

MECHANISM

• low energy falls in elderly
• high energy impact in younger population

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• Associated injuries
• elbow dislocation
• terrible triad injury
• floating elbow
• Volkmann contracture (results from missed forearm compartment syndrome)

CLASSIFICATION

• Can be classified as
1. supracondylar fractures
2. distal single column fractures
• subclassified using Milch classification system
• lateral condyle more common than medial
3. distal bicolumnar fractures
• classified using Jupiter classification system
• 5 major articular fragments have been identified i.e. capitellum/lateral trochlea, lateral epicondyle, posterolateral epicondyle, posterior trochlea and medial trochlea/epicondyle

​

​

CLINICAL PRESENTATION

• Elbow pain and swelling
• Gross instability often present
• Avoid ROM due to risk of neurovascular damage

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IMAGING

Radiographs - AP & lateral

CT scan - often obtained for surgical planning

MRI - usually not indicated in acute injury

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TREATMENT

• NONOPERATIVE
• Cast immobilization (nondisplaced Milch Type I fractures)
• immobilize in supination for lateral condyle fractures
• immobilize in pronation for medial condyle fractures

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• OPERATIVE
• Closed reduction and percutaneous pinning (CRPP) - displaced Mich Type I fractures
• ORIF - supracondylar fractures, intercondylar / bicolumnar fractures, Milch Type II fractures
• Total elbow arthroplasty - distal bicolumnar fractures in elderly patients

PROGNOSIS

• Majority of patients regain 75% of elbow motion and strength
• Goal is to restore elbow ROM 30-130° of flexion
• Unsatisfactory outcomes in up to 25%

COMPLICATIONS

• Elbow stiffness - most common
• Nonunion - low incidence and avoid excessive soft-tissue stripping
• Malunion - avoided by proper surgical technique
• Ulnar nerve injury
• Heterotopic ossification

SUPRACONDYLAR FRACTURES�

• Supracondylar fractures are one of the most common traumatic fractures see in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand (FOOSH)
• Treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not.

Epidemiology

• Occur most commonly in children aged 5-7years
• M = F

MECHANISM OF INJURY

• Fall on outstretched extremity (FOOSH)
• Associated injuries
• anterior interosseous nerve (AIN) neurapraxia (branch of median n.) - the most common nerve palsy
• radial nerve palsy - second most common neurapraxia
• ulnar nerve palsy - seen with flexion-type injury patterns
• ipsilateral distal radius fractures

�GARTLAND CLASSIFICAITON

CLINICAL PRESENTATION

• Pain
• Refusal to move the elbow
• Inspection
• gross deformity
• swelling
• ecchymosis in antecubital fossa
• Motion: limited active elbow motion

​

​

INVESTIGATIONS

• X-RAY Radiographs
• Recommended views - AP and lateral x-ray of the elbow (really of the distal humerus)

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TREATMENT

• NONOPERATIVE
• Long arm casting with less than 90° of elbow flexion
• Indications
• Type I (non-displaced) fractures
• Type II fractures that meet the following criteria
• anterior humeral line intersects the capitellum
• minimal swelling present
• no medial comminution
• Technique
• Typically used for 3 weeks
• Repeat radiographs at 1 week to assess for interval displacement

• OPERATIVE
• Closed reduction and percutanous pinning (CRPP)
• Indications
• Type II and III supracondylar fractures
• Flexion type
• Open reduction (ORIF), percutaneous pinning, +/- vascular exploration
• Indications
• open fracture
• failed closed reduction

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COMPLICATIONS

• Pin migration - most common complication
• Cubitus valgus - caused by fracture malunion
• Cubitus varus (gunstock deformity) - caused by fracture varus malunion, especially in medial comminution pattern
• Recurvatum - common with non-operative treatment of Type II and Type III fractures
• Volkmann ischemic contracture
• Postoperative stiffness

ELBOW JOINT

ELBOW JOINT

• The elbow is the joint connecting the upper arm to the forearm. It is classed as a hinge-type synovial joint.
• Articulating Surfaces
• It consists of two separate articulations:
• Trochlear notch of the ulna and the trochlea of the humerus
• Head of the radius and the capitulum of the humerus

ELBOW DISLOCATION

• Elbow dislocations are the most common major joint dislocation second to the shoulder
• Most common dislocated joint in children
• Account for 10-25% of injuries to the elbow
• Posterolateral is the most common type of dislocation (80%)
• Predominantly affects patients between age 10-20 years old

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MECHANISM

• An elbow dislocation usually occurs when a young child falls on a hand with the elbow flexed.
• The distal end of the humerus is driven through the weakest part of the joint capsule, which is the anterior side.
• The ulnar collateral ligament is usually torn and there can also be ulnar nerve involvement
• Most elbow dislocations are posterior, and it is important to note that elbow dislocations are named by the position of the ulna and radius, not the humerus.
• Posterior dislocations may involve more than one injury mechanism

​

CLASSIFICATION

1. Anatomic description
• Based on anatomic location of olecranon relative to humerus
• There is Posterolateral dislocation - most common and other
2. Simple vs. complex
• Simple
• elbow dislocation with no associated fracture
• accounts for 50-60% of elbow dislocations
• Complex
• elbow dislocation with associated fracture

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CLINICAL PRESENTATION

• Pain and swelling
• Deformity and loss of function
• Physical exam - important to assess are
• the status of the skin - evaluate for open injuries
• presence of compartment syndrome
• neurovascular status
• status of wrist and shoulder
• concomitant injuries occur in 10-15% of elbow dislocations

INVESTIGATIONS

• X-RAY Radiographs
• Recommended views
• AP and lateral view: assess joint congruency, especially after attempted reduction
• Oblique views: assess for associated periarticular fractures
• CT scan
• Indications
• Suspicion of complex injury pattern
• Useful to identify associated periarticular fractures

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TREATMENT

• NONOPERATIVE
• Closed reduction and splinting at least 90° for 5-10 days, early therapy
• Indications : acute simple stable dislocations
• Ensure patient has sufficient analgesia to allow for adequate muscle relaxation
• A palpable "clunk" can be appreciated after most reductions
• Assess post reduction stability
• Place post-reduction posterior mold splint in flexion and appropriate forearm rotation
• Obtain post-reduction radiographs

​

• Reduce the elbow—prone position
• Place the patient prone, with the forearm dangling over the side of the stretcher.
• Have an assistant stabilize the affected upper arm against the stretcher, wrapping both hands around the distal humerus and using the thumbs to apply pressure to distract the posterior aspect of the olecranon.
• Apply steady downward traction to the forearm while maintaining flexion of the elbow. Signs of a successful reduction usually include a lengthening of the forearm and a perceptible “clunk.”
• If the joint is not reduced, ask the assistant to lift the humerus while maintaining the downward pressure on the olecranon while you attempt to further flex the elbow.
• Maintain these forces on the elbow for up to 10 minutes if necessary.
• If the initial approach does not reduce the dislocation, consider using a traction-countertraction technique with the patient supine.

​

• Reduce the elbow—supine position
• Place the patient in the supine position and have an assistant stabilize the humerus with both hands.
• Grasp the patient's wrist, keep it supinated, apply steady axial traction, and slightly flex the elbow to keep the muscles of the triceps loose.
• Maintain these forces on the elbow for up to 10 minutes if necessary.
• Signs of a successful reduction usually include a lengthening of the forearm and a perceptible “clunk.”

​

• OPERATIVE
• ORIF
• Indications
• acute complex elbow dislocations
• persistent instability after reduction
• reduction cannot be performed closed
• Open reduction, capsular release, and dynamic hinged elbow fixator – Indicated in chronic dislocations

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COMPLICATIONS

• Neurovascular injuries – Ulnar and Median nerve, Brachial artery
• Compartment syndrome
• Early stiffness - most common complication after closed treatment of a simple elbow dislocation
• Recurrent instability
• Contracture/stiffness - correlated with immobilization beyond 3 weeks
• Damage to articular surface
• Heterotopic ossification

THE RADIOULNAR JOINTS

• The radioulnar joints are two locations in which the radius and ulna articulate in the forearm:
• Proximal radioulnar joint: This is located near the elbow, and is an articulation between the head of the radius, and the radial notch of the ulna.
• Distal radioulnar joint: This is located near the wrist, and is an articulation between the ulnar notch of the radius, and the ulnar head.

