An orthopaedic overview

Direct Pain: 1. Soft tissue trauma: sharp to dull aching2. Nerve generated: burning, lancing3. Joint effusion: throbbing4. Bone: dull boring painReferred Pain: Joint above and belowRadicular Pain: from c/s nerve root

Young: acute trauma, overuse injury, septic arthritis, RA

Older: Pathological or fragility fracture, degenerative, OA, gout

“acute trauma or overuse”

Supracondylar fractures occur mostly in children and adolescents with immature skeletons.

Transcondylar fractures are more common in elderly persons with osteoporosis.

Intercondylar fractures occur in persons 40-60 years old.

Adults more likely to get radial head fracture for same MOI

Most common fracture in pediatricsMOI: FOOSH extension injury (96%)Clinical: pain, swelling, bruising, deformity,

NVI*Management: sling immobilizer, analgesia,

iceEvacuation: X-ray, surgical consultSurgical fixation if displaced Complications: arthro-fibrosis, NVI

Distal humerus fracture are rareMOI: axial load through elbow in varied flexion and

direction produces multiple fracture patterns, high force trauma, fall, MVA

Clinical: pain, swelling, deformity (altered carrying angle), guarded ROM, ASSESS for NVI

Management: immobilize, analgesia, X-rayRx: Surgical fixation to allow early mobilizationComplications: arthro-fibrosis, NVI

                      

                                                                                                                          

MOI: direct trauma to posterior aspect of elbow (fall onto olecranon)

Clinical: local pain, swelling, bruising, +/- loss of active extension (avulsion of triceps)

Management: immobilize, analgesia, ice, X-ray

Rx: cast, ORIF (displaced)Complication: loss of extension ROM

MOI: elbow hyper-extension via FOOSH, or valgus/supination stress during flexion

Clinical: local pain, swelling, deformity, flexion contracture

*Neurovascular (radial/ ulnar pulses, sensation hand)

Management: immobilize, analgesia, ice, X-ray: 90 % are posterior/ postero-lateralRx: closed reduction with procedural sedation,

splintingComplications: stiffness, NVI, radial head fx, loose

body

MOI: FOOSH, avulsion or shear force from trochlea with dislocation

*occur as part of a complex elbow fracture dislocation or high monteggia fracture, associated with radial head fracture, assess Neurovascular status

Clinical: pain, swelling, bruising, deformity, Management: immobilize, analgesia, ice,

X-rayRx: non operative vs external fixation Complications: persistent elbow instability,

heterotophic ossification

MOI: FOOSH with elbow extended and forearm pronated (common in young adults)

Clinical: Tender on palpation of radial head, decreased ROM (flex/ext), pain and blocked ROM in pron/sup

Management: immobilize, analgesia, iceEvacuation for X-ray, surgical consultRx; Undisplaced – slab and sling, early ROM

Displaced – ORIF, prosthesisComplication: joint stiffness, myositis ossificans

“sail signs”

Less common than Distal radius fractureMOI: direct force (“nightstick”) or FOOSHClinical: pain, swelling, bruising, deformity

(shortening) painful ROMManagement: immobilize, analgesia, ice,Evacuate: X-ray, surgical consultRx: ORIFComplications: compartment syndrome,

malunion, synostosis

A. Secondary necrosis that creates an ulcer or bony synapse

B. Joining of one bone to another by a bony bridge

dominant arm of middle-aged men

strong contraction of the biceps tendon against unanticipated resistance

Early surgical intervention

A. Inability to flex elbow with power, reduced ability to abduct the shoulder and inability to internally rotate arm.

B. Inability to supinate forearm with power, reduced ability to forward flex the shoulder and reduced elbow flexion power.

Flexion Extension

Fractures of the distal radius, ulna, or both, account for approximately three quarters of bony injuries of the wrist.

Transverse distal radius fx, dorsal displacement

MOI: FOOSH. Lunate acts as wedge. Clinical: pain, swelling, bruising, deformity

*Management: immobilize, analgesia, ice, Evacuation: X-ray, surgical consultRx: reduction, cast or ORIF ** Complications: malunion, arthritis60% associated with ulnar styloid fracture.

60% of ulnar styloid fractures also have associated fracture of the ulnar neck.

