Orthopedics - Dr. Ahmad - Lecture 5 - Wrist & Hand Summary of Fractures 1. 2. 3. 4. 5. 6.

Galeazzi Monteggia Isolated Forearm Fractures Colle’s Fracture Smith’s Fracture Fracture of Radial Styloid

Forearm Fractures Radius and ulnar are bound together by: Annular ligament Interosseus membrane Radioulnar ligaments and triagular fibrocartilage. With a direct blow you can break either isolated(radius or ulna), however more likely with indirect (i.e. fall on outstretched hand) to damage both bones. Presentation Nondisplaced diaphyseal fractures of the shafts of both bones of the forearm are rare, and the deformity is often obvious, with the patient supporting the deformed and injured limb with the other hand. The symptoms include pain, deformity, and loss of function of the forearm. Clinical examination should include a careful neurologic evaluation of the motor and sensory functions of the radial, median, and ulnar nerves. Check the vascular status and amount of swelling in the forearm. A tense compartment with neurological signs or stretch pain should arouse the suspicion of compartment syndrome Treatment Non displaced fractures needs only POP holding for 6 weeks. Indications of surgical treatment are

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1. Fracture of both bones (ie, radius and ulna) 2. Fracture dislocations, Monteggia fracture dislocations, and Galeazzi fracture dislocations 3. Isolated radius fractures 4. Displaced ulnar shaft fractures 5. Delayed union or nonunion 6. Open fractures 7. Fractures associated with a compartment syndrome, irrespective of the extent of displacement 8. Multiple fractures in the same extremity, segmental fractures, and floating elbow 9. Pathologic fractures

Fixation done by 1. Plate and screw. 2. K. wires. 3. Rash nails. Complications 1. 2. 3. 4. 5.

Non union and malunion. Infection. Compartment syndrome. Refractures after implant removal. Synostosis.

ISOLATED ULNAR/RADIUS Most fractures of the ulnar/radius shaft are caused by direct blows and result in minimal soft-tissue injury. Generally obvious gross deformity NV exam, evaluate for compartment syndrome. A/P and Lateral of forearm +/- elbow, wrist. Ulnar Shaft Fracture Associated Injuries / Differential Diagnosis Monteggia fracture-dislocation. Radius and ulna shaft fracture. Galeazzi Fracture Treatment : Depends on if it is displaced or not. Can be conservative or ORIF. Fracture Complications

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1. 2. 3. 4. 5. 6. 7.

Superficial wound infection Nonunion: Hardware failure Malunion Painful hardware Ulnar nerve palsy Radial nerve palsy

GALEAZZI Galeazzi Fractured Radius Definition: Fracture of the radial shaft (usually distal 1/3) with dislocation of the distal radioulnar joint. Mechanism is fall on the hand with hyperpronated forearm. Clinically: Pain and swelling in forearm and wrist. Forearm rotation very painful. NV exam, evaluate for compartment syndrome. Galeazzi Radiologically: A/P and Lateral of forearm +/- elbow, wrist. Treatment : ORIF of the radius is indicated in all cases. Further management depending on stability of distal radioulnar joint. Complications 1. 2. 3. 4. 5. 6.

Nonunion Malunion Infection Refracture following plate removal Posterior interosseous nerve injury Instability of the distal radio ulnar joint.

MONTEGGIA # ulna with dislocation of the radial head. More common in children. Adult injuries are typically high energy, fall from heights or MVA. Clinical Evaluation: Pain and swelling in the elbow and ulnar border of the forearm. ROM limited by pain. NV exam, evaluate for compartment syndrome. Radiology: A/P and Lateral of forearm +/- elbow, wrist. Always suspect a radial head dislocation in an ulnar #. A line drawn along the axis of the radius should pass through the capitellus on both lateral + AP views.

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Treatment: always ORIF generally.

Distal radius fractures (DRFs) Distal radius fractures (DRFs) in the time of Hippocrates and Galen were thought to be wrist dislocations. The Irish surgeon Abraham Colles described DRFs in the 1814 volume of the Edinburgh Medical Surgical Journal. Colles based his descriptions on clinical examinations alone because radiography had not yet been invented. Distal radius fractures (DRFs) are among the most common type of fracture, and many authors state that they are the most common type of fracture. DRFs have a bimodal distribution, with a peak in younger persons (aged 18-25 y) and a second peak in older persons (>65 y) persons. The mechanism of injury is unique to each group, with high-energy injuries being more common in the younger group and low-energy injuries being more common in the older group. Younger patients have stronger bone and require more energy to create a fracture. Motorcycle accidents, falls from a height. Older patients have much weaker bones and can sustain a DRF from simply falling on an outstretched hand in a ground-level fall. An increasing awareness of osteoporosis has led to these injuries being termed fragility fractures, with the implication that a workup for osteoporosis should be a standard part of treatment. Distal radius fractures are 1. Colles fracture. 2. Smith fracture. 3. Barton fracture. 4. Radial styloid fracture.

