Ortho

Radiographic Anatomy

Ankle Examination

Compartment Syndrome

Fractures!

Fractures -- Commonly Missed

Open Fracture

Osteochondral Fracture

Salter-Harris Fractures

Stress vs Jones vs Avulsion Fractures

Hand

Distal Radial Fracture/Colles M+R

Hand -- for the Dummies

Kanavel's Sign

Ulnar Variance

Zones in Tendon Injury

Hand for the Dummies

Wrist Anatomy

Radiographic Evaluation of the Wrist -- A Vanishing Art

Salter-Harris Fracture

• Same: fracture along physis
• Above: physis + above (epiphysis/shaft)
• Lower: physis + lower (metaphysis)
• Through: metaphysis + physis + epiphysis
• Rammed: physis is rammed

S-H fracture: is fracture affecting growth plate

S-H IV and V are at high risk for arresting growth plate development

source: http://en.wikipedia.org/wiki/Salter-Harris_fractures

Compartment Syndrome

P's in compartment syndrome

• medical school: Pain, pallor, paralysis, pulseless, paraesthesia, poikilothermia
• most important:
  1. Pain (out of proportion)
  2. Palpation = tender
  3. Passive stretch
  4. Pressure: more than 30 (Stryker)
  5. Delta P (less than 30) : DBP - Intracompartmental P (90-60)
  6. Plaintiff

Colles/DRF Adequacy Post M&R

Volar Tilt Lateral view:
- angle between:

• one line: along distal radial articular surface
• another line: perpendicular to the radial longitudinal axis at the joint margin

Radial Inclination/Angle (15-25): PA view
- angle between:

• one line: connecting the radial styloid tip and ulnar aspect of the distal radius
• second line: perpendicular to the longitudinal axis of the radius

* loss of radial inclination will increase the load across the lunate; difficulty on wrist flexion

Radial height/length/positive (9-12): PA view
- distance between:

• one line: perpendicular to the long axis of the radius passing through the distal tip of radial styloid
• second line: perpendicular to the long axis of the radius passing through distal articular surface of the ulnar head

Normal values (Rosen's):
RI: 15-25 degrees
RH: 9-12 mm
VT: 10-25 degrees

Indications for Reduction: any of these

	Rosen’s	IFSSH*
Volar Tilt	<0°	< -10° (or >10° Dorsal tilt)
Radial Height Shortening	>2mm	>5mm (vs contralateral wrist)
Radial Inclination	<15°	<15°
Intra-articular step-off	>1mm	>2mm

*IFSSH: International Federation of Societies for Surgery of the Hand – through International Distal Radial Fracture Study Group (link)

mnemonic: SHTI-Step-off/Height/Tilt/Inclination: 2-5-10-15

Acceptable Reduction Criteria for Healing

	IFSSH	Graham**
Tilt	<20° volar, <10°dorsal	Between 20° volar & 15° dorsal
Radial Height Shortening	<5mm	<5mm (vs contralat wrist)
Radial Inclination	>10°	≥15°
Intra-articular step-off	<2mm	≤2 mm
Articular incongruity of sigmoid notch***	<2mm

** J Am Acad Orthop Surg. Oct 1997;5(5):270-81.
*** Sigmoid notch is the notch/articular surface of the distal radius where the distal ulnar articulates

*Avoid Cotton-Loder position (marked wrist flexion and ulnar deviation) when immobilising

Sources:

Rosen's

radiologyassistant.nl

Emedicine

Graham

==================

==================

More angles:
1. Scapholunate angle 30-60 degrees: between long axis of scaphoid and lunate at lateral view
2. Capitulolunate angle 0-30 degrees: between capitate and lunate on lateral view
3. Concavity of radius and lunate -- and convexity of capitate: less than 10 degrees

Fractures, etc!

Fractures and Other Bony Injuries

ACETABULUM
PELVIC FRACTURES
SPINE INJURIES
THORACOLUMBAR SPINE INJURIES


AC JOINT INJURIES
BARTON FRACTURE
DISLOCATION OF SHOULDER
DISTAL HUMERUS FRACTURE
DISTAL RADIUS FRATURES
ELBOW DISLOCATION
ELBOW FRACTURES
FOREARM FRACTURES
FRACTURE OF SCAPULA
FRACTURE OF THE CLAVICLE
FRACTURE OF THE HUMERUS
HAND FRACTURES
INTERCONDYLAR FRACTURES
POST DISLOCATION SHOULDER
SC JOINT DISRUPTIONS
SMITHS FRACTURE


notes
ANKLE FRACTURES
FEMORAL FRACTURES
FRACTURES OF THE FOOT
HIP DISLOCATIONS
IT FRACTURES
KNEE DISLOCATIONS
NOF FRACTURES
PATELLA FRACTURE
TIBIA/FIBULA FRACTURE
TIBIAL PLATEAU FRACTURES


EPIPHYSIS

Open Fracture

Q: How many hours is the golden-hour rule that is "currently" followed in Open Fracture to Operative management?

