St Mary Orthopaedic Conference Steven A. Caruso, MD Trenton Orthopaedic Group Trauma and Complex Fracture Surgeon October 25, 2014
Nothing to disclose
Goals To discuss common orthopaedic pathologies and fractures To identify fractures, both adult and pediatric, that can be treated conservative vs those that require operative attention To discuss temporarily and definitive stabilization techniques
Clavicle fractures Epidemiology o incidence - clavicle fractures make up 5-10% of all fractures o demographics - often seen in young active patients Pathophysiology o mechanism direct blow to lateral aspect of shoulder fall on an outstretched arm or direct trauma o pathoanatomy in displaced fractures SCM and trapezius muscles pull the medial fragment posterosuperiorly, while pectoralis major and weight of arm pull the lateral fragment inferomedially
Clavicle fractures Symptoms o shoulder pain Physical exam o deformity o perform careful neurovascular exam o examine skin
Clavicle fractures Radiographs o standard AP view o 45 cephalic tilt determine superior/inferior displacement o 45 caudal tilt determines AP displacement CT o may help evaluate displacement, shortening, comminution, articular extension, and nonunion o useful for medial physeal fractures and sternoclavicular injuries
Clavicle fractures Group 1 - mid shaft/middle third Group 2 - Lateral third Group 3 - medial third
Clavicle fractures nonoperative Tx Sling immobilization with gentle ROM exercises at 2-4 weeks indications o nondisplaced Group I (middle third) o stable Group II fractures o nondisplaced Group III (medial third) o pediatric distal clavicle fractures (skeletally immature)
Clavicle fractures nonoperative Tx Sling Immobilization technique o sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces) o after 2-4 weeks begin gentle range of motion exercises o no attempt at reduction should be made complications of nonoperative treatment o nonunion (1-5%) treatment of nonunion if asymptomatic, no treatment necessary if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
Clavicle fractures nonoperative Tx Outcomes nonunion (1-5%) risk factors for nonunion Group II (up to 56%) comminution fracture displacement & shortening (>2 cm) advanced age and female gender decreased shoulder strength and endurance o risk factors for nonunion Group II (up to 56%) comminution fracture displacement & shortening (>2 cm) advanced age and female gender decreased shoulder strength and endurance
Clavicle fractures operative Tx Open reduction internal fixation absolute unstable Group II fractures (middle third) open fxs displaced fracture with skin tenting subclavian artery or vein injury floating shoulder (clavicle and scapula neck fx) symptomatic nonunion posteriorly displaced Group III fxs displaced Group I (middle third) with >2cm shortening relative and controversial indications brachial plexus injury (questionable b/c 66% have spontaneous return) closed head injury seizure disorder
Clavicle fractures operative Tx Outcomes improved functional outcome / less pain with overhead activity faster time to union improved cosmetic satisfaction improved overall shoulder satisfaction increased shoulder strength and endurance
Clavicle fractures pediatric Fracture patterns include medial/middle/lateral fractures (listed below) medial or distal clavicle physeal injury Treatment pediatric distal clavicle fractures are typically treated non-operatively because of the great osteogenic capacity of the intact inferior periosteum.
Humerus fractures proximal Epidemiology o incidence 4-6% of all fractures third most common fracture pattern seen in elderly o demographics 2:1 female to male ratio increasing age correlates with increasing fracture risk in women Pathophysiology o mechanism low-energy falls elderly with osteoporotic bone high-energy trauma young individuals concomitant soft tissue and neurovascular injuries
Humerus fractures proximal Anatomy anatomical neck o represents the old epiphyseal plate surgical neck o represents the weakened area below the head
Humerus fractures proximal Evaluation Symptoms o pain and swelling o decreased motion Physical exam o inspection extensive ecchymosis of chest, arm, and forearm o neurovascular exam 45% incidence of nerve injury (axillary most common)
Humerus fractures proximal Imaging Radiographs o recommended views complete trauma series true AP scapular Y axillary CT scan MRI indications preoperative planning humeral head or greater tuberosity position uncertain intra-articular comminution indications occult fracture useful to identify associated rotator cuff
Humerus fractures proximal Nonoperative o sling immobilization followed by progressive rehab indications 85% of proximal humerus fractures are minimally displaced and can be treated nonoperatively including minimally displaced surgical neck fracture (1-, 2-, and 3-part) greater tuberosity fracture displaced < 5mm fractures in patients who are not surgical candidates additional variables to consider age fracture type fracture displacement bone quality dominance general medical condition concurrent injuries technique start early range of motion within 14 days
Humerus fractures proximal Operative treatment closed reduction proximal pinning intramedullary nail fixation open reduction internal fixation arthroplasty
Humerus fractures proximal Operative treatment closed reduction proximal pinning intramedullary nail fixation open reduction internal fixation arthroplasty
Humerus fractures proximal Operative treatment closed reduction proximal pinning intramedullary nail fixation open reduction internal fixation arthroplasty
Humerus fractures proximal Operative treatment closed reduction proximal pinning intramedullary nail fixation open reduction internal fixation arthroplasty
Humerus fractures - shaft Incidence 3-5% of all fractures bimodal age distribution o young patients with high-energy trauma o elderly, osteopenic patients with low-energy injuries
Humerus fractures - shaft Presentation Symptoms o pain o extremity weakness Physical exam o examine overall limb alignment o deformity o skin o preoperative or pre-reduction neurovascular exam is critical examine and document status of radial nerve pre and postreduction
Humerus fractures - shaft Risk of radial nerve damage and palsy in both closed as well as open treatment
