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<strong>Dr</strong>. <strong>Dan</strong> <strong>Regev</strong><br />

Plastic Surgery Department<br />

Rabin Medical Center


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BACKGROUND<br />

•Forearm fractures- common limb fractures<br />

•Upper, middle, lower shaft<br />

MECHANISM OF INJURY<br />

•Direct blow: fall + hyperextension / flexion<br />

•Compression, shearing forces & avulsion<br />

EPIDEMIOLOGY (USA)<br />

•Upper limb fractures = 50% overall<br />

•Forearm fractures = 1/3 of upper limb (distal = 17%)<br />

2mm<br />

Radiio-ulnar<br />

inclination<br />

20%<br />

80%<br />

axial load<br />

ANATOMY<br />

23º radial inclination<br />

11º (lateral view)<br />

anteversion<br />

Epiphysis with slits<br />

Metaphysis spongiotic<br />

Thin cortices<br />

BIARTICULAR<br />

Scaphoid<br />

fossa<br />

Lunate<br />

fossa<br />

BICONCAVE


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EPIDEMIOLOGY<br />

•Gender: Infants 2y boys<br />

Adults women (osteoporosis)<br />

•Race: less in blacks (less osteoporosis)<br />

CAUSES<br />

•Sports: skating, skateboarding, mountain<br />

biking and contact sports<br />

•Trauma: automobile collisions, blows with a<br />

blunt object and child abuse<br />

HISTORY<br />

•Direct blow usually<br />

PHYSICAL EXAMINATION<br />

•Local pain, tenderness,<br />

swelling<br />

•Any wound over the<br />

fracture = open fracture<br />

(2 nd most common after<br />

open tibial fractures)<br />

Smith open fractures classification<br />

I<br />

II<br />

III<br />

IIIa<br />

IIIb<br />

Type Description<br />

Clean wound<br />


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NEUROLOGICAL EVALUATION<br />

TPD / MTPD<br />

5mm - OK<br />

Ulnar<br />

sensory<br />

Radial<br />

sensory<br />

Median<br />

ensory<br />

*Misleading:<br />

muscle & tendon<br />

entrapment etc.<br />

Radial Ulnar Median<br />

VASCULAR EXAM<br />

Allen test Capillary refilling<br />

test


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PHYSICAL EXAM<br />

Radial head #<br />

Ulnar styloid #<br />

Dorsal ulnar prominence<br />

IMAGING<br />

A-P<br />

Lateral<br />

Oblique<br />

Post operatively<br />

Also (completion)<br />

3D: high velocity (young)<br />

2D: extra articular


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Descriptive (symptomes & Rx):<br />

