Page 956 - TNFlipTest

OR22 Orthopedics
Wrist
Toronto Notes 2019
2
3
Lateral View
6
AP View
1. Dorsal tilt
2. Dorsal displacement 3. Radial shortening
4. Ulnar styloid fracture 5. Radial tilt
6. Radial displacement
• operative
■ indication: failed closed reduction, or loss of reduction ■ percutaneous pinning, external fixation, or ORIF
Smith’s Fracture
• volardisplacementofthedistalradius(i.e.reverseColles’fracture)
Mechanism
• fallontothebackoftheflexedhand
Investigations
• X-ray:APandlateralwrist
Treatment
• usuallyunstableandneedsORIF
• ifpatientispooroperativecandidate,mayattemptnon-operativetreatment
■ closed reduction with hematoma block (reduction opposite of Colles’) ■ long-arm cast in supination x 6 wk
Complications of Wrist Fractures
• most common complications are poor grip strength, stiffness, and radial shortening
• distal radius fractures in individuals <40 yr of age are usually highly comminuted and are likely to
require ORIF
• 80%havenormalfunctionin6-12mo
Table 13. Early and Late Complications of Wrist Fractures
1
Figure 22. Colles’ fracture and associated bony deformity
A. 22
Early
Difficult reduction ± loss of reduction Compartment syndrome
Extensor pollicis longus tendon rupture Acute carpal tunnel syndrome
Finger swelling with venous block Complications of a tight cast/splint
Scaphoid Fracture
Epidemiology
Late
Malunion, radial shortening
Painful wrist secondary to ulnar prominence Frozen shoulder (“shoulder-hand syndrome”) Post-traumatic arthritis
Carpal tunnel syndrome
CRPS/RSD
C. Volar tilt
5
4
B. 11 mm
RU
AP view
• commoninyoungmen;notcommoninchildrenorinpatientsbeyondmiddleage • mostcommoncarpalboneinjured
• maybeassociatedwithothercarpalorwristinjuries(e.g.Colles’fracture)
Mechanism
• FOOSH:impactionofscaphoidondistalradius,mostcommonlyresultinginatransversefracture through the waist (65%), distal (10%), or proximal (25%) scaphoid
Clinical Features
• painwithresistedpronation
• tendernessintheanatomical“snuffbox”,overscaphoidtubercle,andpainwithlongaxiscompression
into scaphoid
• usuallynondisplaced
Investigations
• X-ray:AP,lateral,scaphoidviewswithwristextensionandulnardeviation • ±CTorMRI(highriskforAVNifmissed)
• bonescanrarelyused
■ note: a fracture may not be radiologically evident up to 2 wk after acute injury, so if a patient complains of wrist pain and has anatomical snuff box tenderness but a negative x-ray, treat as if positive for a scaphoid fracture and repeat x-ray 2 wk later to rule out a fracture; if x-ray still negative, order CT or MRI
Treatment
• earlytreatmentcriticalforimprovingoutcomes • non-operative
■ non-displaced (<1 mm displacement/<15° angulation): long-arm thumb spica cast x 4 wk, then short arm cast until radiographic evidence of healing is seen (2-3 mo)
• operative
■ displaced: ORIF with headless/countersink compression screw is the mainstay treatment
A. Radial inclination B. Radial length
C. 10
Lateral view
Effect of Colles’ fracture on distal radius
Figure 23. Normal wrist angles+ wrist angles in Colles’ fracture
Note the relative shortening of the radius relative to the ulna on AP view in Colles’ fracture
Scaphoid Fracture Special Tests
Tender snuff box: 100% sensitivity, but 29% specific, as it is also positive with many other injuries of radial aspect of wrist with FOOSH
R
© Andreea Margineanu 2012
© Andreea Margineanu 2012