Transcript Fractures hand to elbow

Fractures from Hand to Elbow
Sesamoid bone, found on the palmar surface.
DP
Found within the flexor pollicis brevis tendons
at the MCP. Constant in position.
MP
Biconcave with a
median ridge
Concave
articular surface
PP
Cancellous
bone
MC
CMC joint Saddle
type joint (limited
movement)
Carpals
Radiographic Projections
DPO
DP
Hand
DP
Lateral
Finger
Common Fracture sites
•Fractures of the Phalanges are more common than the
metacarpals
•Fractures of the distal phalanx account for over 50% of all
phalangeal fractures
•Fractures of the middle phalanx are least common, 9-12%
Common Fracture sites
Transverse
Oblique
Spiral
Avulsion
Crush, vary from
sever to marginal
chip fractures
•Transverse and Longitudinal
fractures are less common.
•Result of a direct blow
DP
Marginal Chip fracture
2nd MC
1st
Avulsion of the Flexor
Digitorum Profundus Tendon
DIP
MOI:
• Flexed finger being forcefully extended
•E.g. pulling at some ones garment whilst they are
pulling away.
•Physical signs : inability to Flex finger at the DIP
PIP
•The tendon retracts proximally to the level of the PIP
•With an occasional avulsion fracture at the DIP
•A small fracture fragment lying over the volar aspect at
the PIP may be seen.
•The fragment should not be confused with a fracture
of base of the middle phalanx.
History--22-year-old male who
comes to the A&E after being
injured in a basket ball game.
Swelling and deformity to the
left index finger
Adequacy, Alignment,
Bones, Cartilage , Swelling.
Joint spaces
Which joint ?
What type of # ?
Where – Dorsal / Volar ?
LT.
Index
Diagnosis—Intra-articular, avulsion # on
dorsal aspect of DIP, at the site of extensor
tendon insertion.
• MOI--This injury is due to flexion of a forcibly
extended finger, which therefore results in
either a tendon injury or a dorsal intra
articular avulsion fracture at the dorsal aspect
of the distal phalanx.
Mallet Finger
Or Baseball finger
Forced Flexion
Hyperextension at DIP
Flexion at PIP
Diagnosis--Avulsion
fracture on dorsal aspect ,
At the base of the PIP joint
DIP
PIP
What is this
deformity called ?
Boutonniere injury
and deformity.
(Button hole)
Flexed
PIP
Forced
flexion
Extended
DIP
Struck a wall with fist. Where is the fracture ?
Boxers fracture
History--30-year-old female
injured while skiing. Swelling
and point tenderness over the
MC joint.
film2
U
R
film1
Findings--Films 1 and 2 represent a stress view of the
left thumb with the normal right thumb also stressed for
comparison. There is subluxation of the MCP of the left
when compared to the right. There is no evidence of
fracture. Diagnosis?
• The ulnar collateral ligament
injury is due to a valgus
stress. If there is an
intraarticular avulsion fracture
fragment at the base of the
proximal phalanx of the thumb
on its ulnar side, the diagnosis
is easy.
• If you do not see such a
fracture fragment, stress
views may be required to
make the diagnosis. Should be
compared with the opposite
normal side.
Pole
Hyperabduction
Described in 1881 by Dr. Edward Bennett; An oblique,
intra-articular # at base of the 1st MC (thumb). The
fracture extends into the CMC joint with a dorsal
subluxation.
Due to forced abduction
Unstable # pulled by Abductor
Pollicis Longus Tendon, in a
radial and dorsal direction
A small triangular fracture fragment
on the volar lip of the base of the MC.
This anchored in position by the
anterior oblique ligament attached to
the volar tubercle of the trapezium.
Rolando`s Fracture: 1910.
•A comminuted fracture at the base of the 1st MC,
asscociated with dorsal subluxation.
•Less common than Bennetts
•T or Y type
•ORIF
Carpus
• Highly complex arrangement of bones and
ligaments to allow an infinite variety of
movements
• During injury stresses are focused on
certain sites which lend to the predictability
of the site of fracture
Common fracture sites
Scaphoid
Hamate
Triquetral
Ulna Styloid
Mechanism of injury
• Generally a variation of “foosh”
• Injury depends on many variables –
– Flexion, extension, rotation, deviation etc.
• Results in force focused between radial
styloid & capitate across the scaphoid
• Proximal row tightly bound to the radius
Frequency of Carpal #
Carpal injuries rare in under 12yrs
• 70%-80%Scaphoid
• 10% dorsal chip # usually Triquetrium
• 10% others
Trapezoid
7
Hamate
10
6
Capitate
Triquetral
Lunate
Ulna
4
5
Scaphoid
8
Pisiform
9
3
1
2
Dorsal
Trapezium
Radius
Volar
Scaphoid Fracture
Scaphoid #
• 15 – 40 yr of age (rare
in children & 60+)
• 70% waist
• 20% proximal pole
• 10% distal pole
The scaphoid occupies a
vulnerable position, bridging
between both rows.
With dorsi flexion of hand an
wrist, producess greater stresss
at the waist of the scaphoid.
Fractures of the distal
pole result from
compressive forces
tansmitted by the index
70 to 80% finger and thumb,through
the trapezium and
trapezoid bones
Physical Examination
Tenderness directly over the
scaphoid which lies directly
under the anatomical
snuff box. There is often
swelling in the wrist, and
pain with range of motion.