​

• Both of these joints are classified as pivot joints, responsible for pronation and supination of the forearm.

• Proximal Radioulnar Joint
• The joint is located immediately distal to the elbow joint, and is enclosed with in the same articular capsule. It is formed by an articulation between the head of the radius and the radial notch of the ulna.
• The radial head is held in place by the annular radial ligament, which forms a ‘collar’ around the joint. The annular radial ligament is lined with a synovial membrane, reducing friction during movement.

• Distal Radioulnar Joint
• The joint is located just proximally to the wrist joint. It is an articulation between the ulnar notch of the radius, and the ulnar head.
• Like the proximal radioulnar joint, this is a pivot joint, allowing for pronation and supination.
• In addition to anterior and posterior ligaments strengthening the joint, there is also a fibrocartilaginous ligament present, called the articular disk. It serves two functions:
• Binds the radius and ulna together, and holds them together during movement at the joint.
• Separates the distal radioulnar joint from the wrist joint.

​

MONTEGGIA FRACTURES

INTRODUCTION

• Is the fracture of proximal shaft of ulna and the head of the radius dislocates anteriorly at the elbow
• Usually caused by a force from behind the ulna
• Rare in adults
• More common in children with peak incidence between 4 and 10 years of age

​

​

ASSOCIATED INJURIES

• May be part of complex injury pattern including:
• Olecranon fracture - dislocation
• Radial head fracture
• Coronoid fracture

​

BADO CLASSIFICATION

CLINICAL PRESENTATION

• Pain and swelling at elbow joint
• Abnormal movement and loss of function
• May or may not be obvious dislocation at radiocapitellar joint
• PIN neuropathy (from neurovascular exam)
• radial deviation of hand with wrist extension
• weakness of thumb extension
• weakness of MCP extension
• most likely nerve injury

​

INVESTIGATIONS

• X-RAY Radiographs
• Recommended view - AP and Lateral of elbow, wrist, and forearm
• CT scan - helpful in fractures involving coronoid, olecranon, and radial head

​

​

TREATMENT

• NONOPERATIVE
• Closed reduction - must ensure stability and anatomic alignment of ulna fracture
• Indications : more common and successful in children
• Technique: cast in supination for Bado I and III

​

​

• OPERATIVE
• ORIF of ulna shaft fracture
• Indications :
• acute fractures which are open or unstable (long oblique)
• comminuted fractures
• most Monteggia fractures in adults are treated surgically
• ORIF of ulna shaft fracture, open reduction of radial head
• Indications : failure to reduce radial head with ORIF of ulnar shaft only
• IM Nailing of ulna – Indicated in transverse or short oblique fracture

COMPLICATIONS

• Malunion with radial head dislocation
• PIN neuropathy (up to 10% in acute injuries)

GALEAZZI FRACTURES

INTRODUCTION

• A fracture to the distal radius, with the ulna head dislocating at the distal radio-ulnar joint.
• Less frequent in adults than children
• Incidence of DRUJ instability
• If radial fracture is <7.5 cm from articular surface - unstable in 55%
• If radial fracture is >7.5 cm from articular surface - unstable in 6%

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MECHANISM

• Direct wrist trauma : typically dorsolateral aspect
• Fall onto outstretched hand with forearm in pronation

​

​

�CLINICAL PRESENTATION

• Wrist and forearm pain
• Limitation of wrist motion
• Swelling
• Radial eformity
• Ulnar head prominence or deformity can sometimes be seen
• Physical exam : point tenderness over fracture site
• DRUJ stress: causes wrist or midline forearm pain

​

INVESTIGATIONS

• X-RAY Radiographs
• Recommended views - AP and lateral views of forearm, elbow, and wrist

​

TREATMENT

• NONOPERATIVE
• Closed reduction with long arm casting – indicated as first-line of treatment in children except adults
• Reduction:
• requires anatomic reduction of both the radius fracture and the DRUJ
• supination is required for reduction if there is dorsal subluxation of the ulna
• pronation is required for reduction if there is volar subluxation of the ulna
• Immobilization : place in above elbow cast in supination

​

​

• OPERATIVE
• ORIF of radius with reduction and stabilization of DRUJ
• Indications : all adult cases, as anatomic reduction of DRUJ is required
• ORIF, soft tissue reconstruction of DRUJ and TFCC, +/- corrective osteotomy
• Corrective osteotomy with soft tissue reconstruction of DRUJ and TFCC

COMPLICATIONS

• Compartment syndrome
• Neurovascular injury
• Nonunion
• Malunion
• DRUJ subluxation
• Acute carpal tunnel syndrome

DISTAL RADIUS

CARPAL BONES

COLLES FRACTURE

• Colles fractures are very common extra-articular fractures of the distal radius that occur as the result of a fall onto an outstretched hand.
• It was described by Abraham Colles in 1814, originally described as low energy extra articular fracture of distal radius occurring in elderly
• There is a complete fracture of the radius bone of the forearm close to the wrist resulting in an upward (posterior) displacement of the radius and obvious deformity
• They consist of a fracture of the distal radial metaphyseal region with dorsal angulation and impaction, but without the involvement of the articular surface.

​

EPIDEMIOLOGY

• They are particularly common in patients with osteoporosis, and as such, they are most frequently seen in elderly women.
• Younger patients who sustain Colles fractures have usually been involved in high impact trauma or have fallen, e.g. during contact sports, skiing, horse riding

​

​

MECHANISM

• Most Colles fractures are secondary to a fall on an outstretched hand (FOOSH) with a pronated forearm in dorsiflexion (the position one adopts when trying to break a forward fall).
• The proximal row of the carpus (particularly the lunate and scaphoid) transfer energy to the distal radius, both in the dorsal direction and along the long axis of the radius.
• Most fractures are therefore dorsally angulated and impacted.

CLASSIFICATION

• Frykman Classification
• Melone Classification
• Universal Classification

CLINICAL PRESENTATION

• "Dinner Fork" Deformity”
• History of fall on an outstretched hand
• Dorsal wrist pain
• Swelling of the wrist
• Increased angulation of the distal radius
• Inability to grasp object
• Signs and Symptoms - Pain, numbness, tenderness, bruising, deformity of wrist

INVESTIAGTIONS

• Plain radiograph
• Often comprises an AP and a lateral view; however, it is not uncommon for an oblique view to be included.
• The fracture appears extra-articular and usually proximal to the radioulnar joint.
• Dorsal angulation of the distal fracture fragment is present to a variable degree (as opposed to volar angulation of a Smith fracture).
• Dorsal angulation is severe enough, a dinner fork deformity may be described.

TREATMENT

• NONOPERATIVE
• The vast majority of Colles fractures can be treated with closed reduction and cast immobilization.
• The cast extends from below the elbow to the metacarpal heads and holds the wrist somewhat flexed and in ulnar deviation (This cast is known as a Colles cast)
• OPERATIVE
• Open reduction and internal fixation (ORIF) is considered when the fracture is unstable, and/or unsatisfactory closed reduction is achieved (i.e. >10 degrees dorsal angulation; >5 mm shortening; significant comminution)

COMPLICATIONS

• Malunion - resulting in dinner fork deformity
• Median nerve palsy
• Post-traumatic carpal tunnel syndrome
• Secondary osteoarthritis, more frequently seen in patients with intra-articular involvement

SMITH FRACTURE

• Smith fractures are fractures of the distal radius with associated volar angulation of the distal fracture fragment(s).
• Classically, these fractures are extra-articular transverse fractures and can be thought of as a reverse Colles fracture.
• The term is sometimes used to describe intra-articular fractures with volar displacement (reverse Barton fracture) or juxta-articular fractures
• First named for Jean-Gaspard-Blaise Goyrand, French physician (1746-1814)
• Named by Robert William Smith (1807-1873) who was a surgeon in Dublin, Ireland. He succeeded Abraham Colles (Colles fracture) as Professor of Surgery at Trinity College, Dublin.

