MRAD 2218: Module 3 (Upper Ext Fractures)

Colle's fracture

FOOSH

"Dinner fork" deformity

Features of the injury:

(1) Transverse fracture of the radius

(2) 1 inch proximal to the radio-carpal joint

(3) Dorsal displacement and angulation

Smith's fracture

A.k.a. reverse Colles' fracture

Falling with wrists flexed

Volar angulation of distal radius fragment

Bennett's fracture

First carpometacarpal joint

MOI: Impact on flexed metacarpal; Fist fights!!

X-ray: triangular fragment at ulnar base of metacarpal

Monteggia's fracture

Dislocation: proximal radio-ulnar Fracture: ulna

FOOSH with forced pronation

Needs prompt diagnosis to avoid disability

Monteggia's fracture: dislocation of radioulnar joint and ulna fracture

What fracture may occur with FOOSH and forced pronation?

Galeazzi fracture

Dislocation: distal radio-ulnar

Fracture: radius

Fall on hand with rotational force

Ex: bruising, swelling and tenderness lower end of forearm

XR: displaced radius # with prominent ulnar head

(due to dislocation of the inferior radio-ulnar joint)

Barton's fracture

Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation

Fall onto extended and pronated wrist

Scaphoid fractures

Common

Risk of vascular necrosis

FOOSH

Ex: swelling and tenderness in the anatomical snuff box, pain on wrist movements and thumb compression.

XR: Ulnar deviation AP needed for visualization of it

Immobilization of these fractures difficult

Treat anyway

-Fracture may take 10 days to show due to localized decalcification - return to clinic after 10 days

Management if clinical hx and ex of scaphoid fracture, but negative XR?

scaphoid fracture

what would you need a PA view with ulnar deviation for?

Radial head fracture

Common in young adults.

FOOSH

Ex: tender head of the radius, impaired elbow movements, sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

Scaphoid fracture

Man with a painful swelling over the volar aspect of his hand after receiving a hard blow to his palm.

EX: pain on moving the wrist and on compression of the thumb.

- hard blow to palm or FOOSH

(1) swelling

(2) tender anatomical snuff box

(3) pain on wrist movements and compression of thumb

Fracture type?

radial head fracture

Man with swelling over his left elbow after a fall on an outstretched hand.

Ex: tenderness over proximal part of his forearm, and has severely restricted supination and pronation movements.

(radius rotates around ulna bone to allow supination/rotation)

Common in young adults

FOOSH

Ex: local tenderness radial head, impaired elbow movements, pain at during pronation and supination

Fracture type?

Galeazzi fracture

Lady presents with a painful swelling over the lower end of the forearm following a fall.

Imaging: distal radial fracture with disruption of the distal radio-ulnar joint.

FOOSH + rotational force

Ex: bruising, swelling and tenderness over the lower end of the forearm.

XR: displaced # radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Fracture type?

Buckle fracture

Child who fell on outstretched hand has XR showing incomplete fracture of the radial shaft with bulging of the cortex.

Incomplete #s of long bone shaft

Characterised by bulging cortex

Typically aged 5-10 years.

Mx: self-limiting

- splinting and immobilisation rather than a cast

Type of fracture?

Supracondylar fracture

A 14-year-old landed awkwardly on his arm . The fracture was reduced but the patient is still experiencing extreme pain, particularly on passive stretching. His arm appears swollen and he is complaining of tingling in his hand and forearm.

Compartment syndrome complications possible which include:

- disproportionate pain, esp. on passive stretching

- swelling and paraesthesia

- numbness and paralysis (late)

Tx: prompt fasciotomy

Which fracture is most commonly associated with the condition he is experiencing?

Galeazzi fracture

Woman presents with pain in her wrist after being struck on the back of her right wrist by a ball.

Right wrist: swollen, erythematous and disaffirmed. Skin intact. Extremely tender upon palpation of the distal radius. Difficulty pronating and supinating wrist. Unable to make the 'OK' sign. Sensation intact. Pulses present.

Ex: unremarkable

XR: fractured distal radius and associated dislocation of the distal radio-ulnar joint.

Fracture type?

Humerus shaft

Which part of humerus fractured in patient with wrist drop?

Anterior shoulder dislocation

Man presents with pain after falling onto his backward stretching right hand.

Ex: right shoulder contour is flattened and a small bulge is felt below the right clavicle. There is a small patch of anaesthesia over the distal attachment of the deltoid muscle.

Axillary nerve palsy:

- weak deltoid muscle

- sensory loss over badge area

What injury would explain all the examination findings?

Clavicle fracture

Direct blow to it

Most common in middle third

Mx:

Non-displaced = broad arm sling

Displaced = ORIF

Complications:

- Brachial plexus

- Subclavian vessels

- Pneumothorax

baseball/mallet, boxer’s, bennett’s

list the 3 types of phalangeal fractures

tuft, shaft

what two locations of the phalanges do fractures usually occur at

baseball/mallet finger

a dorsal intra-articular avulsion fracture

base of the distal phalanx

where on the phalanx does a baseball/mallet fracture occur

baseball/mallet finger

forcible flexion of an extended finger

baseball finger

splint to immobilize

baseball finger

bone deformity if not treated, decreased ROM

boxer’s fractures

impacted bone at the neck of MC5

boxers fracture

impact with a closed fist

boxers fracture

surgery w k-wires, immobilization

boxers fracture

bone deformity = rotational deformity of the phalanx

bennetts fractures

oblique intra-articular fracture with dorsal dislocation

base of MC1

where do bennetts fractures occur on the bone

bennetts fractures

direct impact along the LA and hyperextension of the thumb, or axial force applied directly to the MC (ie fist fight, playing volleyball)

