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Common fractures and dislocations PowerPoint Presentation
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Common fractures and dislocations

Common fractures and dislocations

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Common fractures and dislocations

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  1. Filip Gilic CCFP-EM Common fractures and dislocations

  2. A word on terminology

  3. Relations of fragments • Undisplaced/displaced: in anatomical alignment/not in alignment • Translated: expressed either in mm or % of the thickness of the bone (eg translated 50% of the thickness of the radius) • Angulated. Measured in degrees off the long axis of the bone, described in terms of where the apex points • Distracted- separated by a gap • Shortened- shorter then anatomic alignment • Intraarticular: going into the joint

  4. Hand anatomy

  5. Hand exam (for fractures) • Look, Feel, Move, NVS • Palpate all phalanxes/metacarpals/carpals/distal radius and ulna • Axially load all fingers • Look for scissoring (proximal phalanx/metacarpal) • Check grip strength (proximal phalanx/metacarpal) • NVS (median, ulnar, radial)

  6. Hand fractures Distal/middle phalanx: generally buddy tape/gutter. If significant joint involvement (>1/3 surface) send to ortho for possible pinning Proximal phalanx: potentially very disabling. Gutter/buddy tape if ZERO displacement or scissoring. Any angulation/translation scissoring: send to ortho Metacarpals:The closer to the thumb, the more potentially disabling. Acceptable angulation in dorsal plane: 40 deg 5th 20 deg 4th 15 deg 3rd/2nd If more- reduce Can’t reduce/scissoring- ortho

  7. Thumbcommonest fracture is intraarticular # of the metacarpal base Radial displacement Cousin Bennett Cousin Rollando (the comminuted guy)

  8. Skier’s/Gamekeeper’s Thumb Opening of the MCP >40 deg considered a full rupture- ortho

  9. Carpals • Scaphoid: commonest carpal # • hard to see # sometimes, high risk of non union/AVN • Signs of scaphoid # • Snuff box tender (test in ulnar deviation) • Axial load of thumb • Tender scaphoid tubercle • 2 out of 3= thumb spica + ortho in 2 w for re-x-ray or bone scan

  10. Scaphoid #

  11. Lunate injuries • Rarer then scaphoid injuries but easily overlooked as everyone is only looking at the scaphoid • Most important carpal bone as it presents 2/3 of articular surface with radius • Fractures here present risk of AVN as well • Lives right next to scaphoid tubercle-little dimple distal to radius at the base of 3rd finger line

  12. Scaphlunate dislocation:ortho for ligamentous repair

  13. Lunate dislocation:commonest carpal dislocations3 C’s disrupted (line up of radius/lunate/capitate)ortho

  14. Perilunate dislocation

  15. Colle’s/Smith’sColles (points down) Smiths (points up) Ortho after you reduce it

  16. Harmless Torus fracture of Distal radius-splint

  17. Elbow Slight anterior fat pad Radial head Capitellum Ocelranon

  18. Elbow Adults: commonest is radial head fracture Can be subtle 2 clues Abnormal fat pad sign Displacement of the radiocapitellar line Remember: Posterior fat pad is ALWAYS pathological Anterior is likely pathological if wide Rx: sling if undisplaced, ortho if displaced

  19. In children, supracndylar (ie distal humerus fractures) are commonest • Also can be subtle • Also offer 2 clues • Abnormal fat pad • Displacement of the anterior humeral line • Undisplaced- full arm flaster with elbow flexed for 4 weeks. DO NOT keep them in it longer as they will contracture • Displaced- ortho • High Risk of NV compromise if displaced

  20. Intraarticular olceranon fractures: need ORIF

  21. Pulled elbow! • Fun to reduce • Suppination/flexion +/- hyperpronation • Pronation flexion • If unsuccessful, put them in flexion spint, it will generally self reduce in a day or two.

  22. Humerus • Proximal humerus and SURGICAL neck of humerus generally not a big deal • Cast and send to ortho in a week or two • ANATOMICAL neck (above the surgical neck) -surgery CAST ORTHO

  23. BREAK!!!!

  24. Shoulder

  25. Shoulder exam • ROM- active/passive • Impigement • AC joint • Supraspinatus – ABducts • Subscapularis- Internally rotates • Infraspinatus/Teres Minor- Externally rotates • Biceps tendon

  26. Shoulder X rays

  27. AC joint injury Type I: N x ray Type II: acromion/clavicle overlap by 50% or more Type III and above- complete elevation of clavicle Type I + II: RICE + sling Type III –ortho (controversy of surgery vs conservative)

  28. Dislocations • Most are anterior. • Posterior in EEE (epileptics, electricity, EtoH)

  29. Anterior Normal Dislocated

  30. Posterior Posterior Normal Anterior

  31. Reduction method • SEDATE, SEDATE, SEDATE • Arm ADDucted, flexed at elbow 90 deg • Externally rotate while adducted • If fully rotated and no reduction (pop), elevate the arm overhead.

  32. Hip • #: Shortened, Adducted, externally rotated- ortho • Dislocation: Shortened, Adducted, INTERNALY rotated • Dislocation- a true ortho emergency. Delay in reduction increases chances of AVN. • Mostly see in MVAs when a flexed knee is forced backward (ie not belted, flies out of the seat into the dashboard) • 90% are posterior

  33. Reduction • Allis manouver • SEDATE • Flex the hip and the knee. • Get up on the gurney • Lift the flexed leg • Assistant stabilizes the pelvis and thus provides countertraction • Internal/external rotation

  34. Kiddie hips Overweight pubertal boys 4-10 y.o. kids Legg Calves Perthe (AVN) SCFE

  35. Femur • Bleeds. A lot. • High possibility of NV injury • Traction splint (if you have one), unless its open.

  36. Knee • Most injuries are ligamentous or meniscal • Make sure you don’t miss tibial plateau fractures- they generally need an operation- usually axial load injuries • Their X ray can be very subtle- use CT

  37. Osgood Shclahter (teens)essentially avulsion fracture/tear of the tibial tuberosity

  38. Ankle X rays

  39. Ankle The higher the fracture site, The higher the energies involved And higher chance of needing ortho If bimaleolar, generaly displaced- ortho operation

  40. Trimaleolarbimaleolar + posterior tibia= operation

  41. Maissoneuvein high energy ankle fractures make sure you don’t miss a Maissoneuve

  42. Bones of the foot