Castaing, Frykman<br />

Extension-compression:<br />

Type Description<br />

I Colles: 4cm prox. To palm; dorsal<br />

fragmentation, angulation and<br />

displacement + Radius shortening<br />

II Partial = marginals<br />

III T (frontal, saggital)<br />

IV Composite = ex. articular<br />

CLASSIFICATION<br />

CASTAING CLASSIFICATION<br />

Therapeutic:<br />

Universal, Melone


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Flexion-compression:<br />

Type Description<br />

Smith I ex. art. ; palmar angulation<br />

II int. art. ; palmar prox. Displace.<br />

III ex. art. ; palmar displace.<br />

Marginals Palmar = as Smith II<br />

Dorsal = Barton’s<br />

Medial = Die punch<br />

Lateral = Backfire<br />

Extra-articular<br />

Radio-carpal<br />

CASTAING CLASSIFICATION<br />

FRYKMAN CLASSIFICATION<br />

Lunate load #<br />

Axial compression<br />

& Lunate dorsal depression<br />

Radio-ulnar<br />

Radio-carpal-ulnar


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* Die punch<br />

principle<br />

I<br />

II<br />

III<br />

IV<br />

UNIVERSAL CLASSIFICATION<br />

Type Description<br />

Ex. art. , stable, for ex. reduction<br />

Ex. art. , unstable, not for ex. reduct.<br />

Articular, stable<br />

IV a Artic. , stable, for ex. reduction<br />

IV b Artic. , unstable, not for ex. reduct.<br />

* Fracture reducibility<br />

I<br />

MELONE CLASSIFICATION<br />

Type Description<br />

Undisplaced = universal type III<br />

II II a Stable, for external reduction<br />

(50%)<br />

Involved<br />

lunate<br />

III<br />

(5%)<br />

IV<br />

V<br />

(dorsal / palmar compression)<br />

II b Unstable, 15% not for external reduction<br />

(double die punch; fragmented radius)<br />

Articular ant. displacement: neural &<br />

vascular compression, cortical tear<br />

180º rotation of articular fragments<br />

Complicated reduction<br />

Burst of diaphysis-metaphysis-epiphysis<br />

Conservative treatment


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SPECIAL FRACTURES<br />

Galeazzi fracture: # dist. 1/3rd Radius + Dislocation of RadioUlnar Joint<br />

(DRUJ) = “reversed Monteggia” (x3 common)<br />

When DRUJ overlooked – higher morbidity<br />

1) Radius shortening by 5mm<br />

2) # of ulnar styloid<br />

3) Widening DRUJ space by 2mm<br />

- or DRUJ subluxation<br />

* Compare to other wrist; keep exact position!<br />

Essex-Lopresti fracture: # dist. head of Radius + Radioulnar dislocation<br />

with partial / complete tear of radioulnal<br />

interosseous membrane<br />

TREATMENT<br />

Emergency: 1) Neurovascular compromise<br />

2) Severe displacement<br />

3) Tenting of the skin<br />

Principles: 1) Articular anatomy restoration<br />

2) Stability of wrist joint<br />

3) Early mobilization


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1) Closed reduction:<br />

- longitudinal traction<br />

- palmar flexion<br />

- ulnar inclination<br />

METHODS<br />

2) Direct nailing (ORIF):<br />

- lowering consolidation time<br />

and immobilization time (6-8w)<br />

- for radial styloid, posteromedial fragments<br />

and stbilizing the radio-ulna joint (pronosupination)<br />

METHODS<br />

3) Direct osteosynthesis (internal fixation):<br />

- includes special plates and screws<br />

- Anterior / posterior approach (if palmar large<br />

bone loss)<br />

- Can include bone graft (Radius, Iliac crest)<br />

to stabilize fragments<br />

4) External fixation:<br />

- nesscitates preliminar closed reduction<br />

- ligamentotaxis<br />

- duration of 3-8w; if consolidates enough- remove & cast 2w<br />

afterwards mobile cast<br />

- technique: reduction under Rx vision<br />

longitudinal traction -> neutralize articulation<br />

palmar flexion?<br />

mild extension (8º)<br />

Stable fractures<br />

No displacement<br />

CI to surgery<br />

Unstable<br />

Few large<br />