A: Urgent Basis

The 6 hours golden rule probably originated from a 1898 German study on guinea pig (http://www.ejbjs.org/cgi/reprint/88/12/2739.pdf). There are other papers which showed lower infection rate if debridement is done within 6 hours but subsequent studies contradict them.

The current guideline is, it should be done on an urgent basis but the more important management is early (and correct) antibiotics administration. Urgent basis means, if open fracture is seen in ED at night, it would be done first thing in the morning, but will not be done in the middle of the night.

"Single most important fctor in reducing infection rate was the early administration of antibiotics." - Patzakis & Wilkins, Clin Orthop 1989

Review of type of Open Fractures
Gustilo & Anderson Classification

I <1cm, minimal contamination, comminution and soft tissue damage II >1cm, moderate soft tissue damage, minimal periosteal stripping
IIIA severe soft tissue damage and substantial contamination; coverage adequate
IIIB same as IIIA but coverage inadequate
IIIC arterial injury requiring repair

Infection rates:
I 0-2%
II 2-5%
IIIA 5-10%
IIIB 10-50%
IIIC 25-50%

Antibitics:
Type I,II 1st Gen Cephalosporin (usually Cefazolin)
Type III 1st Gen Cephalosporin + Aminoglycoside (Cefazolin + Gentamycin)
High risk of anaerobic contamination (farming, open water injuries) add penicillin or ampicillin

Ulnar Variance

Ulnar Variance:
- in general the most radial part of ulna and the most ulnar side of the radius are at level
- w/ neutral variance, 80% of load is born by radius and 20% by ulna;
- 2.5 mm increase in ulnar varience will increase load borne by ulno-carpal joint from 18% to 42%;
- a 2.5 mm decrease in the ulno-carpal variance will decrease the load borne by the ulno-carpal joint to 4.3%;

- draw transverse line along lunate fossa (ulnarmost part of distal radial surface)
and another at level of ulnar head (radial most part of distal ulnar surface) = the difference is Ulnar Variance
- this requires Zero rotation view (PA view with shoulder 90 deg abducted, elbow 90 deg flexed and forearm neutral
= forearm supination decreases ulnar variance, and pronation decreases ulnar variance
- mean ulnar variance is 0.9mm (range 4.2-2.3mm) [wheelessonline.com]

-ive Ulnar variance: Kienbock's disease
+ive UV: SLD (Scapholunate instability) >4mm scapholunate space = Terry Thomas Sign, Ulnar impaction syndrome, tears of triangular fibrocartilage, lunotriquetral ligament tears, previous excision of radial head, increasing age

*case report of the rare lunate fracture with +ive UV with Kienbock's disease
(link)
*images from standford.edu

Zones in Tendon Injury

Extensor Tendon (7)
1,3,5 (PIP, DIP, MCP)

Smith's Fracture

Thomas Classification
Type I : transverse extra-articular fracture
Type II : oblique fracture that extends from the proximal volar surface distally
through the dorsal articular surface
Type III: volar Barton fracture-dislocation

Mechanism of Injury
Fall on the back of hand
Extremely unstable injury
Management
>65 years old or poor functional status:
Attempt M&R under Bier's block
Traction with forearm supinated and wrist dorsiflexed.
Long arm volar slab. Triangular arm sling. Check X-rays.
If reduction satisfactory : TCU Ortho SOC 1/52
If reduction unsatisfactory : Admit to Ortho Dept for surgery
<65 years old or good functional status:
Long arm volar slab. Triangular arm sling.
Admit to Ortho Dept for surgery

