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12 Cards in this Set
- Front
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Fracture - Treatment: Adult Forearm and Wrist Topics |
Topic List. |
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Monteggia Fx
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: Proximal 1/3 or midshaft ulna fracture with radial head dislocation or instability
Images: -AP/lat of wrist/elbow/forearm -CT elbow helpful if fx involves coronoid, olecranon, or radial head
Acute Tx: Long arm splint. Could try a reduction but don't go overboard.
Definitive Tx: -ORIF of ulna with DCP (approach directly on ulna, between FCU/anconeus proximally and FCU/ECU mid-shaft)
-Check to make sure radial head is reduced (it should reduce with an anatomic ulna)
- If radial head fails to reduce, do an ORIF (via posteriorlateral Kocher approach) to remove the interposed annular ligament.
Timing: Admit for OR next day.
Equipment: Small frag set
Comments: -Be sure to rule out complex elbow fractures
-Be sure to document PIN.
-*PIN neuropathy* in 10% (can't cross fingers)- treat with 3 months observation, then NCS
-*Malunion with radial head dislocation* - due to nonanatomic reduction of ulna. Treat with ulna osteotomy and ORIF of radial head.
-Most Monteggia's in adults are treated operatively, most in children are treated conservatively.
-If the ulna is anatomically reduced but the radial head is still dislocated, *annular ligament* is often interposed.
-There are Type I-IV classification, but it doesn't really affect treatment.
-Most are Type I (60%)= anterior radial head dislocation and apex anterior proximal 1/3 ulna fx.
-Type II (15%)= posterior radial head dislocation and apex posterior proximal 1/3 ulna fx = higher incidence of PIN |
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"Monteggia Equivalent Fx"
-Definition -Tx
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Definition: A proximal 1/3 ulna fracture with a radial head fracture instead of dislocation.
Tx: ORIF of ulna fx. Treat readial head fx as in an isolated. |
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Both Bone Forearm Fx
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: In adults these are always operative. One simply describes them by degree of displacement.
Images: -AP of forearm, elbow, wrist (Radial head must point at capitellum in all angles).
Acute Tx: If very displaced can do a bit of a reduction (can just leave in a finger trap), then long arm cast.
Definitive Tx: -ORIF both bones with 6-plate 3.5 mm DCP (withOUT cancellous graft).
-Approach: Radius via Volar/Henry approach for distal/proximal. Dorsal Thompson approach for middle. Between ECU and FCU for ulna.
-ORIF with cancellous bone graft if significant segmental bone loss, or bone loss associated with open injury.
-EX FIX: Gustillo IIIB and IIIC fractures.
Timing: Next day
Equipment: 3.5 mm DCP (Small frag)
Comments: -be sure to evaluate DRUJ and elbow to rule out a Galeazzi or Monteggia.
-Restoration of radial bow is important for functional outcome.
-Treat nonunions with ORIF and cancellous bone grafting.
-Refracture after premature plate removal at less than 12 or 18 months or large plates (4.5mm). (After plate removal, you should give a functional forearm brace for 6 wk, and protected activity for 3 months).
-Synostosis between radial and ulna associated with single approach ORIF. Treat with early excision (at 4-6 months), irradiation, and indomethicin to prevent HO. |
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Nightstick Fracture
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: Isolated fracture of the ulna
Images: -AP/lat of elbow, forearm, wrist (r/u DRUJ and radial head dislocation) Acute Tx: long arm splint Definitive Tx: Distal 2/3, <50% displaced, <10 degrees angulation = long arm cast to functional brace Proximal 1/3, >50%, >10 degrees angulation = ORIF. [Vrahas says he never fixes these even if they meet the above criterea- they heal fine in just an ACE wrap.] [Smith leaves even very distal moderately displaced fracture conservatively] Timing: Can send home and follow up in clinic Equipment: 3.5 mm DCP (small frag set) Comments: |
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Galeazzi Fracture
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: Distal 1/3 radius fracture with DRUJ dislocation.
Images: -AP, lat of elbow, forearm, wrist -Signs of DRUJ injury = widening on AP, ulnar styloid fracture, shortening of radius >5mm, dorsal/volar displacement of ulna on lateral
Acute Tx: Long arm splint
Definitive Tx: Always surgical -ORIF of radius through Henry volar approach, then supinate and evaluate the DRUJ.
-Stable DRUJ after ORIF of radius: Immobilize in supination for 6 wk
-Reducable but unstable DRUJ after ORIF of radius: Cross-pinning radius to ulna, leave pins in for 4 wks.
-Nonreducable DRUJ: Open reduction via dorsal approach due to **suspected interposition of ECU**
-Large ulnar styloid fracture: Can do ORIF for large fragment.
Timing: Admit for OR the next day (acute repair much better than delayed)
Equipment: Small Frag Set
Comments: -volar and dorsal radioulnar ligaments are the primary stabilizers of the DRUJ
-DRUJ stress causing forearm or wrist pain is suspicious for DRUJ injury |
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Essex Lopresti Lesion
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: Radial head fracture with IOM injury extending to the DRUJ with DRUJ dislocation
Images:
Acute Tx: Long arm splint
Definitive Tx: Treat the radial head fracture per radial head fx guildlines. DRUJ should be pinned for 6 weeks in neutral (0.062 in K wires)
Timing: Option to go home
Equipment:
Comments: |
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Isolated Proximal Radius Fracture
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: No elbow or DRUJ injuries on X-ray or exam.