Humerus fractures - shaft Nonoperative coaptation splint followed by functional brace indications indicated in vast majority of humeral shaft fractures criteria for acceptable alignment include: < 20 anterior angulation < 30 varus/valgus angulation < 3 cm shortening
Humerus fractures - shaft Nonoperative coaptation splint followed by functional brace indications indicated in vast majority of humeral shaft fractures criteria for acceptable alignment include: < 20 anterior angulation < 30 varus/valgus angulation < 3 cm shortening
Humerus fractures - shaft Operative open reduction and internal fixation o absolute indications open fracture vascular injury requiring repair brachial plexus injury compartment syndrome intramedullary nail fixation
Humerus fractures - shaft Operative open reduction and internal fixation o absolute indications open fracture vascular injury requiring repair brachial plexus injury compartment syndrome intramedullary nail fixation
Distal radius fractures Most common orthopaedic injury with a bimodal distribution o younger patients - high energy o older patients - low energy / falls 50% intra-articular Osteoporosis o high incidence of distal radius fractures in women >50 o distal radius fractures are a predictor of subsequent fractures DEXA scan is recommended in woman with a distal radius fracture
Distal radius fractures Mechanism of injury - most common cause is a falling on outstretched upper hand (FOOSH) Wrist extended on impact - Colles fracture Wrist flexion on impact - Smith fracture
Distal radius fractures Presentation dinner fork deformity swelling pain acute carpal tunnel syndrome
Distal radius fractures Physical examination skin - open vs close fx neurovascular exam - sensation, motor, BCR, pulses tenderness to palpation forearm, elbow
Distal radius fractures Diagnosis Xray - AP and lateral CT - to evaluate intra articular involvement and for surgical planning MRI - occult fracture or soft tissue evaluation
Distal radius fractures Treatment Successful outcomes correlate with o accuracy of articular reduction o restoration of anatomic relationships o early efforts to regain motion of wrist and fingers Nonoperative - closed reduction and cast immobilization o indications extra-articular <5mm radial shortening dorsal angulation <5 or within 20 of contralateral distal radius
Distal radius fractures
Distal radius fractures Technique bend to the direction of the deformity to unlock the fracture apply axially tension and bend away from the deformity
Distal radius fractures Operative treatment options open reduction internal fixation external fixation closed reduction percutaneous pinning
Distal radial fractures pediatric Epidemiology incidence o very common, comprising 45% of all pediatric fractures. demographics o 81% of these fractures occur in children who are older than 5 o peak incidence occurring from 10 to 12 years of age in girls and 12-14 in boys most common fracture in children <16 years old
Distal radial fractures pediatric Presentation History o wide range of mechanism for children o rule out child abuse Symptoms o pain and deformity Physical exam o gross deformity may or may not be present o check for puncture wounds indicating open fracture o ecchymosis and swelling o although rare, compartment syndrome should be ruled out in forearm fractures.
Distal radial fractures pediatric Nonoperative immobolization in short arm cast for 2-3 weeks without reduction o indications greenstick fx with < 10 deg of angulation torus fx closed reduction under conscious sedation followed by casting o indications greenstick fx with > 10 degrees of angulation both bone fx in children < 10 years distal radius fx Salter-Harris I Salter-Harris II
Distal radial fractures pediatric Operative o open reduction and internal fixation indications Salter-Harris III and IV fractures of the distal radial physis both-bone fracture with angulation outside of acceptable tolerances Age Acceptable Bayoneting Shaft Acceptable Angulations Malrotation Dorsal Angulation < 9 yrs < 1 cm 15 45 30 degrees > 9 yrs. < 1 cm 10 30 20 degrees
Distal radial fractures pediatric Complications Casting Thermal Injury if o dipping water temperature is > 24C (75F) o more than 8 layers of plaster are used o during cast setting, the arm is placed on a pillow. This decreases the dissipation of heat from the exothermic reaction o fiberglass is overwrapped over plaster
Rib fractures most common injury sustained following blunt chest trauma approximately 10% of all patients admitted after blunt chest trauma have one or more rib fractures rarely life-threatening in themselves but can be an external marker of more severe visceral injury inside the abdomen and the chest most common mechanism of injury in elderly persons is a fall from height or from standing adults - motor vehicle accident (MVA) is the most common mechanism youths - sustain rib fractures most often secondary to recreational and athletic activities, as well as by nonaccidental trauma
Rib fractures Nonoperative treatment observation indications o no respiratory compromise o no flail chest segment (>3 consecutive segmentally fractured ribs) o techniques pain control - systemic narcotics or local anesthetics
Rib fractures Operative open reduction internal fixation o indications displaced rib fractures associated with intractable pain flail chest segment (3 or more consecutive ribs with segmental injuries) rib fractures associated with failure to wean from a ventilator open rib fractures
Ankle fractures Common fracture - both adult and pediatric patients Twisting/rotation mechanism Uni malleolus vs bimalleolar vs trimalleolar Check skin, NV exam Often swelling - wait for wrinkles before surgery
Ankle fractures Classifications AO Laugue-Hansen
Ankle fractures Stable vs non stable stable - nonoperative treatment non stable requires operative fixation
Ankle fractures Nonoperative o short-leg walking cast/boot indications isolated nondisplaced medial malleolus fracture or tip avulsions isolated lateral malleolus fracture with < 3mm displacement and no talar shift posterior malleolar fracture with < 25% joint involvement or < 2mm step-off WBAT
Ankle fractures Operative open reduction internal fixation o indications any talar displacement displaced isolated medial malleolar fracture displaced isolated lateral malleolar fracture bimalleolar fracture and bimalleolarequivalent fracture posterior malleolar fracture with > 25% or > 2mm step-off