Tintinalli's Emergency MedicineSection 22. Injuries to Bones and Joints Chapter 266,267Rosen's Emergency Medicine: Concepts and Clinical Practice, Chapter 48,49

Prapassorn Pattarananakul ,MD

Wrist Distal Radius and Ulna Fractures▪ Colles,Smith,Barton,Radial Styloid fractures▪ Distal Radioulnar Joint Disruption

Forearm Fractures of Both Radius and Ulna Ulna Fractures Radius Fractures

Elbow Soft Tissue Injuries Elbow Dislocation Fractures About the Elbow

Most common injuries affecting the wrist

Distal radial metaphysis fracture Dorsally angulated and displaced

proximally and dorsally"dinner-fork," deformity.Palmar paresthesias

Dorsal angulation Distal radius fragment is displaced proximally and

dorsally Ulnar styloid may be fractured

>20 degrees of dorsal angulation,

Intra-articular involvement,Marked comminution, orMore than a centimeter of

shortening.

Closed reduction, using local anesthesia,

Cast immobilization

Stable fractures may be treated with a compression dressing and splint until they can be evaluated by an orthopedic surgeon; otherwise, closed reduction is performed.

"reverse Colles fracture“Volar angulated fracture of the distal

radius. "garden-spade deformity"

Volar angulation Distal radius

fragment is displaced proximally and volarly

The fracture line extends obliquely from the dorsal surface to the volar surface 1–2 cm proximal to the articular surface

Barton fractures are dorsal or volar rim fractures of the distal radius

Minimally displaced fractures can be treated acutely in a sugar tong splint

Unstable fractures involving >50% of the radial articular surface accompanying carpal subluxation

comminuted fracture of the distal radial metaphysis.

intra-articular fracture of the volar or dorsal rim of the radius,

which may be accompanied by carpal subluxation in the same direction

Hutchinson's fracture, or chauffeur's fracture,

Intra-articular fracture of the radial styloid

Fall on the outstretched hand with either hyperpronation, hypersupination

Radiographs :reported as normal Immobilizing the wrist in

supination ( dorsal dislocations), pronation(volar dislocations)

None displaced :long arm cast 8 wk

Displaced : ORIF compartment

syndrome Volkmann

contractures

Isolated Ulna Fracture (Nightstick Fracture)

direct blowsNondisplace :immobilized

distal third > short arm cast Middle/proximal >long arm cast

Displace : R/O radial head dislocation(>10° ,> 50% diameter ulnar)

Fx proximal third of the ulna with a radial head dislocation

! Posterior interosseus nerve

Type II Monteggia fracture-dislocation

Fx radial head dislocation

Type I Prox. or middle ulnar anterior

Type II Prox.or middle ulnar posterior

Type III distal to coronoid process

lateral

Type IV Prox. or middle ulnaProx. radius

anterior

Consultation in the ED :- ORIF - children : closed reduction and long arm splinting supination

Fx distal third of the radial shaft c DRUJ dislocation

reverse Monteggia fractureConsultation : ORIF

Radiographs : AP :increased DRUJ space Lateral : ulna dorsal displacement

A. Radial nerve innervation.

B. MEDIAN NERVE INNERVATION.

C. ULNAR NERVE INNERVATION.

Proximal Biceps Rupture (long head) result of repetitive microtrauma,

overuse and Steroidsmiddle-aged and older individuals

Distal biceps injuriesmiddle-aged men Pain : antecubital fossa "biceps squeeze test," ED Tx : sling, ice, analgesics, and refer for definitive care.

Young men Fall on an outstretched hand causing a

forceful flexion of an extended elbow Direct blow to the olecranon Spontaneous ruptures from systemic

illnesses, ( hyperparathyroidism)The ability to extend the elbow is

lost. modified Thompson test

"tennis elbow,“Repetitive movement Tenderness over the lateral

epicondylePain with forced extension and

supinationTx : rest, ice, medications,and

immobilization, counterforce brace

"golfer's elbow“Tenderness over

the medial epicondyle

Pain with forced flexion and pronation

Ulnar neuropathy

fall on an outstretched handElbow flexion in 45 °Olecranon is prominentFirst priority of care

neurovascular status brachial a., ulnar, radial, and median nerves

Look for associated fractures coronoid process and radial head. In a child: Fx medial epicondyle

Tx : Reduction long arm posterior mold

90 ° of flexion

Consultation : irreducible dislocations, neurovascular compromise, joint capsule disruption, associated fractures, open dislocations

Children age 1 to 3 years“nursemaid's elbow or pulled elbow” Sudden longitudinal pull on the

forearm while pronationX-rays are not requiredRecurrence rate of about 20%

Supination of the forearm while slight pressure on the radial head

RADIOGRAPHS

"sail sign" Posterior fat pad :

fat from the olecranon fossa

Anterior fat pad:hemarthrosis

Most common fracture about the elbow in children

Gartland Classification of Pediatric Supracondylar Fractures

Extension type Flexion type

Nondisplaced Nondisplaced

Displaced, but posterior cortex intact

Displaced, but anterior cortex intact

Completely displaced Completely displaced

Fall on an outstretched hand with the elbow in extension

Displaced fractures : emergent orthopedic consultation CRPP/ORIF

Direct anterior force against a flexed elbow

Often open Displaced fractures : emergent orthopedic

consultation CRPP/ORIF

Early complications Neurologic ▪ Radial nerve Median nerve (anterior interosseous

branch) Ulnar Vascular ▪ Volkmann ischemic contracture (compartment

syndrome of the forearm) Late complications

Nonunion Malunion Myositis ossificans Loss of motion

Lateral condyle fractures (second most common fractures involving the elbow in children)

Medial Condyle Fractures

Nondisplaced :long arm posterior immobilization

Displaced : immediate orthopedic consultation(CRPP/ORIF)

Milch Classification I/II>Salter Harris type IV/II

Direct trauma to the elbow that drives the olecranon against the humeral articular surface

adults in 50-60 yTx :ORIF

Little Leaguer's Elbow

Tx : controversial simple immobilization

associated with posterior elbow dislocations Classification of Coronoid Fractures Type I Anterior tip of coronoid Type II Up to 50% of the height of the coronoid Type III The base of the coronoid II/III > ORIF, poor outcome

Tx : Long arm posterior immobilization and refer 24hr(elbow flexion /forearm supination)

Direct trauma / fall with forced hyperextension

MayoClassification of Olecranon Fractures Type I Nondisplaced, stable fracture Type II Displaced, stable joint Type III Displaced,

unstable ulnohumeral joint

Type I can be conservative long arm posterior immobilization

(elbow flexion and forearm neutral) Refer 24 hr

Associated injuries are common

“Essex-Lopresti lesion” disruption of the triangular fibrocartilage

Pain on pronation and supination forearm

Obliques and a radial head-capitellum view

radiocapitellar line abnormal fat pad

Nondisplaced :sling immobilization with the elbow in flexion refer within 1 week

Displaced : Refer in 24 hours

1. Colles fracture2. Smith fracture3. Barton fracture

A

B

C

a) Galeazzi Fractureb) Nightstick Fracturec) Monteggia Fracture

a) Supracondylar Fracturesb) Intercondylar Fracturesc) Lateral Epicondyle Fracturesd) Lateral condyle fractures

a) Volkmann ischemic contractureb) Myositis ossificansc) anterior interosseous palsyd) Cubitus varuse) None of above