Named after Abraham Colles (1773-1843)

Volar tilted distal radius fractureMOI: fall onto supinated hand, roll into

hyperpronationClinical: local pain, swelling, bruising,

deformityManagement: immobilize, analgesia, iceEvacuate: X-ray, surgical consult Rx: reduction, cast vs ORIF (unstable)Inability to hold reduction in cast is

notorious and most orthopaedic surgeons will ORIF

Named after Robert William Smith

“Push off fracture”Considered unstable Intra-articular fracture distal end of radius, involves

dorsal rim w/wo dislocation MOI: extreme dorsiflexion force with pronation Clinical: pain, swelling, bruising, +/- deformityManagement: immobilize, ice, analgesiaEvacuate for X-ray, surgical consultRx: ORIF if intra-articular, reduction and casting

Named after John Rea Barton

Bennett’s Rolando

Fracture subluxation of base of 1st MC, APL attachment dislocates proximal fragment*. In Bennett’s, still articulation with carpus. In Rolando, Y-split comminution

MOI: axial loading of partially flexed MCClinical: pain, swelling, bruising, at base

of thumb, CMC instability and dec ROMManagement: immobilize, ice, NSAIDS, X-

rayRx: closed reduction/thumb spica, ORIF,

fixationMust ORIF unstable Rolando

Fracture at neck of metacarpal (4th/5th)MOI: direct axial load (fist impact)Clinical: pain, swelling, bruising, depression of

involved knuckleManagement: immobilize, ice, NSAID, X-rayRx: reduction, gutter splintComplications: excessive volar angulation,

scissoringSome angulation is acceptable, but no twisting

Proximal ulna fracture with dislocation of radio-capitellar joint

MOI: direct trauma to post aspect of forearm, hyperpronation, fall on hyperextended elbow

Clinical: pain, swelling, dec rotation of forearm, ulna angled ant, radial head dislocated ant

Management: immobilization, analgesia, iceRx: ORIFComplication: radial head fracture/ recurrent

dislocationnon union, NVI – posterior interosseous nerve injury

MOI: outstretched pronated arm, high force trauma, rarely isolated, usually complete elbow dislocation, or fracture

Clinical: pain, swelling, bruising, deformity, splinting at 90 degrees

Management: immobilize, analgesia, ice, X-ray* Rx: reduction** splint in supination, 90 flexComplications: compartment syndrome,

recurrence, stiffness

Fracture of distal radial shaft with disrupted DRUJ (usually distal 1/3)

MOI: fall on handClinical: pain, swelling, bruising, deformityManagement: immobilize, analgesia, ice, X-

rayRx: ORIF of radius

MOI: FOOSH – produces transverse fracture at waist ( common in young men > women)

Clinical: pain with wrist movement, snuff box tenderness, swelling

Management: immobilize, ice, analgesia, X-ray*Rx: long arm cast with thumb spica x 4 wk, then

short arm x 8 wks, vs. ext fix screwComplication: non union**, AVN ***, osteoarthritis

*Triangular Fibrocartilage Complex Injuries

TFCC describes the ligamentous and cartilaginous structures that suspend the distal radius and ulnar carpus from the distal ulna.

Degeneration of the TFCC begins in the 30s and progressively increases in frequency and severity in subsequent decades. Post-fifth decade of life, no normal appearing TFCCs are seen.

Pain in ROM, DRUJ, crepitus, instability Bracing with possible surgery

Pain, swelling, and/or ecchymosis of the MCP joint. Painful or weak pinch grip

A palpable mass on the ulnar aspect of the MCP joint may be obvious representing the ruptured UCL that is abnormally displaced proximally and dorsally relative to the adductor aponeurosis.

Administration of local anesthetic may be necessary to facilitate optimal examination.

A displaced avulsion fracture is a contraindication to stress testing; a nondisplaced fracture is not.

Laxity [(angulation) with thumb placed in 30° flexion] of more than 35° or laxity 15° more than the uninjured side suggests a complete rupture of the proper collateral ligament. Similar examination in extension for accessory collateral ligaments

Treatment: displaced and unstable=surgery Stener lesion: occurs when the ruptured end of the UCL

retracts and becomes abnormally displaced proximal to the adductor aponeurosis and may be palpated clinically on the ulnar side of the MCP joint, impeding proper healing.