SC Joint Disruptions

Classifications
Anterior dislocation
Posterior dislocation
A. Normal B. Posterior Dislocation C. Anterior dislocation
First-degree dislocation : Stable injury, sprain of the supporting ligaments
Second-degree dislocation : Unstable injury, subluxation of the SC joint
Third-degree dislocation : Unstable injury, complete dislocation of the SC joint
Mechanism of Injury
Anterior dislocation : Force applied to the anterolateral aspect of shoulder
Posterior dislocation : Force applied to the anteromedial aspect of clavicle or
posterolateral aspect of shoulder
Examination
Swollen and tender over the SC joint
Exclude pneumothorax, SVC obstruction, neurovascular injury (especially in posterior dislocation)
X-rays : AP view, lateral view, Hobbs view, Serendipity view
Management
First-degree dislocations:
Triangular arm sling, analgesics, TCU Ortho SOC within 2/52
Second-degree dislocations:
Triangular arm sling, figure-of-eight bandaging, analgesics, TCU Ortho SOC 1/52
Third-degree dislocations:
Anterior dislocation: Attempt closed reduction at the A&E
Lateral traction to abducted upper limb with controlled posterior force applied on medial clavicle. Triangular arm sling, figure-of-eight bandaging, check X-rays, analgesics, TCU Ortho SOC 1/52
Posterior dislocation:
Triangular arm sling, analgesics, admit to Ortho Dept stat for immediate reduction under anaesthesia.
Assess for possible airway and great vessel injuries.

Posterior Dislocation of the Shoulder

1st image: normal AP
2nd and 3rd images: post dislocation on AP and lateral

Mechanism of Injury
Direct force to anterior aspect of shoulder
Electric shock, seizures with arm in adduction, flexion and internal rotation
Examination
Painful shoulder with arm held in internal rotation and unable to externally rotate
Palpable head posterior to shoulder
X-rays
AP and Y-scapular views; axillary views if possible
AP view: light bulb sign, loss of overlap of humeral head on glenoid rim
Y-scapular and axillary views: humeral head posterior to glenoid cavity
Management
Prompt reduction at A&E after X-rays reviewed
IV pethidine 50mg +/- sedation with IV midazolam
Traction on arm with shoulder in 90 abduction and then externally rotating the arm
Place upper limb in triangular arm sling after reduction, +/- strap arm to chest
Check for neurovascular injuries after reduction
Check X-rays to confirm reduction and exclude fracture
If reduction successful: Analgesics. TCU Ortho SOC within 2 weeks
If reduction unsuccessful: contact Ortho MO-on-call to attempt reduction at the A&E

Intercondylar Fractures

Riseborough and Radin Classification
Type I : Undisplaced
Type II : Slight displacement with no rotation between the condylar fragments
Type III : Displacement with rotation
Type IV : Severe comminution of the articular surfaces


Mechanism of Injury
A force directed against the posterior aspect of the flexed elbow
Examination
Elbow swollen and tender, with decreased range of motion due to pain
Exclude neurovascular injuries
X-rays
AP and lateral views of elbow
Management
Type I : Long-arm backslab. Triangular arm sling. Analgesics. TCU Ortho
SOC within 1/52
Type II to IV : Long-arm backslab. Triangular arm sling. Admit to Ortho Dept

Hand Fractures

METACARPAL FRACTURES
Metacarpal Neck Fractures
Attempt M&R at the A&E
<15 angulation for 2nd and 3rd metacarpals acceptable <40-45 angulation for the 4th and 5th metacarpals acceptable If able to achieve satisfactory reduction : backslab, analgesics, TCU Ortho SOC 1/52 If unable to achieve satisfactory reduction : Admit to Ortho Dept for surgery Metacarpal Shaft Fractures
Attempt M&R at the A&E
2nd, 3rd and 4th metacarpal fractures:
Usually stable; crepe bandage, analgesics, TCU Ortho SOC 1/52
1st or 5th matacarpal fractures:
If undisplaced or minimally displaced, full POP, analgesics, TCU Ortho SOC 1/52
If still grossly displaced after M&R, Admit to Ortho Dept for surgery
Metacarpal Base Fractures
2nd, 3rd and 4th MCs:
Usually minimally displaced; backslab, analgesics, TCU Ortho SOC 1/52
5th MC base fracture:
If minimally displaced, backslab, analgesics, TCU Ortho SOC 1/52
If still grossly displaced after M&R, admit to Ortho Dept for surgery
Extraarticular 1st MC base fracture :
If minimally displaced: Full POP, analgesics, TCU Ortho SOC 1/52
If still grossly displaced after M&R: admit to Ortho Dept for surgery
Bennett's fracture/ Rolando fractures:
Fracture-dislocation of the CMC joints, unstable injuries; admit to Ortho Dept for surgery
PROXIMAL AND MIDDLE PHALANGES FRACTURES
Attempt M&R under digital block
Extraarticular fractures:
If minimally displaced, Zimmer splint/buddy-tapping, analgesics, TCU Ortho SOC 1/52 to put hand in the intrinsic plus position.
If still displaced, buddy-tapping, admit to Ortho Dept for ORIF
Intraarticular fractures :
If undisplaced, Zimmer splint, analgesics, TCU Ortho SOC 1/52
If still displaced, Zimmer splint, admit to Ortho Dept for surgery