bennetts fractures

reduction + fixation with pins or k-wires

bennetts fractures

decreased ROM due to joint pain, loss of thumb function

zigzag

what pattern do the carpals form as they articulate with the MCs

true

T or F: the carpals are uniformly spaced

2mm

how wide are intercarpal joints

the arch; this is where most carpal fractures and dislocations occur

what is the vulnerable zone of the wrist

these are the most severe

the arch of the wrist is a vulnerable zone - injuries that occur at the ulnar aspect

these are the highest in number

the arch of the wrist is a vulnerable zone - injuries that occur at the radial aspect

dorsally (posteriorly)

which direction do the carpals tend to dislocate

true

T or F: when there is trauma, there is a loss of carpometacarpal spaces

properly positioned lateral wrist

MC3 + capitate + lunate + radius in a straight line (teacup)

lunate dislocation

on a lateral wrist view, what does a spilled teacup indicate

pain, loss of grip

what do ligamentous injuries of the wrist cause

lunate dislocation, scaphoid fracture, triquetral injury

list the 3 carpal injuries that occur

lunate dislocation

it loses the articulation with both the capitate and radius = spilled teacup

volar (anterior/palmar)

in lunate dislocations, which direction is the lunate displaced

moves proximally to fill the vacated space

in lunate dislocations, the lunate moves anteriorly. what happens to the capitate

lunate dislocation

forceful dorsiflexion of the wrist (FOOSH)

signs and symptoms of lunate dislocation

limited movement, swelling, tingling in fingers, pain

lunate dislocation

reduction, immobilization, surgery

lunate dislocation

arthritis, wrist instability

scaphoid fractures

occurs at the waist of it, snuffbox becomes swollen and tender

true

T or F: the scaphoid is the most common carpal bone to fracture

scaphoid fractures

FOOSH, direct blow

false negatives are common bc the fracture line doesn’t always show up on the initial image; image again in 7-10 days to look for evidence of healing

what imaging consideration must we keep in mind when imaging for scaphoid fractures

scaphoid fracture

immobilization with a cast, surgery

scaphoid fracture

can take up to 2 years to heal, identify early to avoid avascular necrosis

normal anatomy of the distal surface of the radius

angled 17 degrees towards the palm (anterior)

lateral

on which view do we see that the normal anatomy of the distal radius is angled 17 degrees towards the palm

radius

which extends further distally: radius or ulna

first row of carpals

what structure does the radial styloid line up with (normal anatomy)

colle’s, smith’s

list the 2 fracture types of the distal radius and ulna

colle’s fracture

looks like a fork in the lateral view, it’s within 3-5cm from the wrist joint, distal fragment is displaced dorsally, can be transverse or comminuted

etiology of colle’s fracture

dorsal space of the distal radius compresses the palmar surface, caused by FOOSH with the wrist hyperextended

colle’s fracture

reduction, immobilization, surgery

colles fracture

complex regional pain syndrome, bone deformity, loss of ROM, weak grip, nerve compression

smith’s fracture

reverse of colle’s fracture, garden spade appearance, distal fragment is displaced anteriorly

smith’s fracture

force applied to the posterior aspect of the wrist that causes anterior displacement of the distal fragment (ie falling backward with the wrist in flexion)

smith’s fracture

reduction, immobilization, surgery

smith’s fracture

weak grip, ongoing pain, bone deformity = reduced ROM

compression force along the LA of the bones (via FOOSH)

what is the most common MOI for radius and ulna shaft fractures

Galaezzi, Monteggia, radial head fractures, olecranon fractures, elbow dislocation, elbow joint fracture

list the 6 radius/ulna shaft fractures

Galeazzi fractures

type of fracture dislocation, middle third of the radius fractures, the radioulnar joint is dislocated

signs and symptoms of Galeazzi fractures

pain, swelling, forearm deformity

Galeazzi fractures

blunt force trauma; FOOSH with the forearm in pronation

Galeazzi fractures

surgical fixation with reduction of the fracture and stabilization of the radioulnar joint

Galeazzi

increased risk of compartment syndrome when the fractures are severe, non or mal union

Monteggia fractures

fracture of the ulnar shaft with anterior dislocation of the radial head

Monteggia fracture symptoms

pain, swelling at the elbow joint, decreased ROM

Monteggia

FOOSH with the forearm in pronation

Monteggia

closed reduction, immobilization with a cast, surgery maybe

Monteggia fracture

deformity, bone angulation, non union of the ulnar shaft, radioulnar synostosis, compartment syndrome

radial head fracture

what is the most common type of elbow fracture in adults

radial neck fractures

what is the most common type of elbow fracture in children

signs and symptoms of radial head fractures

pain, swelling

radial head fracture

FOOSH

radiographic appearance of radial head fracture

oblique view needed to show the head clear, or a 45 degree cephalad angle

radial head fracture

splints or casts, surgery

radial head fracture

stiffness, loss of mobility

olecranon fractures

they cause the triceps muscle to separate a bone fragment from the ulna

olecranon fracture

fall onto a moderately flexed elbow

olecranon fracture

surgery

olecranon fracture

ongoing pain, loss of full elbow extension, non-union, scar tissue can fill the gap = decreased mobility

elbow dislocations

Description: usually posterior, the capsule and ligaments surrounding the it can rupture, can cause associated fractures

elbow dislocations

Associated fractures that are caused due to ________ include: coronoid process can fracture as it moves proximal and posterior to the humeral condyles

elbow dislocations

fall onto an extended elbow