Mechanism Fall onto shoulder (87%) Direct blow (7%) Fall onto
outstretched hand (6%)
Slide 5
Clavicle Fractures Clinical Evaluation Inspect and palpate for
deformity/abnormal motion Thorough distal neurovascular exam
Auscultate the chest for the possibility of lung injury or
pneumothorax Radiographic Exam AP chest radiographs. Clavicular
45deg A/P oblique X-rays Traction pictures may be used as well
Slide 6
Clavicle Fracture Closed Treatment Sling or 8 bandage
immobilization for usually 3-4 weeks with early ROM encouraged
Operative intervention Fractures with neurovascular injury
Fractures with severe associated chest injuries Open fractures
Group II, type II fractures Cosmetic reasons, uncontrolled
deformity Nonunion
Epidemiology Most common fracture of the humerus Higher
incidence in the elderly, thought to be related to osteoporosis
Females 2:1 greater incidence than males Mechanism of Injury Most
commonly a fall onto an outstretched arm from standing height
Younger patient typically present after high energy trauma such as
MVA
Slide 10
Proximal Humerus Fractures Clinical Evaluation Patients
typically present with arm held close to chest by contralateral
hand. Pain and crepitus detected on palpation Careful NV exam is
essential, particularly with regards to the axillary nerve. Test
sensation over the deltoid. Deltoid atony does not necessarily
confirm an axillary nerve injury
Slide 11
Proximal Humerus Fractures Treatment Minimally displaced
fractures- Sling immobilization, early motion Two-part fractures-
Anatomic neck fractures likely require ORIF. High incidence of
osteonecrosis Surgical neck fractures that are minimally displaced
can be treated conservatively. Displacement usually requires ORIF
Three-part fractures Due to disruption of opposing muscle forces,
these are unstable so closed treatment is difficult. Displacement
requires ORIF. Four-part fractures In general for displacement or
unstable injuries ORIF in the young and hemiarthroplasty in the
elderly and those with severe comminution. High rate of AVN
(13-34%)
Slide 12
Humeral Shaft Fractures
Slide 13
Mechanism of Injury Direct trauma is the most common especially
MVA Indirect trauma such as fall on an outstretched hand Fracture
pattern depends on stress applied Compressive- proximal or distal
humerus Bending- transverse fracture of the shaft Torsional- spiral
fracture of the shaft Torsion and bending- oblique fracture usually
associated with a butterfly fragment
Slide 14
Humeral Shaft Fractures Clinical evaluation Thorough history
and physical Patients typically present with pain, swelling, and
deformity of the upper arm Careful NV exam important as the radial
nerve is in close proximity to the humerus and can be injured
Slide 15
Humeral Shaft Fractures Radiographic evaluation AP and lateral
views of the humerus Traction radiographs may be indicated for hard
to classify secondary to severe displacement or a lot of
comminution
Slide 16
Humeral Shaft Fractures Conservative Treatment Goal of
treatment is to establish union with acceptable alignment >90%
of humeral shaft fractures heal with nonsurgical management 20
degrees of anterior angulation, 30 degrees of varus angulation and
up to 3 cm of shortening are acceptable Most treatment begins with
application of a coaptation spint or a hanging arm cast followed by
placement of a fracture brace
Slide 17
Humeral Shaft Fractures Treatment Operative Treatment
Indications for operative treatment include inadequate reduction,
nonunion, associated injuries, open fractures, segmental fractures,
associated vascular or nerve injuries Most commonly treated with
plates and screws but also IM nails
Slide 18
Humeral Shaft Fractures Holstein-Lewis Fractures Distal 1/3
fractures May entrap or lacerate radial nerve as the fracture