DISTAL PHALANX FRACTURES
Dorsal lip fracture/Mallet finger
Zimmer splint in slight hyperextension, analgesics, TCU Ortho SOC 1/52
Volar lip fracture
Buddy-tapping, admit to Ortho Dept for ORIF
Extra-articular fractures
Closed reduction and buddy-tapping, analgesics, TCU Ortho SOC 1/52

Fracture of the Clavicle

Classification
Group I : Fracture of the middle third (80%)
Group II : Fracture of the distal third (15%)
Group III : Fracture of the proximal third (5%)
Mechanism of Injury
Fall on shoulder
Direct blow
Fall on outstretched hand
Examination
Localised swelling and tenderness over clavicular fracture site
Check for laceration of subclavian vessels and brachial plexus injury (rare)
Check for tenting of skin caused by sharp fracture ends. (KIV admit)
Exclude upper ribs fracture and pneumothorax
X-rays : AP and oblique views of clavicle
Management
Triangular arm sling
Analgesics
TCU Ortho SOC within 2 weeks
Fractures involving the lateral third of the clavicle may require surgery.

Fracture of the Scapula

Classification
Based on anatomical location of the fracture: A.scapula body, B.acromion process and scapula spine, C.scapula neck, D.glenoid, E.coracoid process


Mechanism of Injury
Usually the result of high-energy trauma
Examination
Exclude associated injuries: rib fractures, pulmonary contusion, pneumothorax, clavicle fracture, brachial plexus injury, vascular injury
X-rays
AP and lateral of scapula
Management
Most scapula injuries can be treated conservatively with analgesics and triangular arm sling. TCU Ortho SOC 1/52.
The following cases are to be admitted to the Department of Orthopaedic Surgery:
1. Displaced intraarticular glenoid fractures involving >25% of articular surfaces
2. Scapula neck fractures with > 40 of angulation or >1cm medial translation
3. Scapula neck fractures associated with a displaced clavicle fracture
4. Associated neurovascular injuries
The following cases are to be admitted to the Department of Surgery:
1. Associated pulmonary contusion
2. Associated multiple ribs fracture +/- pneumothorax

Forearm Fractures

Always order X-rays of the elbow and wrist in addition to the forearm in suspected forearm fractures
MONTEGGIA FRACTURE-DISLOCATION
Dislocation of the radial head with fracture of the ulna
Management : Long arm backslab. Triangular arm sling. Admit to Ortho Dept
GALEAZZI FRACTURE-DISLOCATION
Fracture of the radius with dislocation or subluxation of the distal radioulnar joint
Management : Long arm backslab. Triangular arm sling. Admit to Ortho Dept
REVERSE GALEAZZI FRACTURE-DISLOCATION
Fracture of the distal ulna with disruption of distal radioulnar joint
Management : Long arm backslab. Triangular arm sling. Admit to Ortho Dept
FRACTURE BOTH RADIUS AND ULNA
Management of Adult patients:
Long arm backslab. Triangular arm sling. Admit to Ortho Dept
Management of Paediatric patients:
Undisplaced fracture: Long arm backslab. Triangular arm sling. TCU Ortho 1/52
Displaced fracture : Long arm backslab. Triangular arm sling. Admit to Ortho Dept
ISOLATED ULNA SHAFT FRACTURE
Always check for radial head and DRUJ disruptions, clinically and radiographically
Management of Adult patients:
Long arm backslab (in supination). Triangular arm sling. Admit to Ortho Dept
Management of Paediatric patients:
Undisplaced fracture: Long arm backslab. Triangular arm sling. TCU Ortho 1/52
Displaced fracture : Long arm backslab. Triangular arm sling. Admit to Ortho Dept
(If angulated call Registrar on call for possible reduction at the A & E Department)

--


Combined forearm fractures. (1.) Galeazzi fracture dislocation: radial shaft fracture with dislocation of the distal radioulnar joint. (2.) Monteggia fracture dislocation: ulnar shaft fracture with dislocation of the radial head. (3.) Essex Lopresti lesion: proximal radial fracture, disruption of the interosseous membrane, disruption of the distal radioulnar joint.
(from eatonhand.com)