fragments<br />

Unstable<br />

Multiple fragments<br />

Melone V<br />

Unstable<br />

Multiple fragments


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BACKGROUND<br />

•Carpal fractures- only 25% of wrist fractures<br />

•10% of hand injuries<br />

MECHANISM OF INJURY<br />

•Axial compression + wrist hyperextension<br />

(fall with outstretched hand)<br />

EPIDEMIOLOGY<br />

•Common in adolescents<br />

BASIC FUNCTIONS<br />

1) Positioning<br />

2) Regulating forces<br />

3) Transmitting forces<br />

ANATOMY<br />

Metacarpals<br />

Dist. row<br />

Prox. row


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GREATER ARC:<br />

Perilunate carpal bones<br />

LESSER ARC:<br />

Disruption of ligaments<br />

* follows lunate contour<br />

TRADITIONAL<br />

CONCEPT<br />

Two rows<br />

(distal as one unit)<br />

Scaphoid bridging<br />

Between them<br />

VULNERABILITY ZONES<br />

BIOMECHANICAL MODELS<br />

NAVARRO<br />

TALEISNIK<br />

Central = flex.-extens.<br />

(radio-lunate, luno-capitate)<br />

Lateral = radial dev. = volar rot.<br />

ulnar dev. = neutral<br />

Medial = pronation - supination<br />

radial dev. = high pos.<br />

ulnar dev. = low pos.<br />

*Pisiform not included


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BIOMECHANICAL MODELS<br />

LICHTMAN’S OVAL<br />

RING CONCEPT<br />

Two rows = one ring<br />

Scapho-trapezial link<br />

Triquatrio-hamatum link<br />

Any disruption possible<br />

WRIST KINEMATICS<br />

•Wrist joint = three articular<br />

•Proximal row with intracarpal motion (scaphoid – lunate)<br />

•Distal row moves as one unit<br />

•Pisiform does not contribute and not included<br />

FLEXION / EXTENSION<br />

Radio-carpal & mid-carpal joints<br />

Rows angulate<br />

Lunate moves the list; scaphoid – the most<br />

RADIAL & ULNAR DEVIATION<br />

Proximal row rotates in the sggital plane<br />

Distal row angulates radial / ulnar<br />

PRONATION & SUPINATION<br />

Forearm bones function<br />

Pron. - palmar RadioScaphoCapitate Lig.<br />

Supin. - palmar UlnoLunate Lig.<br />

dorsal RadioTriquetral Lig.<br />

WEBER’S VIEW<br />

Radial column – force bearing<br />

Ulnar column – wrist control<br />

(lunate position vs stable capitate)<br />

PALMAR DORSAL<br />

Radial Ulnar deviation<br />

Prox. row – volar dorsiflex. flex.<br />

Dist. row – dorsal volar flex.


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A WORD ABOUT INSTABILITIES..<br />

•Static (per standard Rx) vs. dynamic (per stress views)<br />

•Lunate position: Dorsal / Volar Intercalated Segmental Instability (DISI / VISI)<br />

•Mayfield classification<br />

DISI: 1) scapho-lunate dissociation; most common instability.<br />

*In radial styloid #<br />

disruption of scapholunate, scaphotrapezoid ligs., FCR floor & radiocarpal lig.<br />

Pain & tenderness in snuffbox / dorsal scapholunate joint + clicks<br />

Watson’s test (+ pain)<br />

Rx: scapholunate space >+3mm (Terry-Thomas sign); scaphoid “cortical ring”<br />

*comparison to other wrist<br />

Tx: arthroscopic tear resection, K-wire pinning (3-4w), ligaments repair<br />

& capsulodesis<br />

2) Scaphoid non-union / mal-union: prox. & dist. Fragments move indipendently<br />

Rx: high resolution CT scan<br />

Tx: correct fusion<br />

A WORD ABOUT INSTABILITIES..<br />

VISI: 1) lunotriquetral dissociation; can lead to synovitis, arthrosis & wrist pain<br />

Rx: may be normal (ulnar sided instabilities?)<br />

*L-T lig. Disruption alone cannot produce VISI<br />

Ulnar sided wrist pain motiom limit<br />

Shear test (+ pain)<br />

Tx: immobilization 4-6w inc. elbow, lig. debridement by arthroscopy<br />

2) Radiocarpal dissociation; in rheumatoid arthritis<br />

Compromise of dorsal radiocarpal capsule (inc. radiotriquetral lig.)<br />

OTHERS: 1) Radiocarpal instabilities; dist. Radius # (DISI), arthritis (ulnar)<br />