Particularly on ulna
deviation or making a fist.
Tenderness over the ASB is not a
specific sign of a scaphoid fracture.
40% with tenderness at this site prove
NOT to have a fracture.
Scaphoid views ?
Dorsi-palmer
Lateral
Oblique
AP Gripping
Zitter 30
30
Fractures at each site
has specific rates of
healing relating to the
blood supply of the
scaphoid bone
AVN
The scaphoid has a
very poor blood supply.
It receives its blood
supply from the radial
artery primarily via
lateral volar , dorsal
and distal branches.
Thus, in one third of
waist (mid) fractures,
there is diminished
blood supply to the
proximal fracture
fragment This may
produce a non-union
and lead avascular
necrosis .
Non-Union
Herbert
Screw
N
UD
RD
Fractured Triquetrum
2nd most common site
amongst the carpal bones
The most common site is a
fracture on the dorsal
surface of the Triquetral
bone.
A fractured is generally only
seen on the lateral wrist
image, always check your
laterals for this appearance.
This is quite a common
fracture.
Dorsal radio-triquetral ligament
avulsion fracture
Lateral with 20 degree
supination
Pisiform : acts like a sesamoid
< 1% of carpal bone
fractures
bone and lies within the Flexor
carpi ulnaris tendon
Trapezium
•Accounts for 3-5 % of the
carpal fractures.
•Located between the base
of the thumb, distal surface
of the scaphoid and lateral
border of the trapezoid
MOI; Abduction of the
thumb results in a
compression of the
radial margin of the
trapezium
Fractures - hook of the hamate may be
sustained in a fall, more often occurs in sports
such as tennis, baseball, and golf, in which a
handle sharply impacts the proximal hypothenar
palm. Patients who participate in racket sports
and present with chronic hand and wrist pain
should be suspected of this type of fracture.
Carpal Dislocations
•
•
•
•
•
Scapho-Lunate dislocation
Alignment – lines: Gilula`s
Lunate dislocation
Peri-Lunate dislocation
Mid carpal dislocation
Terry Thomas sign ?
David
Letterman sign
Scapho-Lunate dislocation
For normal Alignment on a lateral radiograph:
Radius, Lunate and Capitate should all aligned on
the lateral projection.
Lunate dislocation
The lunate lies
outside the carpal
boundaries and is
thus dislocated
Lunate dislocation
Fractures of the Lunate are
rare , accounts for < 3% of
carpal bone fractures.
Gilula`s Arcs to
assess alignment
2mm
Note the overlapping of the proximal and distal
carpal rows in addition to the pyramidal
appearance of the lunate. Disruption of Gilulas
arcs
Peri-lunate Dislocation
The lunate remains in it’s
normal position but the capitate
and neighbouring carpal bones
are now out of position.
This injury is 2 – 3 times more
common than a lunate
dislocation and is associated
with a Scaphoid fracture 75% of
the time.
Mid Carpal dislocation
Both the Lunate AND Capitate are dislocate. This
is known as a midcarpal dislocation
This injury also has a high incidence
of associated scaphoid fracture.
C
L
C
L
R
R
LD
PLD
MCD
Colles`/ Smiths`/ Barton`s
A
Volar
B
C
C
Abraham Colles` in 1814
• Most common fractures of the forearm.
• Age group-adult group over age 40.
• More common in females than in males owing to
the higher incidence of osteoporosis in women.
• 9% of proximal humerus also have colles #
• 8% of hip # also have colles #
MOI-- Foosh
Mechanism “foosh” compression & tension
Compression results in
comminution of the
dorsal surface
• Dorsal displacement of # fragment
+/- ulna styloid # 60% ( ligamentus traction)
• 70% intra-articular, 30% extra articular
• Disruption of distal radioulnar joint 35%
Impacted colles /distal radius #
Smith’s #
•
•
•
•
Oposite of Colles - “Reverse Colles”
Volar displacement
Fall onto back of hand – wrist supinated
Diagnosis on Lateral X-ray
Smith`s fracture
If treated and reduced as
a Colles the deformity is
maintained
John Barton1838, American surgeon- a fracture of
the distal end of the radius involving the dorsal rim, with
intra-articular extension of the fracture.
This injury results from dorsiflexion and pronation of the
forearm.
Radiographically the fracture is sometimes difficult to
distinguish from Colles` fracture, but lateral films show
that Barton's fracture does not violate the volar surface
of the radius.
Pronator fat pad sign:Displaced pronator fat pad. The ventral bulging of the fat
overlying the pronator quadratus muscle (PQM) has been
coined the "pronator sign." Although it typically means an
underlying fracture is present, it may also be seen in simple
soft-tissue injury of the same region.
PQM
Normal
Abnormal
Mid Radius and Ulna #
Monteggia #
• Fractured of the proximal Ulna and
dislocation of radial head
• Direct blow of great force to the forearm
(night stick injury)
# Ulna
Disloc- radial
head
• Isolated ulnar fractures are unusual, one
should also search for a fracture or
dislocations.
• The general rule suggesting that if both
bones of the forearm are not fractured, a
dislocation should be sought.
The other forearm fracture dislocation
pattern involves a fracture of the radius
with a dislocation of the distal radial
ulnar joint (RUJ), termed a Galleazzi
fracture
dislocation.
Radius
Dislocation of the RUJ