Fractures

  1. Fractures
  2. Must always examine the joint as well as the neurologic/vascular function above and below the fracture
  3. 6 P’s of compartment syndrome
  4. Pulselessness, Pallor, Paresthesias, Pain,
  5. Treatment
  6. 1ststep is to stabilize the fracture
  7. Done by immobilization (splints)
  8. 2nd step is to reduce the fracture
  9. If displaced
  10. 3rd step maintain reduction
  11. Splint, cast, surgery
  12. Reduction
  13. Maintain reduction restores acceptable anatomical position
  14. Must allow for normal range of motion
  15. Must preserve vascular and neurologic status of area
  16. Avoid complications
  17. Make patient pain-free long term
  18. Fractures of the proximal humerus
  19. Common in elderly
  20. Fracture of surgical neck or greater tuberosity
  21. Most fractures are acceptable without surgery
  22. Can accept 6-8mm of displacement
  23. Treat with immobilization
  24. Sling and swath
  25. If unstable fracture use cooptation splint
  26. 6 weeks immobilization for adults
  27. Some exceptions
  28. Fractures of the Collarbone
  29. Common in sports
  30. Must be concerned with vascular status and pneumothorax
  31. There will be a lot of pain with cosmetic deformity
  32. Must be careful with proximal 1/3 fractures
  33. 1/3 overlap is considered acceptable
  34. Treatment

  1. Sling and swath
  2. Pain medications

  1. Mid-Shaft Humerus Fractures
  2. Very difficult to maintain in reduction due to rotation of shaft
  3. Must assess vascular/neurologic function above and below the fracture site
  4. Commonly caused by high velocity trauma
  5. Treatment
  6. Immobilization with cooptation splint
  7. Can be immobilized with an intramedullary rod
  8. Screws lock the rod
  1. Elbow Fractures (Olecranon Fractures)
  2. Fracture of the proximal ulna
  3. 3mm is the maximum number for the gap in articular surface that can be allowed
  4. Treatment
  5. Patient will respond well to splint (posterior part of arm)
  6. Splint should be reviewed in first week to 10 days
  7. Further evaluation for casting or maintaining splint
  8. If the gap is more than 3mm the elbow may require surgery
  9. Radial head Fracture
  10. Very common
  11. Can be a subtle finding on x-ray
  12. A good physical exam will detect pain in antecubital fossa
  13. Supination will be painful
  14. Tend to be a very stable fracture
  15. Treatment
  16. Sling for 2 weeks
  17. Start early range of motion to decrease stiffness and maintain ROM
  18. Coracoid Process Fracture
  19. Mostly a non-displaced fracture
  20. Must stress the elbow if x-ray shows displaced fracture to observe humeral displacement
  21. This will assess the stability
  22. If the elbow is not displaced do not stress elbow
  23. Unstable will have to be operated on
  24. Radius and Ulna Mid-shaft Fracture (Both Bone Forearm Fracture, BBFA)
  25. Often transverse fractures with blunt trauma
  26. Oblique is associated with non-blunt trauma
  27. Carrying angle of arm is important
  28. Valgus angle at elbow normally
  29. Large incidence of compartment syndrome
  30. Must assess neurovascular function
  31. Treatment
  32. Splinting
  33. Must assess on weekly intervals in the beginning to observe for compartment syndrome
  34. Colles Fracture
  35. Distal radius fracture
  36. Usually due to slip and fall with hands planted
  37. Displaces dorsally ( if it does not displace dorsally it is not a Colles fracture)
  38. Common in elderly
  39. Generally a stable fracture
  40. Treatment
  41. If in good position fragment may be left alone
  42. Some require reduction
  43. Smith Fracture
  44. Distal radius fracture that displaces volarlly
  45. Slip and fall with a bent-back hand
  46. Generally not a stable fracture
  47. Treatment
  48. Almost always require an ORIF (70-75%)
  49. Distal Radius Fracture
  50. Fracture of the distal radius with no displacement
  51. Golleazzis Fracture
  52. Fracture of the ulna with a radial dislocation at the wrist
  53. Can get ulna and radius fracture occasionally
  54. Monteggia Fracture
  55. Fracture of the ulna causes a dislocation of the radial head towards the elbow
  56. Often missed due to radiology oversight
  57. See ulnar fracture but miss radial dislocation
  58. Must get elbow x-ray to rule out dislocation
  59. Scaphoid Fracture (Carpo navicular Fracture)
  60. Occurs with slip and fall on a dorsiflexed wrist
  61. Scaphoid is the most common carpal bone fractured
  62. Other carpal bones can fracture
  63. Many times in younger people
  64. Scaphoid has very poor blood supply
  65. Can result in non-union even if treatment is correct
  66. Will present with pain in the anatomical snuff box
  67. 30% of the time does not show up on x-ray (navicular view)
  68. Must go on patients symptoms and exam
  69. Splint the patient and have them return to repeat x-rays
  70. MRI is the alternative film for study
  71. Treatment
  72. Splinting- thumb spica
  73. Surgery if non-union
  74. Metacarpal Fracture
  75. Most common fracture in metacarpals is boxer’s fracture
  76. Associated with punches
  77. Most concerned about the rotation of a metacarpal fracture
  78. Treatment
  79. If reduced will require operation
  80. Must maintain metacarpophalangeal joints
  81. Put patient in splint with flexion to prevent shortening
  82. Must put on an ulnar gutter
  83. Immobilize the joint lateral to the fracture
  84. Phalangeal Fracture
  85. Most phalangeal fractures will be okay in the position they are in
  86. Must be concerned with rotation of the phalanges
  87. Lateral Epicondylitis (tennis elbow)
  88. Pain (burning sensation) that runs down forearm into fingers
  89. Tender to direct palpation of the lateral epicondyle
  90. Pain on dorsiflexion of the wrist against resistance
  91. Some patients will have pain on supination
  92. Treatment
  93. Anti-inflammatory or NSAIDS (conservative)
  94. Injection of steroid and lidocaine
  95. May require a long time to heal
  96. Medial Epicondylitis (Golfer’s elbow)
  97. Pain on volar flexion and pronation
  98. Treatment

  1. NSAIDS or anti-inflammatory
  2. Injection of steroid and lidocaine
  3. Rarely requires surgery

  1. Carpal Tunnel Syndrome
  2. Compression of the median nerve
  3. Paresthesias in the first 3 fingers and half of the 4th finger palm side
  4. Phalen’s test and Tinel’s sign
  5. May be negative tests in DM and hypothyroidism
  6. EMG/NCV must be performed
  7. Treatment
  8. Splinting in dorsiflexion
  9. B6 1000mg per day may help
  10. Can be injected with steroid and lidocaine
  11. Surgery is a carpal tunnel release
  12. The longer the patient has carpal tunnel syndrome the worse they will be post-operatively
  13. Dequervain’s Tenosynovitis
  14. Abductor tendon of the thumb
  15. Common in new mothers
  16. Ask the patient to fold fingers around the thumb
  17. Finklestein test- positive test is pain in the thumb
  18. Treatment
  19. NSAIDS
  20. Thumb abduction splint- wear during the day if possible
  21. Injection into the first dorsal compartment
  22. Don’t stress the joint for 1 week after due to weakened tendon
  23. Surgical treatment
  24. Game-Keeper’s Thumb
  25. Refers to the ringing of necks f chickens for killing
  26. Now seen mainly in skiing, driving, and break-dancing
  27. Treatment
  28. Splinting- most of the time this is enough
  29. Hand surgeon (surgery)- For continuation of pain