EPIDEMIOLOGY

• Smith fractures account for less than 3% of all fractures of the radius and ulna
• Have a bimodal distribution: young males (most common) and elderly females

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MECHANISM

• Smith fractures usually occur in one of two ways:
• A fall onto a flexed wrist
• Direct blow to the back of the wrist

CLINICAL PRESENTATION

• “Garden-spade deformity".
• Decreased wrist extension
• Decreased ulnar deviation, and supination.
• Pain and swelling
• Limited range of motion

INVESTIGATIONS

• In most instances, a plain wrist radiographic series will suffice for diagnosis and characterization. The fracture line is usually evident
• Although in undisplaced of mildly impacted fractures it can be difficult to see and subtle cortical breaches/buckling should be sought. In intra-articular fractures (type II) the degree of articular step-off and gap should be assessed, and this may require CT.

TREATMENT

• In most cases, these fractures can be treated with closed reduction and cast application - Sugar tong splint in supination similar to Colles' fracture
• If the fracture can be reduced but remains unstable, or cannot be reduced then operative fixation (ORIF) is usually required

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FRACTURE OF LOWER LIMBS

PELVIC BONE

RELEVANT ANATOMY

• The left and right hip bones (innominate bones, pelvic bones) are two irregularly shaped bones that form part of the pelvic girdle – the bony structure that attaches the axial skeleton to the lower limbs.
• The hip bones have three main articulations:
• Sacroiliac joint – articulation with the sacrum.
• Pubic symphysis – articulation between the left and right hip bones.
• Hip joint – articulation with the head of femur.
• The hip bone is comprised of the three parts; the ilium, pubis and ischium.
• Together, the ilium, pubis and ischium form a cup-shaped socket known as the acetabulum (literal meaning in Latin is ‘vinegar cup‘). The head of the femur articulates with the acetabulum to form the hip joint.

HIP JOINT

• The hip joint is a ball and socket synovial joint, formed by an articulation between the pelvic acetabulum and the head of the femur.
• The acetabulum is a cup-like depression located on the inferolateral aspect of the pelvis
• The head of femur is hemispherical, and fits completely into the concavity of the acetabulum.
• The capsule of the hip joint attaches to the edge of the acetabulum proximally. Distally, it attaches to the intertrochanteric line anteriorly and the femoral neck posteriorly
• Hip joint forms a connection from the lower limb to the pelvic girdle, and thus is designed for stability and weight-bearing – rather than a large range of movement.

• Hip joint inherently stable due to
• Bony anatomy
• Soft tissue constraints including
• labrum
• capsule
• ligamentum teres

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HIP DISLOCATION

INTRODUCTION

• Hip dislocation occurs when the joint between the femur and the pelvis is disrupted and the head of femur is forced out of its socket
• Hip dislocation can be of three types
• Posterior dislocation
• Anterior dislocation
• Central dislocation (protrusio) always associated with acetabular fracture
• Hip dislocation is a relatively rare entity and may be congenital or acquired. But high incidence of associated injuries
• Mechanism is usually young patients with high energy trauma

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​

​

CLASSIFICATION

• Simple vs. Complex
• simple
• pure dislocation without associated fracture
• complex
• dislocation associated with fracture of acetabulum or proximal femur
• Anatomic classification
• Posterior dislocation (90%)
• Anterior dislocation (9%): inferior (obturator) hip dislocation, superior (pubic/iliac) hip dislocation (rare)
• Central dislocation (protrusio)

EPIDEMIOLOGY

• Hip dislocations account for ~5% of all dislocations

ETIOLOGY

• Acquired
• Acquired hip dislocation is normally associated with high-speed trauma, with motor vehicle collisions account half of the dislocation with other causes such as falls and sports injuries, less common
• Hip dislocation is the second most common complication of hip joint replacements and occurs in ~5% (range 0.5-10%) of patients with ~60% of dislocations being recurrent
• Congenital
• Congenital hip dislocation is now considered part of the spectrum of developmental dysplasia of the hip

POSTERIOR DISLOCATION

• Occur with axial load on femur, typically with hip flexed and adducted
• axial load through flexed knee (dashboard injury)
• Position of hip determines associated acetabular injury
• Increasing flexion and adduction favors simple dislocation
• associated with osteonecrosis, posterior wall acetabular fracture, femoral head fractures, sciatic nerve injuries, ipsilateral knee injuries (up to 25%)

CLINICAL PRESENTATION

• Acute pain, inability to bear weight, deformity
• Hip and leg in slight flexion, adduction, and internal rotation
• Associated with posterior wall and anterior femoral head fracture
• Detailed neurovascular exam (10-20% sciatic nerve injury)
• Examine knee for associated injury or instability

​

INVESTIGATIONS

• X-RAY Radiographs
• Recommended views
• AP
• cross-table lateral (used to differentiate between anterior vs. posterior dislocation)
• obtain AP, inlet/outlet, judet views after reduction
• Findings from X-Ray
• femoral head appears smaller than contralateral femoral head
• femoral head superimposes roof of acetabulum
• decreased visualization of lesser trochanter due to internal rotation of femur
• loss of congruence of femoral head with acetabulum
• disruption of shenton's line

​

Shenton’s line is an arc along inferior femoral neck + superior obturator foramen.

Disruption of Shenton’s line (left) indicates hip dislocation

• CT helps to determine direction of dislocation, loose bodies, and associated fractures
• MRI useful to evaluate labrum, cartilage and femoral head vascularity

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​

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• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821229/

TREATMENT

• NONOPERATIVE
• Emergent closed reduction within 6 hours
• OPERATIVE
• Open reduction and/or removal of incarcerated fragments
• Indications
• irreducible dislocation
• radiographic evidence of incarcerated fragment 
• ORIF
• Indications: associated fractures of
• acetabulum 
• femoral head
• femoral neck 

​

REDUCTION MANEUVERS

• Allis maneuver
• The patient is placed in the supine position, grasp the ipsilateral leg at the knee and flexes the knee to 90 degrees.
• While an assistant stabilizes the pelvis against the bed, apply traction in line with the femur while flexing the hip up to 90 degrees by grasping the patient’s knee .
• According to Allis’s original description, no rotation is performed. As the hip reduces, gently extend the hip and externally rotate the leg to allow the femoral head to enter the acetabulum.

• Bigelow maneuver
• The patient is placed in the supine position, grasp the ankle of the affected leg with one hand and place opposite forearm under the patient’s knee.
• The hip is flexed to 90 degrees, ensuring the affected leg is kept in an adducted and internally rotated position.
• While an assistant stabilizes the pelvis with downward pressure, apply traction in line of the femur while abducting, externally rotating, and extending the affected hip.
• The preferred method for physician safety is to perform this maneuver while standing at the side of the bed; however, at times, entering the bed is a necessity.

• Traction counter maneuver
• The patient is placed in the lateral decubitus position with the affected leg up.
• An assistant positions the affected leg into hip flexion, internal rotation, and adduction and flexes the knee to 90 degrees in a manner similar to the Skoff method.
• Standing within a looped strap, the assistant places the strap around the patient’s groin and over the iliac crest.
• The physician stands in a separate looped strap and places it around the patient’s knee.
• The physician then leans back against the looped strap, providing a lateral traction in line of the femur, while manipulating the affected leg with his/her free hands.

• At the same time, the assistant leans back against his/her looped strap, providing a lateral traction force, palpates the deformity in the gluteal region, and pushes the femoral head until reduction into the acetabulum is achieved

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• Captain Morgan maneuver
• Described in 2011, this technique calls for the patient to be placed in the supine position on a backboard on a gurney with the pelvis strapped to the board if no assistant
• The physician stand on the side of the gurney of the affected hip and places his/her foot closest to the hip on the backboard and flexes the patient’s affected leg over his/her own thigh, close to popliteal fossa.
• The physician grasps the ankle of the affected leg with one hand and places the opposite hand underneath the patient’s affected knee.
• The physician then plantar flexes his/her own foot under the patient’s affected leg while applying upward traction with the hand behind the affected knee

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• Internal and external rotation, adduction, and abduction can be applied using the hand grasping the ankle until reduction is achieved
• The differences between this maneuver and the Lefkowitz maneuver include use of a backboard and the hand being placed under the patient’s knee, not on the lower anterior thigh.