MOI: direct force trauma (crush), sports injuries

Clinical: pain, swelling, bruising, dec ROM, Deformity: Dorsal/Volar apex depending upon proximal or middle phalanx fracture, rotational ( scissoring effect)

Management: immobilize, ice, analgesia, X-ray

Rx: reduction, splinting* vs. surgical**

MOI: hyper-extension force, trauma, sports injuries

Clinical: MCP,IP dislocation – swelling, bruising, dec ROM, deformity (most are dorsal)

Volar plates are strong stabilizing structures* Management: immobilize, analgesia, ice, X-

ray**Rx: closed reduction vs surgery, splinting,

physioComplications: soft tissue interposition

preventing reduction, stiffness, boutonniere deformity***, unstable

MOI: FOOSH with hand in dorsiflexion/ ulnar deviation- Lunate or perilunate dislocation

Clinical: Pain, swelling, bruising, dec ROMManagement: immobilize, ice, NSAIDS, X-rayRx: r/o fracture, reduction, splinting, plastics

consultComplication: chronic pain if undiagnosed,

instability, AVN - lunate

MOI: forced flexion from active extended position (ball strike, volar dislocation)

Clinical: pain at dorsal prox aspect of middle phalanx, worse with resisted ext, swelling, loss of active extension, *

Management: ice, splint, NSAIDS, +/- X-ray**Rx: splinting – strict PIP extension x 6 wks Complications: boutonniere deformity

Most common closed finger tendon injury

MOI: forced flexion of extended DIP joint (ball strike to finger tip

Clinical: pain and swelling at DIP joint, flexion deformity, loss of Active extension

Management: splint, ice, NSAIDS, X-ray*Rx: strict extension splinting 6-8 wks **, maintain

PIP ROMComplications: mallet finger, extensor lag

MOI: forced extension of actively flexed finger (Jersey Finger), most common Ring finger*

Clinical: pain, swelling at volar aspect of IP joint, local tender and fullness if tendon retracts, loss of active flexion (isolate FDP and FDS )

Management: splint in current position**, ice, NSAIDS, X-ray***

Rx: early surgical repair****

MOI: puncture wound, high pressure wound injection, disseminated GC

Clinical: febrile/toxic patient, Kanavel’s cardinal signs: 1.uniform swelling

2. slight flexion position3. pain along sheath, 4. +++pain with passive extension/

flexion*Management: early Antibiotics**, analgesia Evacuate for ongoing Rx and surgical evaluation***

A. Olecranon bursitis

B. Partial distal tricep rupture

Because of its superficial location, the olecranon bursa is susceptible to inflammation from a variety of mechanisms: acute trauma, cumulative trauma, infection, inflammatory

“Goose egg” swelling classic Redness and increase in temperature

suggestive of infection Aspiration of fluid helpful for diagnosis and

treatment

UCL critical for valgus stability of the elbow Chronic: during the acceleration phase of a

throw, valgus stress can exceed 60 Newton meters (Nm), which is significantly higher than the measured strength of the UCL in cadavers

Acute: valgus stress on the elbow in locked or new full extension

Swelling and tenderness is commonly found approximately 2 cm distal to the medial epicondyle

3-6 months of conservative therapy, surgery for acute tears in competitive athletes/workers

Inflammation of Thumb extensors (EPB,APL)*MOI: repetitive strain/ overuse injuryClinical: pain, swelling, crepitation along

tendon sheath, +ve FinkelsteinManagement: Rest, Ice, NSAIDS, bracing,

injection**

Medial - Golfer’s Elbow Lateral – Tennis ElbowInflammation of Tendon and Common Flexor/

Extensor Origin on elbowMOI: repetitive strain injury, poor ergonomicsClinical: local pain, dull ache at rest, worse with

active movement of elbow/wrist, and resisted testing, radiates into forearm

Management: Rest, Ice, NSAIDS, brace, injection,physiotherapy, ergonomic evaluation

MOI: multifactorialPAR: common, may be acute or more often overuse

but host of conditions and diseases associated – IDDM, hypoT4

SSx: pain and paresthesias in nerve distributionExam: sensorineural, provocative testingTx: acute decompression, surgeryComplications: Cutting the TCL can alter the

kinematics of the carpus

A.

B.

Intersection syndrome involves the first 2 of 6 extensor compartments.

can be caused by direct trauma to the second extensor compartment. It is more commonly brought on by activities that require repetitive wrist flexion and extension.

radial wrist or forearm pain. discrete swelling. Active or passive wrist motion

produces a characteristic "wet leather" crepitus Conservative treatment includes bracing,

consider cortisone injection

Degenerative condition characterized by ulnar wrist pain, swelling, and limitation of motion related to excessive load bearing across the ulnar aspect of the wrist

Chronic impaction between the ulnar head and the TFCC and ulnar carpus results in a continuum of pathologic changes

Ulnar variance should be measured on radiographs

Treatment is complex

Slowly growing, slightly tender mass on dorsum of wrist.

A. GanglionB. Absendine node

Let’s take a break.