*Volar subluxation is rare<br />

2) Perilunate fracture-dislocations: in the lesser arc; can include<br />

greater arc and even distal radiolunate joint


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•Most fractured<br />

•In young male adults<br />

•Mechanism: fall, sport injury, MVA<br />

•Isolated / combined with others<br />

•Wrist extension = distal #<br />

Blood supply: distal = distal pole (1/3)<br />

dorsal = proximal 2/3<br />

*prox. Pole – retrograde flow from<br />

vessels distal to waist<br />

(avascular necrosis – bad prognosis)<br />

SCAPHOID FRACTURES<br />

Trapezium<br />

Trapezoid<br />

articulation<br />

History: radial wrist pain post fall with outstretched hand<br />

Examine: pain in snuffbox, mild swelling<br />

Rx: may be without signs (2%); A-P, Lat., oblique x2<br />

compare to other scaphoid, repeat in 10-14d<br />

SCAPHOID FRACTURES CLASSIFICATIONS<br />

Horizontal<br />

oblique<br />

Russe<br />

Stable<br />

Transverse Vertical<br />

oblique<br />

Herbert<br />

&<br />

Fisher<br />

Base<br />

(tubercle)<br />

Waist<br />

Body<br />

Radius<br />

articulation


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Scaphoid fractures<br />

Nonunion: wide # zone, sclerosis (resorption); shortening,<br />

fragments discrepancy, angulation<br />

Delayed union: wide # zone, NO sclerosis (after 4m)<br />

Unstable: 1) displacement + any step-off v>=1mm<br />

2) angulation<br />

3) motion of fracture<br />

4) association with carpal instability<br />

Treatment: 1) Immobilization – stable & non-displaced<br />

* Thumb spica cast – long, for first 6w, short afterwards<br />

2) Internal fixation – unstable # & displaced<br />

3) Bone grafting: only if severe comminution<br />

Preiser’s disease: idiopathic avascular necrosis; ~40y old, steroid usage<br />

Tx: revascularization / resection + prox. Row carpectomy<br />

LUNATE FRACTURES<br />

Possible #: body, palmar / dorsal<br />

Tx: Cast immobilization (6w)<br />

KienbÖck’s disease: avascular necrosis<br />

From repeated trauma; male workers,<br />

18-40y; short ulna; fragmentation-collapse-<br />

-loss of carpal alignment-carpal arthrosis<br />

TRAPEZIUM FRACTURES<br />

Rare<br />

Direct blows<br />

Rx mostly enough<br />

Closed vs. open reduction<br />

TRAPEZOID FRACTURES<br />

The list frequently injured<br />

Dorsal dislocation by palmar<br />

forces on M2<br />

Anatomic reduction + stabilize.<br />

CAPITATE FRACTURES<br />

Rare<br />

Prox. 2/3 (perilunate injuries)<br />

Non-displaced # - immobilize<br />

fragments – open reduction<br />

TRIQUETRIUM FRACTURES<br />

Common<br />

With ligs. & bony damage<br />

Mostly dorsal cortex chip fractures<br />

Tx: immobilize for 4-6w.


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PISIFORM FRACTURES<br />

Rare<br />

Confines FCU<br />

Immobilize (if needed)<br />

HAMATE FRACTURES<br />

Body #; association with other wrist pathology<br />

Hamulus #; seen in golf, squash, tennis;<br />

Deep ulnar pain, aggrevated by activities<br />

Body exam: tenderness over hamate<br />

painful D5 abduction<br />

Internal fiixation<br />

Often progress to non-union<br />

BACKGROUND<br />

•Most common fractures (10% of all fractures)<br />

•In the US more than 16 million per year<br />

MECHANISM OF INJURY<br />

•Different trauma patterns: fist / open hand, with<br />

associated injuries (wounds, foreign bodies)<br />

EPIDEMIOLOGY<br />

•In all age groups<br />

•In small children – suspect abuse


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HISTORY<br />

Trauma pattern: occured in dirty / clean place<br />

associated crush injuries<br />

hand position at injury<br />

high preesure injection<br />

jewelry on fingers<br />

* fist / open hand<br />

* lacerations (over MCP?)<br />

* fist in mouth<br />

Domiant hand and hobbies<br />

Dist. phalanx<br />

Middle phalanx<br />

Prox. phalanx<br />

Metacarpals<br />

ANATOMY<br />

Thumb-Trapezium free articulation<br />

D4-5 with 20-25º of A-P movement<br />

D2-3 with minimal flex.-ex.


