Page 955 - TNFlipTest

Toronto Notes 2019
Wrist
Orthopedics OR21
Nightstick Fracture
• isolatedfractureofulnawithoutdislocationofradialhead
Mechanism
• directblowtoforearm(e.g.holdingarmuptoprotectface)
Treatment
• non-operative
■ non-displaced
■ below elbow cast (x 10 d), followed by forearm brace (~8 wk)
• operative
■ displaced
■ ORIF if >50% shaft displacement or >10° angulation
Galeazzi Fracture
• fractureofthedistalradialshaftwithdisruptionoftheDRUJ
• mostcommonlyinthedistal1/3ofradiusnearjunctionofmetaphysis/diaphysis
Mechanism
• handFOOSHwithaxialloadingofpronatedforearmordirectwristtrauma
Clinical Features
• pain,swelling,deformity,andpointtendernessatfracturesite
Investigations
• X-ray:AP,lateralelbow,wrist,andforearm
■ shortening of distal radius >5 mm relative to the distal ulna ■ widening of the DRUJ space on AP
■ dislocation of radius with respect to ulna on true lateral
Treatment
• allcasesareoperative
■ ORIF of radius; afterwards, assess DRUJ stability by balloting distal ulna relative to distal radius ■ if DRUJ is stable and reducible, splint for 10-14 d with early ROM encouraged
■ if DRUJ is unstable, ORIF or percutaneous pinning with long arm cast in supination x 6 wk
Wrist
Colles’ Fracture
• extra-articulartransversedistalradiusfracture(~2cmproximaltotheradiocarpaljoint)withdorsal displacement ± ulnar styloid fracture
• mostcommonfractureinthose>40yr,especiallyinwomenandthosewithosteoporoticbone
Mechanism
• FOOSH
Clinical Features
• “dinnerfork”deformity
• swelling, ecchymosis, tenderness
Investigations
• X-ray:APandlateralwrist
and useful forearm rotation • non-operative
■ closed reduction (think opposite of the deformity)
■ hematoma block (sterile prep and drape, local anesthetic injection directly into fracture site) or
conscious sedation
■ closed reduction: 1) traction with extension (exaggerate injury), 2) traction with ulnar deviation,
pronation, flexion (of distal fragment – not at wrist)
■ dorsal slab/below elbow cast for 5-6 wk
■ obtain post-reduction films immediately; repeat reduction if necessary
■ x-ray at 1 wk, 3 wk, and at cessation of immobilization to ensure reduction is maintained
Figure 20. Nightstick fracture
For all isolated radius fractures assess DRUJ to rule out a Galeazzi fracture
Fracture of distal radius
DRUJ
Dislocation of ulna
Figure 21. Galeazzi fracture
Indications for Surgical Management of Colles’ Fracture
• Displaced intra-articular fracture
• Comminuted
• Severe osteoporosis
• Dorsal angulation >5° or volar tilt >20° • >5 mm radial shortening
ORIF Colles’ Fracture if Post-Reduction Demonstrates
• Radial shortening >3 mm or,
• Dorsal tilt >10° or,
• Intra-articular displacement/step-off >2 • goalistorestoreradialheight(13mm),radialinclination(22°),volartilt(11°),aswellasDRUJstability mm
Treatment
© Desmond Ballance 2006
© Chesley Sheppard