COLLES FRACTURE Mechanism is fall on outstretched hand. Clinical features 1. Dinner fork deformity.( prominence in the back of the wrist and depression in front). 2. Pain 3. Local tenderness. 4. Swelling. X-ray

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a. Transverse fracture at the cortico-cancellous junction.

b. The fragment is 1. Shifted and tilted backwards. 2. Shifted and tilted radially. 3. Impacted. c. Ulnar styloid may be fractured. Treatment 1. Undisplaced fractures: posterior slab for 3 weeks followed by complete cast or functional brace for another 3 weeks. 2. Displaced fractures: must be reduced under anaesthesia, the posterior slab done with the forearm pronated, the wrist slightly flexed and ulnar deviated. After 3 weeks the slab changed to complete cast for another 3 weeks. 3. Severely comminuted and unstable fractures: external fixation is treatment of choice. Complications Early 1. Circulation which lead compartment syndrome. 2. Nerve injury: median nerve injury or compression is rare. 3. Reflex sympathetic dystrophy, Late 1. Malunion. 2. Delayed and non union. 3. Stiffness. 4. Sudeck’s atrophy. 5. Tendon injury ( extensor pollicis longus tendon rupture)

SMITH FRACTURE Also called reversed Colles The fragment will displaced anteriorly. Mechanism : fall on the back of the hand ( on stretched hand ). There will be pain, swelling, tenderness, and deformity but not dinner fork deformity. X-ray anterior displacement. Treatment

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Reduction under anesthesia and wrist should be kept in anterior slab with wrist in extension and forearm supinated foe 3 weeks then followed by complete cast for another 3 weeks.

BARTON’S FRACTURE The fracture line run obliquely across the volar lip of the radius into the wrist joint and the fragment displaced anteriorly and called volar Barton. This is unstable fracture and need open reduction and internal nternal fixation with small buttress plate. Dorsal Barton in which the fracture line run obliquely across the dorsal lip of the radius into the wrist joint. The fragment displaced posteriorly. The fracture is more stable than volar one and closed reduction and slab hold is suitable.

RADIAL STYLOID FRACTURE URE Mechanism: forced radial deviation of the wrist. Treatment Undisplaced POP hold for 3 weeks. Displaced fracture closed reduction and POP foe 3 weeks, if faile failed d open reduction and K. wire fixation.

WRIST AND HAND Wrist is the most complex joints of the body due to the numerous joints combined to create one. Wrist and Hand Anatomy Carpal bones- Create a Mnemonic for them: S-L-T-P-T-T-C-H Two rows of bones starting on the thumb side. Scaphoid, lunate, triquetrum, pisiform Second row of carpals bones, is more proximal Trapezium, trapezoid, capitate, Hamate. SCAPHOID FRACTURES Account for 75% of all wrist injuries. It is rare in children and elderly. May associated with scapho scapho-lunate lunate ligament disruption and tilting of lunate. Mechanism of injury is fall on out stretched hand. Clinical features 1. Fullness in the anatomical snuffbox.

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2. Tenderness in the anatomical snuffbox.

X-ray AP, Lateral and oblique views are essential. Initial x-ray may be negative and must be repeated after 10 – 14 days ( two occasions ). Fracture line usually transverse C-T scan and MRI may be needed. Classification Typically by location: 1. 2. 3. 4.

Proximal third Middle third (Waist) Distal Third Tuberosity

Scaphoid Fxs: Location Of Fracture Tuberosity: 17% to 20% Distal Pole: 10% to 12% Waist: 66% to 70% Horizontal oblique: 13% to 14% Vertical Oblique: 8% to 9% Transverse: 45% to 48% Proximal Pole: 5% to 7% Why is Fracture Location so Important in the Scaphoid? Blood supply: Primary vascular supply enters dorsal ridge and runs retrograde to the proximal scaphoid. Management of Suspected Scaphoid Fracture Clear injury and positive exam with normal x-rays immobilize for 7-10 days (thumb spica ) Repeat x-rays if patient still symptomatic If pain still present but x-ray continues to be normal consider MRI early recast and f/u at 3 weeks If acute diagnosis necessary

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consider MRI or CT early

Treatment Options - Acute Injuries Nonoperative Thumb spica Operative Percutaneous pin or screw fixation ORIF Indications for Nonoperative Treatment Ideal indication - nondisplaced distal third fracture Tuberosity fractures also heal well with casting 80-90% of middle third fractures heal Only 60-70% of proximal third fractures heal Nonoperative Treatment Immobilize in slight flexion and slight radial deviation. Initial cast: long-arm thumb spica cast for 6 weeks shown to lead to more rapid union and less nonunion Gellman et al, JBJS, 1989 Replace with short-arm thumb spica cast until united. Expected time to union: Distal third = 6-8 weeks Middle third = 8-12 weeks Proximal third = 12-24 weeks Cast Management: Alternatives Open reduction, internal fixation (ORIF) Headed screws placed radially Headless screws ( Herbert screw ). K-wires Percutaneous fixation with cannulated screw Volar approach Dorsal approach Indications for Surgery Unstable Scaphoid Fractures Displacement of > 1 mm intra-scaphoid angle >10 degrees

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Nonunion

Outcomes and Complications 1. 2. 3. 4.

AVN of proximal pole Nonunion Malunion Arthritis (SNAC) wrist

Treatment Options - Scaphoid Nonunion: ORIF with cancellous bone graft ORIF with structural tricortical graft ORIF with vascularized graft Percutaneous fixation alone

HAND FRACTURES METACARPAL (II TO V) FRACTURES 2nd and 3rd metacarpals are relatively immobile and fractures require anatomic reduction. 4th and 5th MC have 15 to 20-degree AP motion, which allows for some compensation. MC fractures are categorized as head, neck, shaft, or base fractures. Head: Usually caused by a direct blow, crush or missile. Fractures are distal to the insertion of the collateral ligaments and are often comminuted. If a laceration is present a human bite must be considered. Treatment: Ice, elevation, immobilization, and referral to a hand surgeon. Neck: Usually caused by a directed impaction force. Fracture of the fifth MC neck is often referred to as a unskilled boxer’s fracture Fracture are usually unstable with volar angulation. Angulation of < 20 degrees in the 4th and 40 degrees in the 5th MC will not result in functional impairment If greater angulation in these MC occur, reduction should be attempted Fractures should be splinted with the wrist in 20-degree extension and the MP flexed at 90 degrees.

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In the 2nd and 3rd MC, angulation of