Dafydd LoughranFY2 Wrexham Maelor

13/5/14

*Wrist & Forearm Fractures

*Learning Goals

*Understand the relevant anatomy*Build confidence using management

principles*Recognise common fracture patterns*Competently describe radiographs

*The BonesThe Mnemonic…

Some Lovers Try Positions That They Cant Handle

Scaphoid, Lunate, Triquetrium, Pisiform,

Trapezium, Trapezoid, Capitate, Hamate.

*Neurovascular Status

*Nerves – Median, Ulnar, & Radial nerves

*Muscles – As determined by nerve function

*Vessels – Radial & Ulnar arteries, & assess for compartment syndrome

*Common Sites of Injury

*Median Nerve – At carpal tunnel in Forearm #

In antecubital fossa in Supracondylar # of Humerus

*Ulnar Nerve - # of Medial epicondyle of humerus

*Radial Nerve – Radial neck # (Humeral shaft #)

*Autogenous zones

*Each nerve has an area that is solely provided by that nerve and so sensation should be checked here:

*Median nerve: Volar aspect of index finger*Ulnar nerve: Volar aspect of little finger*Radial nerve: Dorsum of first web space

*Muscle power testing

* Median nerve (flexors and LOAF muscles):Test Abductor pollicis brevis by asking patient to resist pushing thumb into palmAnterior interosseous nerve (branch of median nerve arising at elbow) tested by ‘OK sign’ – tests Flexor pollicis longus, and is crucial to test especially in supracondylar fractures

* Ulnar nerve (intrinsic muscles of hand, flexor carpi ulnaris & half of flexor digitorum profundus):

Test finger abduction by patient resisting pushing fingers together

* Radial nerve (extensors):Test by finger extension and wrist extension against resistance

*Vascular status

* Palpate radial and ulnar nerve* Is the hand warm & well perfused?* Is there good capillary refill (<2sec)?

* Is there a risk of compartment syndrome?Predominantly clinical diagnosis requiring prompt management.High index of suspicion if increasing pain, or if pain exacerbated by passive stretch of the muscles• Immediate senior involvement• Split cast if already casted• Decision to be made re fasciotomy

*Management PrinciplesATLS Protocol

•ABCDE

Neurovascular status•Autogenous zones•Focused muscle power testing•Pulses / Perfusion / Compartment syndrome

Open / Closed fracture •IV antibiotics (Co-amoxiclav)•Check tetanus status – booster if in doubt•Remove large debris then photograph and cover until formal washout & closure

Definitive fracture management +/- Medical optimisation•?Conservative•?Operative•Decisions depend of fracture pattern but vary depending on comminution, translation, angulation & rotation

*Common Fracture Patterns

Colles # Smith’s #

Barton’s # Chauffer’s #

Scaphoid #

*Colles #

*Fracture of distal radius with dorsal displacement of hand*Usually from fall on outstretched hand (FOOSH)*Named after Abraham Colles, Irish Surgeon, who

recognised the classic deformity before the existence of Xrays*Instability criteria which increases the likelihood

for requiring operative management:1. Dorsal tilt > 20deg2. Comminuted #3. Abruption of ulnar styloid process4. Intra-articular displacement >1mm5. Loss of radial height >2mm

*Smith’s (Reverse Colles) #

*Fracture of distal radius with volar displacement.*Fall onto flexed wrist*Named after Robert William Smith, also an

Irishman, who got involved in an academic argument with Colles regarding the position of the so called Colles #. (Also described neurofibromatosis 33years before von Recklinghausen did so and named it after himself.)*Simplified management principles:

• Undisplaced = Cast• Mild angulation/displacement = Attempted closed

reduction• Significant angulation / displacement = ORIF

*Barton’s #

*Intra-articular fracture of distal radius with dislocation of the radiocarpal joint (these are the 2 features distinguishing from Colles/Smith)*Can be either volar Barton (more

common) or dorsal Barton*Management is usually ORIF*For a change he was an American

*Chauffeur #

*Intra-articular Radial styloid process #*Due to compression of scaphoid against

the styloid process of radius*Name originates due to hand crank on old

fashioned cars backfiring from drivers grasp and striking back of wrist*Now more commonly after FOOSH

*Scaphoid #* Commonest Carpal #* Pain in anatomical snuffbox* # often not visible initially – if clinical suspicion then cast & reimage at 10 days.* Risk of avascular necrosis (AVN) as it receives supply from lateral & distal branches of

radial artery that then flow retrograde to proximal pole.* Risk of AVN much greater (30%) if proximal pole #.* Management:

• Conservative if: Less than 1mm displacement waist (mid-part) Immobilise in cast for 9-12/52• Internal fixation if: Displaced >1mm, or radiolunate angle >15deg, or

scapholunate angle >60deg• Internal fixation if: Open Fracture• Internal fixation if: Perilunate dislocation• Internal fixation if: Proximal pole fracture

*Final Case!*28yr male attends following high velocity RTA*Frontal impact to chest and abdomen then ejected from car*Severe right arm pain, increasingly SOB

*Obs on arrival: T37.2C, HR 115, BP115/80, RR27, SpO2 90% on Air

Describe your step by step management plan…

*In Summary…

*Know the anatomy and use it to think what might be at risk.*Follow structured management principles*Always consider associated injuries and follow

ATLS protocols*Thoroughly assess neurovascular status and

be vigilant of compartment syndrome*Recognise the common fracture patterns so

that anticipating definitive management plans is easier

Any questions?