• Lefkowitz maneuver
• Described in 1993, this technique calls forthe patient to be placed in the supine position on the gurney.
• The physician stands on the affected side, placing his/her knee closest to the hip under the patient’s ipsilateral knee in the popliteal fossa and placing his/her foot on the gurney
• The physician then flexes the patient’s leg over his/her knee by applying a downward force on the patient’s lower leg until the hip is reduced.
• One of the physician’s hands is on the patient’s lower anterior thigh and the other hand applies the downward force at the patient’s ankle

• Stimson Gravity Maneuver
• The patient is placed in the prone position with the lower limbs at 90 degrees flexion over the edge of the gurney.
• The physician flexes the knee to 90 degrees and applies a downward force on the lower leg while using the ankle to apply internal and external rotation until reduction in achieved.
• Alternatively, the physician can use his/her knee to apply the downward force in the popliteal fossa of the patient’s affected leg.
• While this technique uses gravity as a reduction aide, positioning the patient partially off the bed requires a great deal of caution because the patient must be sedated for a hip reduction.
• The patient must be protected from falling off the bed, and the patient’s airway must be monitored because s/he is in the prone position while sedated.

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• Lateral traction method
• The patient is placed in the supine position on the gurney. An assistant wraps a sheet around the inner thigh of the patient’s affected leg.
• The physician applies longitudinal force along the length of the femur, while the assistant using the sheet provides lateral traction until reduction is achieved.
• Internal rotation is used as necessary.

• Howard maneuver
• The patient is placed in the supine position. The physician and assistant stand on the side of the affected hip. The affected hip is flexed to a 90-degree angle.
• The assistant applies a lateral traction force on the thigh of the affected side and can help to stabilize the pelvis.
• The physician, while holding the lower leg by grasping the knee, then applies traction in line of the femur and uses internal and external rotation until reduction is achieved.
• Preferably, the physician stands on the side of the bed, rather than entering the bed. Entering the bed, however, is necessary at times.

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• East Baltimore Lift maneuver
• The patient is placed in the supine position on the gurney. The physician stands on the side of the affected hip, with the assistant on the opposite side of the patient.
• The physician and assistant, while slightly flexing their own knees, place their arms beneath the knee of the patient’s affected hip and rest their hands on each others’ shoulders.
• The physician or assistant uses his/her free hands to stabilize the pelvis. A second assistant at the foot of the gurney applies a downward leveraging force on the ankle while the physician and first assistant concomitantly apply an upward force in line with the femur by extending their knees
• This action should lead to a reduction of the dislocated hip. The physician can also apply adduction, abduction, and internal and external rotation using the patient’s ankle until reduction is achieved

• If no second assistant is available, the physician uses his/her arm closest to the affected hip as the fulcrum and places the arm farthest from the affected hip on the ankle of the patient’s affected leg.
• While the assistant stabilizes the pelvis, the physician and assistant then apply traction to the affected femur by extending their legs

• Piggyback method
• The patient is placed in the supine position at the end of the gurney. The patient’s affected leg is flexed at the hip and the patient’s knee is placed over the physician’s preferred shoulder.
• Using the shoulder as fulcrum, the physician applies a downward force on the patient’s tibia until reduction is achieved.
• A variant of this maneuver is to place both of the patient’s legs on the physician’s shoulders.

• Tulsa technique/Rochester method/Whistler technique
• The patient is placed supine on the gurney with both legs flexed. While standing on the side of the affected hip, the physician uses his/her arm closest to the head of the bed to hold the patient’s knee on the unaffected side so the patient’s leg on the affected side is flexed over the physician’s forearm.
• The physician places his/her other hand on the ankle of the patient’s affected leg.
• The physician applies downward traction using the ankle and a combination of internal and external rotation to reduce the hip.

• Skoff maneuver
• The patient is placed in the lateral decubitus position with the affected leg facing up.
• The assistant positions the affected leg into 90-100 degree hip flexion, 40-45 degree internal rotation, and 40-45 degree adduction and flexes the knee to 90 degrees.
• The assistant then leans back, providing a lateral traction in line of the femur.
• At the same time, the physician palpates the deformity in the gluteal region and pushes the femoral head until reduction into the acetabulum is achieved.

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• Flexion adduction method
• The patient is placed in the supine position and is under general anesthesia.
• Standing on the unaffected side of the patient, the physician lifts the affected leg into flexion and maximum adduction while pulling traction in line with the femur.
• An assistant stabilizes the pelvis and provides manual pressure to the head of the femur toward the acetabulum.

ANTERIOR DISLOCATION

• Associated with femoral head impaction or chondral injury
• Occurs with the hip in abduction and external rotation
• Inferior ("obturator") vs. superior ("pubic")
• hip extension results in a superior (pubic) dislocation
• Clinically hip appears in extension and external rotation
• flexion results in inferior (obturator) dislocation
• Clinically hip appears in flexion, abduction, and external rotation

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CLINICAL PRESENTATION

• Acute pain, inability to bear weight, deformity
• Hip and leg in extension, abduction, and external rotation

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INVESTIGATIONS

• X-RAY Radiographs
• Recommended views
• AP
• cross-table lateral
• Findings
• Femoral head appears larger than contralateral femoral head
• Femoral head is medial or inferior to acetabulum
• loss of congruence of femoral head with acetabulum
• disruption of shenton's line

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TREATMENT

• Non-operative
• Emergent closed reduction within 6 hours

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• Operative
• Open reduction and/or removal of incarcerated fragments
• ORIF

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REDUCTION OF ANTERIOR DISLOCATIONS

• Anterior dislocations require the same inline traction on the femur; however, flexion of the hip is not usually possible because the femoral head is resting on the anterior surface of the pelvis in most cases.
• Each require slight variations in technique but usually require hip extension, in-line traction, and external rotation for reduction.
• Department-specific sedation is required for patient comfort and to overcome the strong surrounding hip muscles.
• Pictures of the reductions for anterior dislocations are not included as they are performed in a similar manner as posterior dislocations

• Allis leg extension method
• With the patient in the supine position, the physician either enters the bed or stands beside it
• While an assistant stabilizes the pelvis against the bed, the surgeon grasps the ipsilateral leg at the knee and applies traction in line with the deformity.
• With this maneuver, the additions noted by Toms, Dawson and Dingley can be applied.
• These include adduction, external rotation and hip flexion. If the patient has a pubic dislocation, hip hyper-extension will be necessary.

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• Bigelow leg extension method
• The patient is placed in the supine position. The physician grasps the ankle of the affected leg with one hand and places the opposite forearm under the patient’s knee.
• While an assistant stabilizes the pelvis with downward pressure, the physician applies traction in line of the femur while adducting, externally rotating, and extending the affected hip.
• The preferred method for physician safety is to perform this maneuver while standing at the side of the bed; however, at times, entering the bed is a necessity.

• Lateral traction method
• The patient is placed in the supine position on the gurney. An assistant wraps a sheet around the inner thigh of the patient’s affected leg.
• The physician applies longitudinal force along the length of the femur, while the assistant uses the sheet to provide lateral traction until reduction is achieved. External rotation is used as necessary.

