ORTHOPEDICS
- Test questions are part of the "trauma” section
- Remember, an orthopod can do this
- It is not ALL fractures
- Ligamentous injuries, tendon problems, joint dislocations and associated injuries seem to be disproportionately important
- Part of day in / day out EM
- Focused review should suffice for the exam
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Fracture Complications
- Compartment syndrome
- Fat emboli (long bones)
- Nonunion, malunion
- Arthritis
- Avascular necrosis
- Osteomyelitis
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Anatomy of a Growing Bone
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Parts of a Growing Bone
Wrist Bones
wrist joint
Ulna Radius
Epiphysis
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Physis (Growth Plate)
Metaphysis
Diaphysis
Salter Fractures (1)
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- SALTER Mnemonic
1 (S) = Slip through growth plate
2 (A) = Above the level of the growth plate
Assumes shaft of bone is proximal to epiphysis (e.g., knee joint and femur)
3 (L) = Lower than growth plate
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4 (T) = Through the growth plate
5 (R) = Ram the growth plate
Salter Fractures (2)
IV V
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S= Slipped
A = Above
L = Below
T = Through
eR = Ram
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Salter Fractures (3)
- Epiphyseal growth plate is weaker than supporting ligaments
- Long bones in children
- All involve growth plate or joint surface
- May result in growth complications
- Growth complications increase from I-V
- X-ray may be negative for types I and V
- Salter II most common
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Complication of S-IV, S-V: future growth impairment Crush injury (Salter V) has worst prognosis (no further bone growth)
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Salter-Harris Type I Fracture
?
Salter-Harris Type II Fracture
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Salter-Harris Type III Fracture
Salter-Harris Type IV Fracture
?
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Salter Fracture Facts (1)
- Core concept: Physis (growth plate) is composed of cartilage cells – not visualized on X-ray) weaker than supporting ligaments
- Blood supply to the growth plate comes through the epiphysis. The worse the injury to the epiphysis, the greater the likelihood of growth disturbances
- Type I least likely to be associated with growth disturbances, type V most likely
- Most common ages: 10 to 16 (80%)
- Mostly males (due to delayed skeletal maturation compared to females and more physical activity)
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Salter Fracture Facts (2)
- Type I, 6%, mostly infants and toddlers
- Type II, 75%, growth problems uncommon
- Type III, 10%, growth problems related to
- Extent of epiphyseal injury
- Size of the fracture fragment
- Amount of fragmentation
- Type IV, 10%, same as above, most commonly distal humerus
- Type V, 1%, usually due to crush / compression associated with severe abduction or adduction / knee & ankle most commonly
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The Hand
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Distribution of the Sensory Nerves of the Hand
M
U
R
Radial nerve
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R
Median nerve
Ulnar nerve
M
U
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The Nerves of the Hand
| Sensory | Motor | |
|---|---|---|
| Radial Nerve | Dorsal web space between thumb and index finger | Extension of fingers and wrist |
| Median Nerve | Thumb, index, long and ½ of ring finger | Thumb opposition and flexion of index and middle fingers |
| Ulnar Nerve | ½ of ring and little finger | Finger adduction and abduction; flexion of ring and little fingers |
The Million Dollar Nerve
- The recurrent median nerve
- Purely motor to the thenar muscles
- Motor exam of the thumb is complex with opposition and abduction
- Exam is difficult especially with volar 1st web space injuries
- A Pure Sensory Nerve Too
- Dorsal branch of the radial nerve is a purely sensory nerve
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Recurrent Branch of the Median Nerve
opponens digiti minimi
opponens pollicis
Draws 1st metatarsal laterally to oppose thumb toward the center of the palm and rotates it medially
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flexor digiti minimi
flexor pollicis brevis
abductor digiti minimi
abductor pollicis brevis
APB - abducts thumb and helps oppose it FPB - flexes thumb
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Amputation Care (1)
- In a plastic bag in ice water (not directly in water)
- Thumb has better outcome proximal to IP joint
- Distal third of fingertip doesn't need graft in small children
- General indications for replantation
- Multiple digits
- Thumb
- Single digit between PIP & DIP (distal to the superficialis insertion)
- Metacarpal (palm)
- Wrist, forearm
- Almost any part in child
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Amputation Care (2)
Clean and Sharp is Best
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Amputated Part Storage
Boutonniere Deformity
- Central slip extensor hood disruption near PIP joint
- Forced flexion at PIP joint
- Lateral bands of extensor hood split and become PIP flexors
- +/- avulsion fracture
- Deformity (PIP flexion and DIP extension)
- Treatment: splint PIP in extension
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Boutonniere Deformity
Disruption of the central extensor mechanism allows the PIP joint to protrude through the extensor hood
Displaced intact lateral components of the extensor mechanism hold the DIP joint in extension while flexing the PIP joint.
Felon (1)
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- Staph. aureus
- Pulp space infection
- Distal fingertip
- Treatment: I&D, antibiotics
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Felon (2)
Pus pocket
The fibrous septa tend to loculate the infection. The optimal incision site is where the infection points, or over the area of greatest fluctuance.
