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 platescrew 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

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