Elbow Fractures

ELBOW FRACTURES

OLECRANON FRACTURE
Schatzker Classification
Transverse
Transverse-impacted
Oblique
Comminuted
Oblique-distal
Fracture-dislocation
Mechanism of Injury
Direct : Fall on the elbow
Indirect : Fall on outstretched hand with elbow in flexion
Examination
Haemorrhagic effusion of elbow
Palpable sulcus at the fracture site over the subcutaneous border
Exclude neurological deficits, esp. ulnar nerve
X-rays
AP and lateral views of the elbow
Management
Undisplaced fractures : Long-arm backslab. Triangular arm sling. Analgesics.
TCU Ortho SOC 1/52
Displaced fractures : Long-arm backslab. Triangular arm sling
Admit to Ortho Dept

CORONOID FRACTURE
Regan and Morrey Classification
Type I : < 25% fracture Type II : 50% fracture Type III : > 50% fracture
Management
Type I : Long arm backslab. Triangular arm sling. TCU Ortho SOC 1/52
Type II & III : Long arm backslab. Triangular arm sling. Admit to Ortho Dept

RADIAL HEAD FRACTURES

Mason Classification
Type I : Undisplaced fracture
Type II : Marginal fracture with displacement
Type III : Comminuted fracture of entire head
Type IV : Fracture-dislocation of elbow
Mechanism of Injury
Fall on outstretched hand
Examination
Well-localised tenderness over the radial head
Painful rotation of the forearm
Examine DRUJ for pain (Essex-Lopresti lesion)
X-rays
AP, lateral, oblique views
Management
Type I : Long arm backslab. Triangular arm sling. TCU Ortho SOC 1/52
Type II to IV : Long arm backslab. Triangular arm sling. Admit to Ortho Dept

Elbow Dislocations

Classification
Posterior / Anterior / Lateral / Medial / Divergent




Examination
Exclude neurological injuries: median, ulnar, anterior interosseous, radial nerves
Exclude brachial artery disruption, compartment syndrome
X-rays
AP and lateral views of the elbow
Determine direction of dislocation
Exclude associated fractures: radial head, radial neck, medial or lateral epicondyle, olecranon, coronoid process
Management
Prompt reduction at A&E after X-rays reviewed.
Check and document neurovascular status before and after reduction.
Check X-rays are mandatory after M&R.
IV pethidine 50mg +/- sedation with IV midazolam
Posterior dislocation: Distal traction on forearm with elbow flexed and countertraction on distal humerus. (Beware of fracturing coronoid process)
Anterior dislocation : Posterior and downward pressure on flexed forearm while distal humerus is pushed forward
If reduction successful: Long arm backslab with elbow in 90 flexion. Triangular arm sling. Admit to Ortho Dept for circulation chart.
If reduction unsuccessful: contact Ortho MO-on-call stat for further management.

Distal Radius Fracture

Normal radiographic anatomy of the wrist:
Radial inclination : 23 (13 - 30 )
Radial positive : 13mm (8 - 18mm)
Volar tilt : 11 (1 - 21 )
COLLES' FRACTURES
Frykman Classification
Type I, II : Extraarticular fracture
Type III, IV : Involve radiocarpal joint
Type V, VI : Involve distal radioulnar joint
Type VII, VIII : Involve both radiocarpal and distal radioulnar joints
Type I, III, V, VII : Intact ulnar styloid
Type II, IV, VI, VII : Fractured ulnar styloid
Mechanism of Injury
Fall on outstretched hand
Examination
Tender and swollen wrist with dinner-fork deformity
Management
Extra-articular fractures:
Attempt M&R under Bier's block
Apply traction with forearm pronated, wrist slightly flexed and ulnar deviated
> 65 years old or poor functional status : Short arm backslab
< 65 years old or good functional status : Long arm backslab Check X-rays to assess adequacy of reduction: 1. volar tilt or at least neutral position on lateral X-ray 2. Radial positive 3. Radial inclination at least 10 4. < 1mm intraarticular gap ( for intraarticular fractures ) If reduction satisfactory : TCU Ortho 1/52 with X-rays OA If reduction unsatisfactory : Consider repeat M&R. Admit to Ortho Dept if reduction still poor Intraarticular Fractures >65 years old or poor functional status : Manage as for extraarticular fractures
<65 years old or good functional status : Admit to Ortho Dept for surgery