passes through the intermuscular septum
Slide 19
Supracondylar humerus fracture
Slide 20
Forearm Fractures
Slide 21
Epidemiology Highest ratio of open to closed than any other
fracture except the tibia More common in males than females, most
likely secondary mva, contact sports, altercations, and falls
Mechanism of Injury Commonly associated with mva, direct trauma
missile projectiles, and falls
Slide 22
Forearm Fractures Clinical Evaluation Patients typically
present with gross deformity of the forearm and with pain,
swelling, and loss of function at the hand Careful exam is
essential, with specific assessment of radial, ulnar, and median
nerves and radial and ulnar pulses Tense compartments, unremitting
pain, and pain with passive motion should raise suspicion for
compartment syndrome Radiographic Evaluation AP and lateral
radiographs of the forearm Dont forget to examine and x-ray the
elbow and wrist
Slide 23
Distal Radius Fractures
Slide 24
Epidemiology Most common fractures of the upper extremity
Common in younger and older patients. Usually a result of direct
trauma such as fall on out stretched hand Increasing incidence due
to aging population Mechanism of Injury Most commonly a fall on an
outstretched extremity with the wrist in dorsiflexion High energy
injuries may result in significantly displaced, highly unstable
fractures
Slide 25
Distal Radius Fractures Clinical Evaluation Patients typically
present with gross deformity of the wrist with variable
displacement of the hand in relation to the wrist. Typically
swollen with painful ROM Ipsilateral shoulder and elbow must be
examined NV exam including specifically median nerve for acute
carpal tunnel compression syndrome
Slide 26
Radiographic Evaluation 3 view of the wrist including AP, Lat,
and Oblique Normal Relationships 23 Deg 11 mm 11 Deg
Slide 27
Distal Radius Fractures Eponyms Colles Fracture Combination of
intra and extra articular fractures of the distal radius with
dorsal angulation (apex volar), dorsal displacement, radial shift,
and radial shortenting Most common distal radius fracture caused by
fall on outstretched hand Smith Fracture (Reverse Colles) Fracture
with volar angulation (apex dorsal) from a fall on a flexed wrist
Barton Fracture Fracture with dorsal or volar rim displaced with
the hand and carpus Radial Styloid Fracture (Chauffeur Fracture)
Avulsion fracture with extrinsic ligaments attached to the fragment
Mechanism of injury is compression of the scaphoid against the
styloid
Slide 28
Colles fracture
Slide 29
Smith fracture
Slide 30
Barton fracture
Slide 31
Galeazzi fracture
Slide 32
Montegia fracture
Slide 33
Distal Radius Fractures Treatment Displaced fractures require
and attempt at reduction. Hematoma block-10ccs of lidocaine or a
mix of lidocaine and marcaine in the fracture site Hang the wrist
in fingertraps with a traction weight Reproduce the fracture
mechanism and reduce the fracture Place in sugar tong splint
Operative Management For the treatment of intraarticular, unstable,
malreduced fractures. As always, open fractures must go to the
OR.
Slide 34
Slide 35
Schaphoid Fracture
Slide 36
Metacarpal Fractures
Slide 37
Boxers Fracture
Slide 38
First Metacarpal Fractures I- Bennetts fracture II-Rolandos
fractures III-IV Extra articuler fractures
Slide 39
Bennetts Fracture
Slide 40
Rolando Fracture
Slide 41
Phalanx Fractures
Slide 42
Mallet Finger
Slide 43
Hip fractures High energy forces falls car accidents pelvic
(side impacts) high mortality rates Femoral neck fractures >
250,000 women 3 times likely to get fracture
Slide 44
Hip fractures Young people: high energy impacts Mechanism
direct impact lateral rotation of leg Stress fractures femur
Dynamic models of falls impact forces 3-10 kN
Slide 45
INTERTROCHANTERIC FRACTURE
Slide 46
POST OPERATIVE X-Ray
Slide 47
