Fracture of the Upper Extremities part II

Fracture of Ulna & Radius

Oleclanon fracture

-       Mechanism of injury

-       Clinical features

• Pain
• Swelling
• Limit ROM
• Fracture gab

-       Investigation

-       Plain X ray: Elbow (AP, Lateral)

-       Classification

• Transverse fracture: traction force(triceps)
• Comminuted fracture : Direct force

-       Treatment

• Transverse fracture
• Non displace: Long arm cast
• Displaced   : ORIF with TBW

-       Comminuted fracture

• Non displace: arm sling
• Displaced   : ORIF with Plate

Radial head fracture

-       Mechanism of injury

• Elbow extension with forearm pronation

-       Clinical features

• Pain
• Swelling
• Limit ROM : prono-supination

-       Investigation

-       Plain X ray: Elbow (AP, Lateral)

-       Classification

-       Mason classification

-       • Type 1 : Non-displaced fracture

-       • Type 2 : Displaced single fragment

-       • Type 3 : Comminuted fracture

Treatment

-       Type 1 : Non-displaced fracture    : Arm sling, early motion

-       Type 2 : Displaced single fragment

• <1/3 : conservative
• >1/3 : Internal fixation

-       Type 3 : Comminuted fracture

• Internal fixation or Radial head resection

Fractur shaft of Ulna & Radius

-       Anatomy

• Ulnar,Radius, proximal radio-ulnar joint (PRUJ),
• distal radio-ulnar joint (DRUJ) และinterosseous membrane

-       Mechanism of injury

• Bending : Transver fracture
• Twisting : Spiral fracture

-       Clinical features

• Pain
• Swelling
• Limit ROM : prono-supination
• Deformity

-       Investigation

• X ray : Forearm (AP,Lateral)

-       Common Forearm Fractures

• Both-bone fractures
  • ORIF with plate-screw
• Night-stick fracture
  • Long arm cast : angulation < 10 degree
  • ORIF with Plate and screw : open fracture, unstable fracture
• Monteggia fracture
  • fracture ของproximal ulna shaft ร่วมกับPRUJ (radial head) dislocation
  • Treatment ทำาผ่าตัดORIF with plate-screw ของulna ส่วนradial head มักจะเข้าที่ได้เองหลังผ่าตัด
• Galeazzi fracture : fracture distal ofradial shaft with DRUJ injury
  • ORIF with plate‐screw ของ radius, evaluate DRUJ.

Fracture distal end radius

-       Mechanism of injury

• Low-energy trauma : osteoporosis
• High-energy trauma :

-       classification

• Fernandez classification
  • Type 1 : Bending fractures of the metaphysic
  • Type 2 : Shearing fractures of the joint surface
  • Type 3 : Compression fracture of the joint surface
  • Type 4 : Avulsion fractures of ligament attachments 
  • Type 5 : Combined type

-       Common Distal Radius Fractures

• Colles’ fracture
• Smith’s fracture (reverse Colles)
• Barton’s fracture
• Die punch fracture

-       Treatment

• High-demand hand (Physiologically young or active)
  • Conservative(SAC) : Type I
  • ORIF with plate and screw : Type II-V
• Low-demand hand (Physiologically old or inactive)
  • Conservative treatment
  • Osteoporosis treatment

-       Complications

• Compartment syndrome
• Median nerve neuropathy
• Distal Radio-Ulnar Joint (DRUJ) instability
• Post-traumatic arthritis
• Malunion

Carpal bone fractures

Scaphoid fracture

-       MCM carpal bone fracture 

-       Mechanism of injury

• Elbow extension with forearm pronation

-       Clinical features

• Pain
• Swelling
• Tender : Anatomical snuffbox 

-       Investigation

• Plain X ray
  • Wrist (AP, Lateral, Oblique)
  • scaphoid view (AP ulnar deviation)
  • clenched-fist view

-       Classification

• Mason classification
  • Type 1 : Non-displaced fracture
  • Type 2 : Displaced single fragment
  • Type 3 : Comminuted fracture

-       Treatment

• Non-displaced fracture : short arm cast (thumb spica cast)
• Displaced fracture : ORIF with headless compression screw

-       Complication

• Avascular necrosis
• Non union
• SX when:
  • non-comminuted fracture > 25%
  • comminuted fracture

Metacarpal fracture

Metacarpal head fracture : intra-articular fracture

Metacarpal neck fracture (boxer’s fracture)

-       Closed reduction (Jahss maneuver)

-       Complications: loss of knuckle

Metacarpal shaft fracture

-       Treatment

• closed reduction with immobilization (MCPJ flexion 70 Degree,PIPJ full extension )
• Indication for ORIF : open fracture, multiple fractures, unstable fracture

Fracture of distal phalanx

-       MCM hand fracture

-       nail injury

-       Treatment

• aluminum splint
• SX when : intra-articular fracture> 25%

Fracture of the middle and proximal phalanges

-       Shaft fracture

-       Treatment

• closed reduction with pinning
• ORIF if failclosed technique

-       Base fracture

• Volar base fracture of middle phalanx
  • > 40% à ORIF
• Dorsal base fracture of middle phalanx
  • boutonniere deformity
• Lateral base fracture of middle phalanx
• Comminution intra-articular base fracture

Head fracture

Neck fracture

Fracture of the thumb

-       Bennett’s fracture

• fracture-dislocation of thumb CMCJ
• Mainly ORIF

-       Rolando’s fracture

• Mainly ORIF