Felon (3)
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Paronychia (1)
- Nailbed infection
- Acute infection usually Staph
- Chronic infection:
- C. albicans, other fungi
- Moist hands (dishwashers, bartenders)
- Treatment: I&D, soaks, ABX not indicated
- Consider osteo if not improving
- DO NOT I&D herpetic whitlow as this will often result in herpetic myositis
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Paronychia (2)
Paronychia (3)
Paronychia Drainage: Simple Paronychia
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1. Use a #11 scalpel blade to separate and lift the eponychium from the nail, permitting drainage of the pus.
2. (Optional) A small drainage wick or packing of Adaptec or vaseline gauze can be inserted under the eponychium to discourage reaccumulation of pus. This is probably not necessary in most cases.
Abscess
Cuticle
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- Palmar aponeurosis prevents extension volarly
- Pus spreads between MC bones and erupts dorsally creating a hand abscess
- A volar and dorsal abscess connected by a tract
- Look for splinter/FB on the palm!
Sporotrichosis
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- Rose gardener
- Fungal infection with skip lesions
- SSKI or itraconazole treatment
Gamekeeper's (Skier's) Thumb
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- Ulnar collateral ligament (UCL) of thumb MCP joint
- UCL critical for pincher and grasp function
- Forced radial abduction MCP joint
- Associated avulsion fracture is common
- Treatment
- Partial tear: thumb spica splint
- Complete tear: surgery
- Complication: chronic instability
- Bull rider's thumb = RCL injury
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Mallet Finger (1)
- Extensor tendon disruption (DIP)
- Forced flexion of DIP (ball striking a fully extended digit)
- Avulsion fracture dorsal base of distal phalanx
- +/- avulsion fracture
- Treatment: splint in extension, hand referral
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Mallet Finger (2)
Mallet Finger (3)
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Tear of extensor tendon
Avulsion fracture of dorsal base of distal phalanx
Deformity resulting from inadequate treatment
Metacarpal Fractures (Neck)
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- Fracture of the metacarpal neck is most common hand fractures
- Boxer's fracture: fracture of the neck of 5th mc
- All have volar angulation
- Ring & 5th mc tolerate greater angulation
- Ring < 35°, 5th < 45°
- Ulnar gutter splint
- Index and middle fingers
- Less mobility, tolerate less angulation (<15°)
- Radial gutter splint
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Rotational displacement = unacceptable
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Boxer's Fracture
Metacarpal Fractures (Shaft)
- Angulation is unacceptable for 2nd and 3rd metacarpals
- Angulation amounts that are acceptable:
- Index 10° Long 20° Ring 30° Small 40°
- All rotational deformities must be corrected
- Operative fixation is usually required for 2nd and 3rd metacarpals
- Ulnar gutter splints usually fail to maintain any significant correction of angulation
- Short-arm casting with "outriggers” do work
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Metacarpal Fractures (Head)
- Intraarticular fractures
- Direct trauma or crush
- Laceration over MCP suspect human bite
- Any displacement gives poor outcome
- All require hand referral
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Metacarpal Fractures (Special)
Bennett's Fracture
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- Axial load with hand closed
- Ulnar aspect of base of thumb at metacarpal joint
- Intraarticular with dislocation or subluxation at the CMC joint
- Anatomical reduction required, ORIF
Rolando Fracture
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- Comminuted intraarticular, requires ORIF
- No subluxation dislocation of CMC joint
- Worse prognosis
Thumb spica + emergent ortho referral
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Bennett's Fracture | Rolando Fracture
Flexor Tenosynovitis (1)
- Secondary to puncture wound of volar surface: especially cat bites
- Kanavel's signs
- Diffuse fusiform swelling, erythema
- Pain on palpation proximal sheath
- Severe pain on extension
- Held in slightly flexed position
- Treatment: surgical I&D
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Flexor Tenosynovitis (2)
Fingertip Injuries
- Zone 1: 2/3 of proximal nail bed preserved, no bone exposure, heals with secondary intention
- Require surgical treatment
- Zone 2: exposed bone
- Zone 3: loss of entire nail bed plus exposed bone
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ZONE II
International Classification
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Finger Dislocations (1)
- DIP dislocation is uncommon
- PIP dislocation is common
- Dorsal dislocation very common (rupture of volar plate, ulnar deviation 2° RCL rupture)
- Reduction: digital block: distraction and slight hyperextension, then repositioned
- Splint at 30° flexion, refer
- Can't reduce? (due to volar plate entrapment)
- MCP
- Less common then PIP dislocation
- Hyperextension, rupture of volar plate, dorsal dislocation
- Volar plate is commonly entrapped in joint space making closed reduction impossible
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Finger Dislocations (2)
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Finger Facts
- High pressure injection injury: OR
- Subungual hematoma requires trephination
- Flexor digitorum profundus (FDP)
- Flexion of DIP joints
- Test: immobilize MCP and PIP of same digit
- Flexor digitorum superficialis (FDS)
- Primary flexor of PIP
- Test: immobilize MCP and IP of adjacent digit
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Intrinsic Plus Splinting
"Safe Position"