• Stimson gravity method
• The patient is placed in the prone position, with the lower limbs at 90 degrees flexion over the edge of the gurney.
• The physician flexes the knee to 90 degrees and applies a downward force on the lower leg while using the ankle to apply internal and external rotation until reduction is achieved.
• Alternatively, the physician uses his/her knee to apply the downward force in the popliteal fossa of the patient’s affected leg.
• While this technique uses gravity as a reduction aide, positioning the patient partially off the bed requires a great deal of caution because the patient must be sedated for a hip reduction.
• The patient must be protected from falling off the bed, and the patient’s airway must be monitored because s/he is in the prone position while sedated

COMPLICATIONS OF HIP DISLOCATIONS

• Post-traumatic arthritis 
• up to 20% for simple dislocation, markedly increased for complex dislocation
• Femoral head osteonecrosis
• 5-40% incidence
• Increased risk with increased time to reduction
• Sciatic nerve injury
• 8-20% incidence
• associated with longer time to reduction
• Recurrent dislocations
• less than 2%

PELVIC FRACTURE

INTRODUCTION

• Pelvic fractures can be simple or complex and can involve any part of the bony pelvis. Pelvic fractures can be fatal, and an unstable pelvis requires immediate management.
• Mechanism typically high energy blunt trauma.
• Mortality rate 1-15% for closed fractures, as much as 50% for open fractures, hemorrhage is leading cause of death overall.
• Increased mortality associated with
• Systolic BP <90 on presentation
• Age >60 years
• Increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
• Need for transfusion > 4 units

• Associated injuries
• Orthopaedics
• Chest injury in up to 63%
• Long bone fractures in 50%
• Spine fractures in 25%
• non-orthopaedic
• urogenital
• sexual dysfunction up to 50%
• head and abdominal injury in 40%

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RELEVANT ANATOMY

• Ring structure made up of the sacrum and two innominate bones
• Stability dependent on strong surrounding ligamentous structures
• Displacement can only occur with disruption of the ring in two places
• Neurovascular structures intimately associated with posterior pelvic ligaments
• High index of suspicion for injury of internal iliac vessels or lumbosacral plexus

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EPIDEMIOLOGY

• Pelvic fractures can be seen in any group of patients. Like much trauma, there is a bimodal distribution with younger male patients involved in high-energy trauma and older female patients presenting after minor trauma.
• Mortality rate 1-15% for closed fractures, as much as 50% for open fractures

ETIOLOGY

• Most pelvic fractures result from trauma 3:
• Motor vehicle collision (~50%)
• Pedestrian vs motor vehicle (~30%)
• Fall from height (~10%)
• Motorbike collisions (~4%)
• Other e.g. sports injury, low-energy fall
• The type of fracture that occurs is a result of the type of injury (impact or compression), the energy involved and the strength of the bones.
• Direct impact low-to-moderate energy injuries usually result in a solitary and localized fracture. Compression injuries tend to cause fractures that involve the pelvic ring and are unstable.

TILE CLASSIFICATION

• TYPE A: Stable
• A1: fracture not involving the ring (avulsion or iliac wing fracture)
• A2: stable or minimally displaced fracture of the ring
• A3: transverse sacral fracture (Denis zone III sacral fracture)
• TYPE B: Rotationally unstable, vertically stable
• B1: open book injury (external rotation)
• B2: lateral compression injury (internal rotation)

B2-1: with anterior ring rotation/displacement through ipsilateral rami

B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)

• B3: bilateral
• TYPE C: Rotationally and vertically unstable
• C1: unilateral

C1-1: iliac fracture

C1-2: sacroiliac fracture-dislocation

C1-3: sacral fracture

• C2: bilateral with one side type B and one side type C
• C3: bilateral with both sides type C

CLINICAL PRESENTATION

• They will often be immobilized by ambulance crews on arrival and potentially have other life-threatening conditions associated with high-energy trauma.
• Pain & inability to bear weight
• Inspection
• Test stability by placing gentle rotational force on each iliac crest (perform only once)
• Look for abnormal lower extremity positioning
• external rotation of one or both extremities
• limb-length discrepancy

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• skin
• scrotal, labial or perineal hematoma, swelling or ecchymosis
• flank hematoma
• lacerations of perineum
• degloving injuries (Morel-Lavallee lesion)
• neurologic exam
• up to 10-15% of patients will sustain neurologic injury

• Urogenital exam
• most common finding is gross hematuria
• more common in males (21% in males, 8% in females)
• Vaginal and rectal examinations
• mandatory to rule out occult open fracture

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INVESTIGATIONS

• X-RAY Radiographs
• Recommended views
• AP looks for asymmetry, rotation or displacement of each hemipelvis
• Inlet view : Xray beam angled 40° caudad (may be as little as 25 degrees) – to see internal or external rotation of the hemipelvis
• Outlet view: Xray beam angled ~40° cephalad (may be as much as 60 degrees) - adequate image when pubic symphysis overlies S2 body
• Findings
• Radiographic signs of instability: > 5 mm displacement of posterior sacroiliac complex, presence of posterior sacral fracture gap, avulsion fractures (ischial spine, ischial tuberosity, sacrum

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• CT
• Routine part of pelvic ring injury evaluation
• Better characterization of posterior ring injuries
• Helps define comminution and fragment rotation
• Visualize position of fracture lines relative to sacral foramina

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• LAB
• Hgb level
• Serum lactate
• Base excess

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INITIAL MANAGEMENT & RESUSITATION

• Control the bleeding Source: intraabdominal (present in up to 40% of cases), venous injury (80%), arterial injury (10-20%)
• Resuscitation:
• PRBC:FFP:Platelets ideally should be transfused 1:1:1
• this ratio shown to improve mortality in patients requiring massive transfusion
• Pelvic binder/sheet
• Indications
• Initial management of an unstable ring injury - should be centered over the greater trochanters
• NOTE: binder can mask pelvic ring injuries, creating false negative radiographs and CT images

• Pelvic Binding technique
• Centered over greater trochanters to effect indirect reduction
• Do not place over iliac crest/abdomen

Ineffective and precludes assessment of abdomen

• May augment with internal rotation of lower extremities and taping at ankles
• Transition to alternative fixation as soon as possible

Prolonged pressure from binder or sheet may cause skin necrosis

• Working portals may be cut in sheet to place percutaneous fixation

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• External fixation
• Indications
• Pelvic ring injuries with an external rotation component (APC, VS, CM)
• Unstable ring injury with ongoing blood loss
• Should be placed before emergent laparotomy
• ORIF
• Diverting colostomy - consider in open pelvic fractures

COMPLICATIONS

• Urogenital Injuries - posterior urethral tear, bladder rupture
• Neurologic injury
• DVT and PE
• Hemorrhagic shock

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FEMUR

THE FEMUR

• The femur is the only bone in the thigh and the longest bone in the body.
• It acts as the site of origin and attachment of many muscles and ligaments, and can be divided into three parts; proximal, shaft and distal.
• The proximal aspect of the femur articulates with the acetabulum of the pelvis to form the hip joint.
• It consists of a head and neck, and two bony processes – the greater and lesser trochanters.
• The shaft of the femur descends in a slight medial direction. This brings the knees closer to the body’s centre of gravity, increasing stability
• Shaft can be divided into proximal, mid and distal third of shaft of femur
• The distal end of the femur is characterised by the presence of the medial and lateral condyles, which articulate with the tibia and patella to form the knee joint.