Images: Elbow, wrist, forearm
Acute Tx: Long arm Splint in supination
Definitive Tx: nondisplaced: LAC in supination
displaced proximal 1/5: closed
displaced 1/5-2/3: ORIF
Timing: Home after ED
Equipment:
Comments: -Be very sure to rule out DRUJ injury on physical exam (test for pain) and X-ray |
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Distal Radius Fracture
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: Several eponyms, They are helpful because many intra-articular patterns are operative.
Die-Punch Fx: Lunate fossa depression fx (ORIF) Barton's Fx: Intra-articular fracture of the volar or palmar DR lip (ORIF from side of fracture) Chauffer's Fx: Radial styloid fx (ORIF) Colle's Fx: Dorsally displaced extra-articular fx Smith's Fx: Volar displaced extra-articular fx
Images: Normals (Acceptables)- Radial Height 11 mm (<5 mm shortening) Radial Inclination 22 degees (<5 change) Articular steopff (< 2mm) Volar tilt 11 degreees (<5 dorsal tilt or within 20 of the contralateral side).
Acute Tx: Hematoma block, reduce in ED (use a dorsal hematoma block, then put in traction for 15 minutes) and splint with AP volar slab splint in mild palmar tilt and radial deviation.
Definitive Tx: Conservative with repeat X-rays every week for 3 weeks. If alignment becomes unacceptable, ORIF for patients <65. (>65 does ok no matter what).
Can use ORIF/CRPP/Ex-fix. Do NOT have to fix an associated ulnar styloid fracture.
Timing: Home from ED, return in 1 week for a SAC. Instructions to elevate!
Equipment: Small frag set
Comments: -Acceptable parameters (for >65): Radial length = <5 mm shortening Intra-articular stepoff = < 2mm Radial inclination = <5 change Palmar Tilt = <5 dorsal tilt or within 20 degrees of the normal side
-How to identify acute carpal tunnel: After reduction, if the patient complains of worsening pain (often re-presenting to the ED), unwrap the splint and elevate. If they don't get better after 6 hours they need an urgent carpal tunnel release (Rockwood's)
-If compartment syndrome of the hand is suspected, check pressure of the adductors and the dorsal interoessei
-Progressive loss of volar tilt and radial length is expected in closed treatment, so they must be monitored with progressive X-rays for several weeks.
-PT is not helpful compared to home excersises for simple DR fx treated with casts.
-Ex-Fix is useful in an old lady with a very bad fracture; can also combine with CRPP or ORIF. 2 pins in the 1st MC (that you may let go into the second) and 2 pins in the dorsal radius 4cm proximal to the joint (i.e. where APL and APB muscle bellies are safe). Avoid the radial sensory nerve.
-ORIF is necessary for Barton's fractures (i.e. volar or dorsal lip intra-articular fractures), die punch fractures, associated distal ulnar shaft fractures, or extensive volar comminution.
-Volar plating associated with FPL rupture (placement of plate too distal in watershet area past the PQ)
-Dorsal plating associated with extensor tendon rupture (classically), but newer plates are lower profile and it is indicatd with intra-articular fractures wtih extensive dorsal comminution.
-Lanate facet fragment may require fragment specific fixation to prevent early post-op failure.
-EPL ruptures associated with closed treatment. Treat with EIP transfer to EPL.
-Angulation malunions should get an openning wedge osteotomy with ORIF and bone grafting. -RDS in about 5%, AAOS recommends Vitamin C supplementation post-operatively.
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Isolated DRUJ injuries
-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition: Purely ligamentous injury
Images: Wrist, forearm, elbow Wrist AP may show widening of DRUJ Lateral may show ulnar dorsal or volar displacement
(Nonacute - Dynamic CT for subtle chronic DRUJ injury, MRI for TFCC).
Acute Tx: Redux and Long arm splint. Ulna DORSAL displacement - SUPINATION Ulna VOLAR displacement - PRONATION
Definitive Tx: LAC x 4-6 wk Ulna DORSAL displacement - SUPINATION Ulna VOLAR displacement - PRONATION
If highly unstable: DRUJ pinning (2 x 0.062 inch K wires across the joint)
Timing: Send home from ED.
Equipment:
Comments: -Be sure to rule out elbow, forearm, wrist fractures.
-May have a fracture of the base of the ulnar styloid which are often associated wtih TFCC injury. Both can be ignored acutely (unless the DRUJ is extremely unstable), if pain after conservative treatment can fix or excise the ulnar styloid fragment and debride the TFCC open or arthroscopically. |
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-Definition -Images -Acute Tx -Definitive Tx -Timing -Equipment |
Definition:
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Acute Tx:
Definitive Tx:
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Equipment:
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isolated DRUJ dislocation
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xrays: ulna dorsal dislocated on lateral, possibly widening of druj
Reduction by supination (consider an injection in the ulnar sided wrist for pain) In Ed place patient in Long Arm Cast in Supination bivalved. do not do a long arm splint because it cannot control it and it will dislocated [Crosby and Mudgal] |