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FINGER FRACTURE<br />

Intra / extra articular, stable / unstable<br />

Very precise reduction (rotation error)<br />

Closed reduction if possible (tendons & ligs.)<br />

usually with k-wire<br />

For a cast: alignment ±10º<br />

no rotation error<br />

maintan flex.-ex. Balance<br />

no bone tissue loss<br />

normal finger gross appearance<br />

DISTAL PHALANX FRACTURES<br />

•Common d/t crush injury<br />

•Min. displacement – simple splint<br />

•Damage to fingernail : hematoma, laceration<br />

repair lacerations<br />

*clear fractured surface from nailbed tissue<br />

•In children may be through growth plate<br />

Wide epiphysis


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MIDDLE PHALANX FRACTURES<br />

•Condylar #: closed reduction + k-wire<br />

if open reduction: fine screw<br />

•Shaft #: unstable (FDS)<br />

closed reduction + k-wire + splint<br />

PIPJ #: most serious (volar plate)<br />

bad comminution<br />

closed fixation (trans art. Pins)<br />

early mobilization (after 3-4)<br />

PROXIMAL PHALANX FRACTURES<br />

•Unstable<br />

•Most accurate reduction (intra-articular)<br />

•Shaft # (transverse, oblique) - ant. angulation<br />

•MPJ #: nesscitates + stabilization


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METACARPAL FRACTURES<br />

•Shaft #: oblique shortens, trans. angulates & spiral - rotates<br />

•Goals for reduction:<br />

- No rotational error<br />

- less 3mm shortening<br />

- angulation up to 15º<br />

unstable<br />

- surface contact >50% of all bone fragments<br />

•Usually closed reduction<br />

•Neck #: most common D5 neck #<br />

- Reduction by k-wire<br />

•Head fracture: uncommon; Tx as discussed above.<br />

METACARPAL THUMB FRACTURES<br />

Neck #<br />

Bone loss<br />

•Head & shaft #: stable; k-wire debridement after long. traction<br />

•Angulation


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A WORD ABOUT JOINT DISLOCATIONS..<br />

PIPJ: dorsal dislocation; hyperex.+longitudinal compression<br />

Simplecomplex fracture-dislocation (most unstable)<br />

Simple & complex- immobilization 3-4w<br />

Fracture-dislocation (volar plate tear)- immobilization or<br />

K-wire or even open reduction (volar plate arthroplasty)<br />

Lateral dislocation; collat. Lig. rupture & volar plate tear<br />

small rupture – body taping 4-6w; major- surgical repair<br />

Volar dislocation; rare; unstable; extensive trauma, central slip disruption<br />

Central slip repair + immobilization;<br />

Boutonierre deformity sequela<br />

DIPJ: open dislocation is more common (cutaneous anchoring to bone<br />

Debridement, reduction, splinting. Antibiotics; if closed- reduced & stable<br />

A WORD ABOUT JOINT DISLOCATIONS..<br />

MCPJ: dorsal dislocation; forced hyperextension<br />

Simple- reduction by wrist flex. & MCPJ tract. + flex.<br />

Early active motion<br />

Complex- prominence in palm & skin dimpling<br />

Rx: intra articular sesamoid bone (volar plate)<br />

Open redcution (dorsal approach)<br />

Lateral dislocation; forceful adduction / abduction; may not be noticed<br />

Partial tear- buddy taping protection 3w<br />

Complete tear- surgical repair<br />

CMCJ: axial loading<br />

If acute – easy reduction; pinning to maitain reduction<br />

Failure – pain, weakness,degenerative arthritis


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A WORD ABOUT JOINT DISLOCATIONS..<br />

Thumb IPJ: dislocation is rare; lateral (collateral lig.) or dorsal (volar plate)<br />

Immobilization for 3-4w<br />

Thumb MCPJ: ulnar collateral lig. Injuries; common; forced palmar abduct.-ex. (ski)<br />

Swollen & tender MPJ; at dist. origin; examination under local anesthesia<br />

Deviation under stress 20º = severe tear repair / arthrodesis<br />

* Stener lesion- adductor policis between the torn parts<br />

* Gamekeeper thumb- chron. UCL stertching<br />

Radial collateral lig. Injuries; at prox. Origin<br />

immediate repair vs. late arthrodesis<br />

Dorsal dislocation; forced hyperex. + longitudinal compression<br />

Neuropraxia possible;<br />

If simple – closed reduction, immobilization (25º flex.) for 2-3w<br />

If complex tear- of collateral ligs. & volar plates<br />

Thumb CMCJ: rare; can lead to chronicsubluxation

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