PROXIMAL FEMORAL FRACTURES

INTRODUCTION

• They can occur anywhere between the joint surface of the femoral head and the upper shaft (proximal diaphysis) of the femur.
• High incidence of low-energy osteoporotic fractures in the elderly
• Smaller peak in younger patients involved in high-energy trauma

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EPIDEMIOLOGY

• Increasingly common due to aging population
• Women > men
• Whites > blacks
• Most expensive fracture to treat on per-person basis

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MECHANISM

• High energy in young patients
• Low energy falls in older patients

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• Associated injuries: Femoral shaft fractures

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CLASSIFICATION

• They are classified into Intracapsular and Extracapsular fractures based on the capsular insertion medial to the intertrochanteric line
• INTRA-CAPSULAR FRACTURE
• Subcapital: just below the femoral head (capitis)
• Transcervical: across the femoral neck
• Basicervical: at the bottom (base) of the neck (cervical)

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• EXTRA-CAPSULAR FRACTURE
• Pertrochanteric: fractures that span the intertrochanteric line
• Intertrochanteric: fracture passes between two trochanter
• Subtrochanteric: fractures below the trochanters

CLINICAL PRESENTATION

• Slight pain in the groin or pain referred along the medial side of the thigh and knee
• For displaced fractures, pain in the entire hip region
• Leg in external rotation and abduction, with shortening
• Loss of function
• Painful hip and inability to weight-bear

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INVESTIGATIONS

• X-RAY Radiographs
• Recommended views
• AP
• cross-table lateral
• full-length femur
• CT Scan: helpful in determining displacement and degree of comminution in some patients

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TREATMENT

• Nonoperative
• Observation alone - may be considered in some patients who are non-ambulators, have minimal pain, and who are at high risk for surgical intervention.
• Operative
• ORIF
• Displaced fractures in young or physiologically young patients
• ORIF indicated for most pts <65 years of age
• Hemiarthroplasty for displaced intracapsular fractures
• Dynamic hip screw if hemiarthroplasty not required

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COMPLICATIONS

• Osteonecrosis
• Nonunion
• Dislocation

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FEMORAL SHAFT FRACTURES

INTRODUCTION

• Femoral shaft fracture results from high energy injury that is associated with life-threating conditions such as ipsilateral femoral neck fractures, tibial shaft fracture, cerebral hemorrhage, thoracic injuries.
• Treatment involves reamed, statically locked, intramedullary nails that is associated with >95% union rates.
• More common in male > female
• The fracture can happen in the proximal, mid or distal third of shaft of femur

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MECHANISM

• Traumatic high-energy
• most common in younger population
• often a result of high-speed motor vehicle accidents
• Low-energy
• more common in elderly
• often a result of a fall from standing
• gunshot 

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ASSOCIATED CONDITIONS

• Orthopaedic
• Ipsilateral femoral neck fracture
• often basicervical, vertical, and nondisplaced
• Bilateral femur fractures  
• significant risk of pulmonary complications
• increased rate of mortality as compared to unilateral fractures
• Ipsilateral tibial shaft fractures
• Ipsilateral acetabular fracture

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• Thoracic
• Pulmonary injury
• treatment can proceed when patient is appropriately resuscitated

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• Cerebral hemorrhage, subdural hemorrhage
• intraoperative hypotension can decrease brain perfusion

COMMON FRACTURE PATTERNS

• Transverse 
• pure bending moment 
• Spiral 
• rotational moment
• Oblique
• uneven bending moment
• Segmental  
• 4-point bending moment
• Comminuted
• high-speed crush or torsion mechanism

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CLINICAL PRESENTATION

• Pain in thigh
• Loss of function
• Abnormal movement on the thigh
• Inspection
• Tense, swollen thigh (blood loss in closed femoral shaft fractures is 1000-1500ml and blood loss in open fractures may be double that of closed fractures). for closed tibial shaft fractures, 500-1000ml
• Affected leg often shortened
• Tenderness about thigh
• A patient can have distal neurovascular injury

INVESTIGATIONS

• LABORATORY
• CBC: check Hematocrit in acute bleeding, WBC differentials for Septic nonunion, platelets level
• CRP: most sensitive to the presence of a occult infection
• ESR

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• For adequate resuscitation, check the following
• Serum lactate should be less than 2.5 mmol/L, base deficit within -2 or +2, Interleukin-6 of less than 500 pg/dL

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• IMAGING
• X-RAY Radiographs
• Recommended views
• AP and lateral views of entire femur
• AP and lateral views of ipsilateral hip
• important to rule-out coexisting femoral neck fracture  
• AP and lateral views of ipsilateral knee
• CT - may be considered in midshaft femur fractures to rule-out associated femoral neck fracture

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MANAGEMENT

• Initial evaluation
• Advanced Trauma Life Support (ATLS) should be initiated
• Adequate resuscitation
• Normal vital signs
• HR < 100 bpm
• SBP >100 mm Hg
• DBP >70 mm Hg
• normothermia (> 35° C)
• Adequate urine output
• 0.5 - 1.0 mL/kg/hr (30 mL/hr)

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• Labs
• lactate <2.5 mmol/L
• base deficit within -2 and +2
• IL-6 levels <500 pg/dL
• gastric mucosal pH >7.3
• Compensated shock commonly missed, CHECK FOR
• Tachycardia without fever
• Cold extremities
• Narrowing pulse pressure
• Weak peripheral pulses
• Delayed capillary refill

TREATMENT

• NONOPERATIVE
• long leg cast or hip spica cast
• Indications
• Nondisplaced femoral shaft fractures in patients with multiple medical comorbidities
• Pediatric patients
• Skeletal traction in elderly(not fit for surgery) and skin traction for childen

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• OPERATIVE
• ORIF with either plate, antegrade/retrograde intramedullary nail,
• External fixation with conversion to intramedullary nail within 2-3 weeks

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INTRAMEDULLARY NAILS

Fixation with plate

EXTERNAL FIXATION

COMPLICATIONS

• Malunion and rotational malalignment
• Delayed union
• Nonunion
• Femoral artery or nerve injury
• Heterotopic ossification

DISTAL FEMUR FRACTURE

INTRODUCTION

• Distal femoral fractures involve the femoral condyles and the metaphyseal region and are often the result of high energy trauma such as motor vehicle accidents or a fall from a height. In the elderly, they may occur as a domestic accident
• Traumatic injuries involving the region extending from the distal metaphyseal-diaphyseal junction to the articular surface of the femoral condyles
• It occurs in 3-6% of femur fractures and <1% of all fractures
• It has a bimodal distribution, in young healthy males and elderly osteopenic females
• Surgical treatment options include ORIF, IM nail and distal femur replacement

RELEVANT ANATOMY

• Osteology
• anatomical axis of the distal femur is 6-11 degrees of valgus
• medial condyle extends more distal than lateral
• distal femur becomes trapezoidal in cross-section towards the knee
• Muscles
• key deforming forces 
• quadriceps
• hamstrings
• adductor magnus
• gastrocnemius

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• Ligaments
• anterior cruciate ligament (ACL)
• posterior cruciate ligament (PCL)
• medial collateral ligament (MCL)
• lateral collateral ligament (LCL)

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• Biomechanics
• hamstring and quadriceps
• cause the femur to shorten
• adductor magnus
• leads to distal femoral varus or valgus
• gastrocnemius
• extension at the fracture site (apex posterior)

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MECHANISM

• young patients
• high energy trauma to the flexed knee/dashboard injury with significant displacement
• older patients
• low energy, often fall from standing, in osteoporotic bone, usually with lesser degree of displacement

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CLASSIFICATION

• Descriptive
• Supracondylar
• Intercondylar
• OTA: 33 
• A: Extraarticular (Supracondylar)
• B: Partial articular (Unicondylar)
• portion of the articular surface remains in continuity with shaft
• 33B3 is in the coronal plane (Hoffa fragment)
• C: Complete articular (Intercondylar/Intra)
• articular fragment separated from the shaft

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There is type A, B and C

CLINICAL PRESENTATION

• Patients commonly present after fall or traumatic event and presents with pain on weight-bearing
• Pain of distal femur that is made worse with knee movement
• Swelling and bruising
• Deformity
• Inspection
• tenderness, swelling, ecchymosis of the distal thigh and knee
• varus or valgus deformity
• knee effusion may be present with intraarticular involvement

INVESTIGATIONS

• X-RAY Radiographs with recommended views
• AP
• lateral
• additional views
• traction views
• AP, lateral, and oblique traction views can help characterize injury but are painful for the patient
• adjacent joints
• obtain imaging of entire femur to rule out associated injuries
• contralateral femur
• consider views of the contralateral femur for pre-operative planning and templating

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• CT scan: indications
• preoperative planning
• evaluating intra-articular involvement
• after external fixation to assess pattern, comminution, and intraarticular extension
• Angiography: indications 
• obvious signs of vascular injury
• i.e., hard and soft signs (pulselessness, rapidly expanding hematoma, massive bleeding, etc.)
• Findings
• Identifies vascular segments with diminished flow
• vascular injury
• displaced distal femur fractures may result in injury to the popliteal artery 