MCP
PIP 90° 0°
DIP 0°
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wrist 20°
- Metacarpal and unstable proximal / middle phalanx fractures
- Decrease "freeze" at MCP
- Decrease "freeze" at PIP
- "Blade of the hoe" position
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Splinting Position of the Hand
45°
15° 10°
30°
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Distal wrist / carpal fractures
The thumb is abducted slightly away from the palm
Fractures of the Wrist
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Colles' Fracture (1)
- Most common fracture in adults >50
- Distal radius at the metaphysis
- Dorsal displacement
- "Dinner fork" deformity
- Ulnar styloid fracture is common
- Treatment: closed reduction
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Complication: median nerve injury
Colles' Fracture (2)
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Colles' Fracture (3)
Smith's Fracture (1)
- "Reverse Colles"
- Volar displacement of distal radius
- Associated median nerve and flexor tendon injury
- Closed reduction
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Triquetrum Fracture
- Most common dorsal chip fracture of the wrist
- Pain on dorsum of wrist and ulnar styloid
- Painful to flexion
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Smith's Fracture (2)
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Guyon's Canal Syndrome
- A palmar ligament connects the pisiform and the hamate forming a tunnel = Guyon's canal
- The ulnar nerve runs in this canal and is subject to entrapment within it
- Cause numbness and tingling in the ring and small finger
- Causes = canal cyst, repetitive trauma (cyclist [handlebar neuropathy], golf, hitting baseballs)
- Splint
- Surgically decompress
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Scapholunate Dissociation
- Most common ligamentous injury of hand
- Commonly missed
- Fall outstretched hand
- > 3 mm widening of scapholunate space
- Thumb spica, hand referral
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Perilunate / Lunate Dislocation (1)
- Forceful hyperextension
- Median nerve injury common
- Lateral X-ray (most helpful)
Perilunate: capitate displaced, lunate aligned Lunate: capitate aligned, lunate displaced
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- X-ray: "piece of pie"
- Lunate fracture associated with avascular necrosis
Complications: median nerve injury, scaphoid fracture
Perilunate Dislocation (2)
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Scaphoid
Capitate
Lunate
Lunate Dislocation
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Lunate
Capitate
Scaphoid Fracture
- Most common carpal fracture
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Tenderness in "snuff box"
- Initial X-rays may be negative
- Thumb spica splint
Complication: avascular necrosis
Repeat X-ray in two weeks (or bone scan in 3 days) or CT or MRI
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Ulna, Radius, and Scaphoid Fracture
High Pressure Injection Injuries
- Substance under high pressure is injected into the hand
- Grease, paint, hydraulic fluid
- Oil-based paint causes the most severe reaction (ischemia, possible amputation)
- X-ray for radiopaque substance, subcutaneous air
- Complications: compartment syndrome, ischemia
- May appear benign initially
- Requires emergency débridement and decompression
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Point of entry
The Forearm
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Carpal Tunnel Syndrome
- Entrapment of the median nerve
- May be worse at night
- Tinel's sign: tap volar wrist ? paresthesias
- Phalen's sign: hyperflex wrist ? paresthesias
- Risk factors: pregnancy, hypothyroid, DM, RA
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De Quervain's Tenosynovitis
- Overuse syndrome
- Dorsal and radial compartments of the wrist
- Finkelstein's test: ulnar deviation of the fisted hand reproduces pain
- Treatment: splint, NSAIDs, rest
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Galeazzi Fracture (1)
- Distal radial fracture, usually displaced
- Disrupted distal radio-ulnar joint
- Pain and swelling of wrist
- Complication: ulnar nerve injury
- Treatment: ORIF
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Galeazzi G M Radial fx ? ? Ulnar fx R U Monteggia
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Galeazzi Fracture (2)
Galeazzi Radial fx Ulnar fx Monteggia
Monteggia Fracture (1)
- Proximal ulnar shaft fracture, usually displaced
- Proximal radial head dislocation
- Annular ligament disruption
- Pain and swelling of elbow
- Complications
- Radial head fracture
- Radial nerve injury
- Nonunion
- Treatment in adults: ORIF
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Monteggia Fracture (2)
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Galeazzi Radial fx Ulnar fx Monteggia
Essex-Lopresti Injury
- Radial head fracture
- Dislocation of distal RU joint
- Interosseous membrane disruption
- ORIF generally needed
- Severe wrist pain with "negative” wrist films
- FOOSH mechanism
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Ulnar Nightstick Fracture (1)
- Nondisplaced ulnar shaft fracture
- Common defense injury
- Complications include
- Missed Monteggia fracture (radiohumeral dislocation)
- Radial nerve injury
- Nonunion
- Treatment
- Nondisplaced: splint, early ROM
- Displaced fracture may require ORIF
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Ulnar Nightstick Fracture (2)
Both Bone Forearm Fracture (1)
- Requires great amount of force
- Nondisplaced fractures are very rare
- Requires ORIF
- Closed reduction is possible in children
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This download link is referred from the post: MBBS 2025 Lecture Notes for all subjects
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