CT SCAN PELVIS ACETABULAR FRACTURE
Slide 48
Thigh injuries Three muscular compartments anterior medial
posterior Quadriceps contusion blunt trauma extensive hematoma
swelling increase muscle weight loss of strength Myositis
Ossificans Ant. Post. Medial
Slide 49
Femoral fractures High energy trauma car & motorcycle and
or pedestrian accidents (78%) Classified by location, configuration
and level of comminution Dangerous near epiphyseal plates
Slide 50
AP LAT FRACTURED LT. FEMUR
Slide 51
Femoral fractures Gunshot fractures affected by bullet
diameter, velocity, weight, shape, and tumbling Low-velocity
splintering High velocity or close range shotgun blasts More soft
tissue damage Torsional loading young skiers high skill level
(risk)
Slide 52
Hamstring Excessive tension applied to the muscle eccentric
action Predisposing factors: fatigue muscle imbalance lack of
flexibility lack of warm up Biarticular muscles bicep femoris
MTJ
Slide 53
PATELLA FRACTURE NORMAL
Slide 54
QUADRACEPS TENDON INJURY Patella tendon injury NORMAL
Slide 55
ANTERIOR CRUCIATE LIGAMENT INJURY Normal
Slide 56
POST OPERATIVE LIGAMENT REPAIR
Slide 57
POSTERIOR CRUCIATE LIGAMENT INJURY normal
Slide 58
AP TIBIA & FIBULA (LOWER LEG)
Slide 59
Lower Leg Injuries Four muscle compartments Anterior lateral
sup and deep posterior Compartment Syndrome fluid accumulation as a
result of acute or chronic exertion can affect vascular and neural
function Ischemia Fascia adaptations Fasciotomy
Slide 60
Lower Leg Injuries Tibial stress syndrome: Inflammatory
reaction of the deep fascia Mechanism chronic overload can lead to
periostitis common in runners multifactor
Slide 61
Lower leg injuries Stress reaction: bone with evidence of
remodeling but without actual fracture Stress fracture 50% occur on
the tibia runners: middle and distal third jumpers: proximal
fractures dancers midshaft
Slide 62
Lower leg injuries High energy fractures car accidents: direct
impact skiing: torsional and boot fractures Baseball bats
Slide 63
Foot & Ankle injuries Most complex areas in the human body
due to large number of muscle, ligaments and bones Ligaments
deltoid: eversion ATFL: restrict inversion CFL PTFL 26 bones
Achilles tendon
Slide 64
Foot & Ankle injuries Arches Longitudinal medial lateral
Transverse Absorb and distribute loads during weight bearing
Supported by bones, muscles, plantar ligaments and plantar
fascia
Slide 65
Foot & Ankle injuries Achilles tendon: largest and stronger
forces = 10 times BW Injuries peritenitis bursitis multifactorial
etiology training malaligments trauma footwear
Slide 66
Foot & Ankle injuries Tendon rupture degeneration Men 30-40
years Blood type (O) Mechanism sudden dorsiflexion rapid change in
direction excess tension on taut tendon taut tendon struck by
object
Slide 67
Foot & Ankle injuries Plantar Fasciitis: inflammation of
the plantar fascia involving microtears of partial rupture of the
fascia Repetitive loading compressing the plantar fascia (1.3- 2.9
BW) Factors lack of flexibility lack of ankle strength overtraining
poor mechanics leg length discrepancies over pronation
Slide 68
Foot & Ankle injuries Ankle sprains: most common injuries
Irregular talus & stability plantar flexion: unstable Involve
ankle and subtalar joint 85% inversion sprain (supination sprains)
ATFL-CFL-PTFL Sometime deltoid (taut in plantar flexion)
Slide 69
Fractures through the medial and lateral malleoli
Slide 70
Slide 71
Foot & Ankle injuries Eversion sprains (pronation) less
common Fractures malleolus Deltoid ligament Tibia and fibula
separation (high forces)
Slide 72
Foot & Ankle injuries Lisfranc Low energy: tripping or
bumping High: falls, crashes, object drop Axial loading foot in
extreme plantar flexion or dorsiflexion Violent twisting Turf toe
damage to capsule and ligaments of 1st MP joint