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TREATMENT

• NONOPERATIVE
• Non-operative management is rare and considered in stable non-displaced fractures in non-ambulatory patients with unacceptable risk
• Hinged knee brace
• Indications (rare)
• Stable, nondisplaced fractures
• Non-ambulatory patient
• Patient with significant comorbidities presenting an unacceptably high degree of surgical/anesthetic risk
• Outcomes
• variable and dependent on multiple factors including patient characteristics and fracture pattern

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• Hinged knee brace 
• Technique 
• full time bracing for 6-8 weeks
• closed-chain ROM exercises at 3-4 weeks
• restricted weight-bearing until evidence of fracture union
• serial radiographs to assess for displacement
• Complications
• wounds from immobilization and bracing
• knee stiffness

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• OPERATIVE
• They will usually require open reduction and internal fixation (ORIF) particularly in case of displaced or intraarticular fractures ^-
• Extra-articular or simple intra-articular fractures may be treated with intramedullary nailing and screw fixation
• Simple unicondylar or epicondyle fractures may be treated with simple screw fixation
• Very comminuted, non-reconstructable fractures or patients with pre-existing osteoarthritis might need arthroplasty

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COMPLICATIONS

• Knee pain/stiffness
• treatment
• early ROM
• physical therapy
• Malunion
• Nonunion
• Implant failure
• Osteoarthritis
• Symptomatic hardware (excessively long screws can irritate soft tissues)

KNEE JOINT

INTRODUCTION

• The knee joint is a hinge type synovial joint, which mainly allows for flexion and extension (and a small degree of medial and lateral rotation). It is formed by articulations between the patella, femur and tibia.
• The knee joint consists of two articulations – tibiofemoral and patellofemoral. The joint surfaces are lined with hyaline cartilage and are enclosed within a single joint cavity.
• Tibiofemoral – medial and lateral condyles of the femur articulate with the tibial condyles. It is the weight-bearing component of the knee joint.
• Patellofemoral – anterior aspect of the distal femur articulates with the patella. It allows the tendon of the quadriceps femoris (knee extensor) to be inserted directly over the knee – increasing the efficiency of the muscle

LIGAMENTS

• The major ligaments in the knee joint are:
• Patellar ligament – a continuation of the quadriceps femoris tendon distal to the patella. It attaches to the tibial tuberosity.
• Collateral ligaments – two strap-like ligaments. They act to stabilise the hinge motion of the knee, preventing excessive medial or lateral movement
• Cruciate Ligaments – these two ligaments connect the femur and the tibia. In doing so, they cross each other, hence the term ‘cruciate’ (Latin for like a cross)
• Anterior cruciate ligament - It prevents anterior dislocation of the tibia onto the femur.
• Posterior cruciate ligament - It prevents posterior dislocation of the tibia onto the femur.

MOVEMENTS

• There are four main movements that the knee joint permits:
• Extension: Produced by the quadriceps femoris, which inserts into the tibial tuberosity.
• Flexion: Produced by the hamstrings, gracilis, sartorius and popliteus.
• Lateral rotation: Produced by the biceps femoris.
• Medial rotation: Produced by five muscles; semimembranosus, semitendinosus, gracilis, sartorius and popliteus.
• NB: Lateral and medial rotation can only occur when the knee is flexed (if the knee is not flexed, the medial/lateral rotation occurs at the hip joint).

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KNEE DISLOCATION

INTRODUCTION

• Knee dislocations are rare, but a significant number have a serious associated neurovascular injury
• Knee dislocations are traumatic injuries characterized by a high rate of vascular injury and treatment is generally emergent reduction and assessment of limb perfusion
• Occurs in 0.02% of orthopedic injuries
• 4:1 male to female ratio
• Risk factors: morbid obesity is a risk factor for "ultra-low energy" knee dislocations with activities of daily living

MECHANISM

• Forced hyperextension is the most common mechanism of injury, and can occur in both high-velocity (e.g. motor vehicle collisions) and low-velocity (e.g. sports injuries) trauma.
• High-energy vs low energy
• high energy is usually from MVC, crush injury, fall from a height, or dashboard injury resulting in axial load to a flexed knee
• low energy may be from an athletic injury or routine walking
• Hyperextension injury leads to anterior dislocations
• Posteriorly directed force across the proximal tibia (dashboard injuries) leads to posterior dislocations

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ASSOCIATED INJURIES

• Vascular injury
• Nerve injury
• usually common peroneal nerve injury (25% incidence)
• tibial nerve injury is less common
• Fractures
• present in 60% of dislocations
• Soft tissue injuries
• patellar tendon rupture
• periarticular avulsion
• displaced menisci

• Knee dislocations are invariably associated with ligamentous injuries.
• The most common pattern is bi-cruciate (i.e. both anterior and posterior) cruciate ligament tears with either medial collateral ligament tear or posterolateral corner injury.
• Fractures of the distal femur or proximal tibia are also common (~15%

TYPES OF KNEE DISLOCATION

• Five types of knee dislocation have been described, with respect to tibial displacement compared to the femur
• Anterior (40%)
• due to hyperextension injury
• usually involves a tear of PCL
• an arterial injury is generally an intimal tear due to traction
• Posterior (~33%)
• due to axial load to the flexed knee (dashboard injury)
• the highest rate of vascular injury (25%)
• the highest rate of a complete tear of the popliteal artery

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• Lateral (~20%)
• due to a varus or valgus force
• usually involves tears of both ACL and PCL
• the highest rate of peroneal nerve injury
• Rotatory (~5%)
• posterolateral is most common rotational dislocation
• usually irreducible
• buttonholing of femoral condyle through the capsule
• Medial (~5%)
• varus or valgus force
• usually disrupted posterolateral corner and PCL

CLASSIFICATION

1. Descriptive
1. KENNEDY CLASSIFICATION BASED ON THE DIRECTION OF DISPLACEMENT OF THE TIBIA
1. Anterior dislocation
• most common
• due to hyperextension injury
• usually involves tear of PCL
• an arterial injury is generally an intimal tear due to traction
• the highest rate of peroneal nerve injury
2. Posterior dislocation
• 2nd most common
• due to axial load to the flexed knee (dashboard injury)
• the highest rate of vascular injury (25%) based on Kennedy classification
• has highest incidence of a complete tear of the popliteal artery

• Lateral dislocation
• due to a varus or valgus force
• usually involves tears of both ACL and PCL
• Medial dislocation
• varus or valgus force
• usually disrupted PLC and PCL
• Rotational dislocation
• posterolateral is most common rotational dislocation
• usually irreducible
• buttonholing of femoral condyle through the capsule

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2. SCHENCK CLASSIFICATION
1. The Schenck classification categorizes knee dislocation based on the pattern of multiligamentous injury and is the usual system used by sports medicine physicians; it has superseded the older position (Kennedy) classification system.
2. Trauma surgeons tend to use a different classification based on the energy and velocity of the trauma

CLINICAL PRESENTATION

• Dislocation of the knee is usually obvious clinically with a marked deformity.
• There is a history of trauma and deformity of the knee
• Knee pain & instability
• “Dimple sign" - buttonholing of medial femoral condyle through the medial capsule
• indicative of an irreducible posterolateral dislocation
• a contraindication to closed reduction due to risks of skin necrosis
• Reduce immediately, especially if absent pulses

• Stability
• Diagnosis based on instability on physical exam (radiographs and gross appearance may be normal)
• May see recurvatum when held in extension
• Assess ACL, PCL, MCL, LCL, and PLC
• Assess sensory and motor function of peroneal and tibial nerve
• Rule out vascular injury on exam both before and after reduction

INVESTIGATIONS

• X-RAY Radiographs
• Pre-reduction AP and lateral of the knee
• Post reduction AP and lateral of the knee
• CT - obtain post reduction CT for characterization of fracture if identified in a plain radiograph
• MRI - required to evaluate soft tissue injury (ligaments, meniscus) and for surgical planning

