Trauma II

Shoulder down

Young adults (high energy trauma), elderly patients (osteopenia, low energy injuries)

Humerus fractures make up 3-5% of all broken bones who are they commonly seen in?

Proximal, middle (most common), distal

Location of humerus fractures

spiral, transverse, comminuted

Common patterns of humerus fractures

radial (loss of sensory on dorsal part of hand, loss of wrist, finger, and thumb extension)

What nerve are we worried about with humeral shaft fractures

Varus (bow leg)

Humeral shaft fractures often fall into what angulation

Coaptation spint (hard to place in peeps with boobs, swole chest, or obese) → Sarmiento brace; DO NOT SLING

Non-operative management for humeral shaft fractures (takes 3+ months to heal)

less than 20 degree anterior angulation, less than 30 degree varus/valgus, less than 3 cm shortening

Criteria for humeral shaft fractures to be treated non-op (depends on location, displacement, fracture type, other ipsilateral injuries)

open, brachial plexus injury, angulation over 20 anterior and 30 varus/valgus, floating elbow, compartment syndrome

Indications for surgical humeral shaft fracture management (RISK OF DAMAGING THE RADIAL NERVE)

Normal elbow

Normal elbow

radial head

Most common elbow fracture in adults

limitations in extension and supination, tender on palpation on lateral side, pain on movement

What might you find in a radial head fracture on physical exam

posterior splint for 3-5 days then ROM especially extension and supination (test); sling (IRL)

Game plan for radial head fracture

Condylar fractures (peds), radial head fractures (adults)

What are fat pad signs associated with

NEVER normal, occult non-displace fracture

If you see a posterior fat pad or a GIANT anterior fat pad (sail sign)…

Direct trauma (high energy in young, low energy in old)

What is the MOI for olecranon fractures?

NO extension (triceps gone, flapping in the wind)

If the olecranon breaks what do you lose

long-arm splint at a 45 degree angle

Non-operative management for olecranon fractures (non-displaced, intact extensor mech)

extensor mechanism is gone, displaced

Indications for surgical management (hook plate) of olecranon fractures

elbow dislocation

Most common dislocation in kids (second in adults)

Posterior

Elbow dislocation usually occurs in which direction

extension (more unstable)

What position does elbow dislocation often occur in

elbow dislocation, radial head fracture, coronoid process fracture

Terrible triad of the elbow

Reduction in the ER (Grab the forearm, Pull out into extension, Flex, Clunk it back in), long arm splint at 45 for 7-10 days, throw it in a sling for early ROM (no loss of extension)

treatment plan for elbow dislocation

associated fracture, persistent instability, failed closed reduction

Indications for surgical management of elbow dislocation

Both bone, monteggia, galeazzi, nightstick

Adult forearm fractures

both bone, buckle, greenstick

Peds forearm fractures

Both bone forearm fracture

A fracture of both the radius and the ulnar that usually needs surgical intervention

NV exam (test anterior interosseous with the OK sign, posterior interosseous with thumbs up), Elbow and wrist x-rays, evaluate for compartment syndrome, sugar tong splint for stability and patient comfort (prevents flexion, extension, supination, and pronation)

Initial eval of Both bone forearm fracture includes

Fall from a height

Both bone fractures are very common in kids, what is their MAOI

Closed reduction, flexible intermedullary nailing (operative)

Game plan for both bone fractures in kids

Buckle fracture

A fracture that results due to a failure of cortex compression side 2-3 cm proximal to physis that is common in young children (FOOSH) and the volar cortex remains intact

volar splint, short arm cast

Gameplan for buckle fracture

Greenstick

An incomplete fracture of the cortex - typically in children

Do not overcorrect in reduction, long arm cast (4-6 weeks)

Gameplan for greenstick fractures

Galeazzi fracture

A fracture of the distal 1/3 radial shaft with injury of the DRUJ (bust it wide open) - get and document nerve function

FOOSH

MOI of Galeazzi fracture

ORIF (usually pretty unstable)

Treatment for Galeazzi fracture

Monteggia fracture

A fracture of the proximal 1/3 of the ulna with dislocation of the radial head

hyper-pronation

MOI for Monteggia fracture

operative (unstable), once ulna is brought back to the length of the radial head it typically reduces

Game plan for Monteggia fracture

Nightstick fractures

Ulnar shaft fracture usually at the distal 1/3 junction due to a direct blow when trying to block/shield

If less than 50% displaced → muenster cast

Gameplan for nightstick fractures

normal wrist

normal wrist

Distal radius fracture

A very common fracture that is often due to a FOOSH injury in the elderly

Reduce and immobilize IMMEDIATELY (sugar tong), can be treated non-op if stable and non-displaced

With a Distal radius fracture, what is the gameplan

Colles fracture

A transverse distal radius fracture DORSALLY displaces and extra-articular - dinner fork deformity

Smith’s fracture

A transverse distal radius fracture VOLARLY displaces and extra-articular

Barton’s fracture

A fracture-dislocation of the radiocarpal joint that is intra-articular and can be displaced dorsally or volarly

Chauffer’s Fracture

Fracture of the radial styloid

Scaphoid bone fracture

The most common carpal bone fracture that is a result of a FOOSH and leads to pain in the anatomical snuff box dorsally and scaphoid tubercle volarly

High incidence of avascular necrosis (palmar carpal branch is at risk) and nonunion

Quicks of a scaphoid bone fracture

Even with normal xray if they have pain in snuff box give them a thumb spica splint, re-xray in 2 weeks, MRI most sensitive, CT scan is best for pre-op

Treatment plan for scaphoid bone fracture

Waist (65%), Proximal 1/3 (25%), distal third (10%)

Locations of scaphoid bone fractures

6 weeks in long arm thumb spica cast → 6 weeks of short arm thumb spica cast → removable thumb spica splint for 4-6 weeks

Non-operative management of scaphoid fractures

screw placement (return to work sooner), high rate of AVN and non-union

Operative management for scaphoid fractures

increases incidence on wrist arthritis and instability of joint

IF AVN or non-union occurs for a scaphoid fracture what does this mean for our patient?