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TREATMENT

• NONOPERATIVE
• Emergent closed reduction followed by vascular assessment
• considered an orthopedic emergency
• Immobilization as definitive management
• indications (rare)
• successful closed reduction without vacular compromise
• most cases require some form of surgical stabilization following reduction
• outcomes
• worse outcomes are seen with nonoperative management
• prolonged immobilization will lead to loss of ROM with persistent instability

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• Closed reductionapproach
• Anterior dislocation - traction and anterior translation of the femur
• Posterior dislocation - traction, extension, and anterior translation of the tibia
• Medial/lateral - traction and medial or lateral translation
• Rotatory - axial limb traction and rotation in the opposite direction of deformity
• Splinting
• 20 to 30 degrees of flexion

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• OPERATIVE
• Open reduction
• indications
• irreducible knee
• posterolateral dislocation
• open fracture-dislocation
• obesity (may be difficult to obtain closed)
• vascular injury
• External fixation
• indications
• vascular repair (takes precedence)
• open fracture-dislocation
• compartment syndrome
• obese (if difficult to maintain reduction)
• polytrauma patient

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• Delayed ligamentous reconstruction/repair 
• indications
• instability will require some kind of ligamentous repair or fixation
• patients can be placed in a knee immobilizer until treated operatively
• improved outcomes with early treatment (within 3 weeks) 

COMPLICATIONS

• Vascular compromise
• Stiffness (arthrofibrosis) - most common complicationwith delayed mobilization (38%)
• Laxity and instability
• Peroneal nerve injury

TIBIA AND FIBULA

TIBIA

• The tibia is the main bone of the lower leg, forming what is more commonly known as the shin.
• It expands at its proximal and distal ends; articulating at the knee and ankle joints respectively. The tibia is the second largest bone in the body and it is a key weight-bearing structure.
• The proximal tibia is widened by the medial and lateral condyles, which aid in weight-bearing. The condyles form a flat surface, known as the tibial plateau.
• Located between the condyles is a region called the intercondylar eminence – this projects upwards on either side as the medial and lateral intercondylar tubercles.

• The shaft of the tibia is prism-shaped, with three borders and three surfaces; anterior, posterior and lateral.
• The shaft has a proximal, mid and distal third of shaft of tibia
• The distal end of the tibia widens to assist with weight-bearing.
• The medial malleolus is a bony projection continuing inferiorly on the medial aspect of the tibia.
• Laterally is the fibular notch, where the fibula is bound to the tibia – forming the distal tibiofibular joint.

FIBULA

• The fibula is a bone located within the lateral aspect of the leg. Its main function is to act as an attachment for muscles, and not as a weight-bearer.
• It has three main articulations:
• Proximal tibiofibular joint – articulates with the lateral condyle of the tibia.
• Distal tibiofibular joint – articulates with the fibular notch of the tibia.
• Ankle joint – articulates with the talus bone of the foot.

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• At the proximal end, the fibula has an enlarged head, which contains a facet for articulation with the lateral condyle of the tibia. On the posterior and lateral surface of the fibular neck, the common fibular nerve can be found
• The fibular shaft has three surfaces – anterior, lateral and posterior. The leg is split into three compartments, and each surface faces its respective compartment e.g anterior surface faces the anterior compartment of the leg.
• Distally, the lateral surface continues inferiorly, and is called the lateral malleolus. The lateral malleolus is more prominent than the medial malleolus, and can be palpated at the ankle on the lateral side of the leg.

TIBIOFIBULAR JOINTS

• The proximal and distal tibiofibular joints refer to two articulations between the tibia and fibula of the leg.
• These joints have minimal function in terms of movement but play a greater role in stability and weight-bearing

TIBIAL PLATEAU FRACTURES

INTRODUCTION

• Periarticular injuries of the proximal tibia frequently associated with soft tissue injuries.
• Bimodal distribution
• males in 40s (high-energy trauma)
• females in 70s (falls)

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RELEVANT ANATOMY

• Osteology
• lateral tibial plateau
• convex in shape
• proximal to the medial plateau
• medial tibial plateau
• concave in shape
• distal to the lateral tibial plateau
• Muscles
• anterior compartment musculature
• attaches to anterolateral tibia
• pes anserine
• attaches to anteromedial tibia

MECHANISM

• Varus/valgus load with or without axial load
• High energy
• frequently associated with soft tissue injuries
• Low energy
• usually insufficiency fractures
• Associated conditions
• meniscal tears
• lateral meniscal tear
• more common than medial
• associated with Schatzker II fracture pattern
• medial meniscal tear
• most commonly associated with Schatzker IV fractures
• ACL injuries - more common in type IV and VI fractures (25%)

SCHATZKER CLASSIFICATION

CLINICAL PRESENTATION

• There is a History
• high-energy trauma in young patients
• low-energy falls in elderly
• Physical exam
• inspection
• look circumferentially to rule-out an open injury
• palpation
• consider compartment syndrome when compartments are firm and not compressible
• varus/valgus stress testing
• any laxity >10 degrees indicates instability
• often difficult to perform given pain
• neurovascular exam
• any differences in pulse exam between extremities should be further investigated 

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INVESTIGATION

• X-RAY Radiographs
• Recommended views
• AP
• lateral
• oblique
• oblique is helpful to determine amount of depression
• optional views
• plateau view
• 10 degree caudal tilt
• CT scan - important to identify articular depression and comminution
• MRI - useful to determine meniscal and ligamentous pathology

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TREATMENT

• NONOPERATIVE
• Hinged knee brace, PWB for 8-12 weeks, and immediate passive ROM
• Indications
• minimally displaced split or depressed fractures
• low energy fracture stable to varus/valgus alignment
• nonambulatory patients
• OPERATIVE
• External fixation/Ilizarov +/- limited open/percutaneous fixation of articular segment in severe open fracture with marked contamination and highly comminuted fractures where internal fixation not possible
• ORIF - all medial plateau and all bicondylar fractures

COMPLICATIONS

• Post-traumatic arthritis
• Rate Increases with
• meniscectomy during surgery
• axial malalignment
• intra-articular infection
• joint instability

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PROXIMAL THIRD TIBIA FRACTURE

• Relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise
• Occurs in 5-11% of all tibial shaft fractures
• Treatment consists of IMN or ORIF

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RELEVANT ANATOMY

• Osteology
• proximal tibia
• triangular
• wide metaphyseal region
• narrow distally
• Muscles
• Patellar tendon
• proximal fragment into extension
• fracture into apex anterior, or procurvatum

• Gastrocnemius
• distal fragment into flexion
• Pes anserinus
• proximal fragment into varus
• varus deforming force of the fracture
• Anterior compartment musculature
• valgus deforming force of the fracture

MECHANISM

• Low energy
• result of torsional injury (spiral oblique fracture)
• indirect trauma
• High energy
• direct trauma
• Associated conditions
• compartment syndrome
• soft tissue injury
• critical to outcome
• severity of muscle injury has the greatest impact on need for amputation

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CLASSIFICATION

CLINICAL PRESENTATION

• Pain, inability to bear weight
• Inspection
• contusions
• blisters
• open wounds

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• Neurovascular injury assessment

INVESTIGATION

• X-RAY Radiographs
• Recommended views
• AP
• lateral
• ipsilateral knee, tibia, and ankle
• Findings
• proximal fracture extended, apex anterior, varus
• varus due to pes anserinus + anterior compartment
• distal fragment flexed
• flexed due to gastrocnemius
• CT – when suspect of intra-articular fracture extension

TREATMENT

• NONOPERATIVE
• Closed reduction / cast immobilization - closed low energy fractures with acceptable alignment
• Technique
• place in long leg cast and convert to functional brace at 4 weeks
• cast in 10 to 20 degrees of flexion
• OPERATIVE
• External fixation - fractures with extensive soft-tissue compromise
• Intramedullary nailing - enough proximal bone to accept two locking screws (5-6 cm)
• Percutaneous locking plate - extreme proximal fractures

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COMPLICATION

• Anterior knee pain
• Nonunion
• Malunion

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