+

Activate Windows

Go to Settingsto-acitvyLe Wtndovrt.

0R16 Orthopaedic Surgery Toronto Notes 2023

Acromioclavicular Joint Pathology

•subluxation or dislocation of AC joint

•2 main ligament groups attach clavicle to scapula: AC and CC ligaments

Mechanism

•fall onto shoulder with adducted arm or direct trauma to point of shoulder (usually fall onto the

posterosuperior aspect of the lateral shoulder)

Pneumothorax or pulmonary contusion

are potential complications of severe

clavicle fracture and rarely severe AC

joint dislocation

Clinical Features

•pain with adduction of shoulder and/or palpation over AC joint

•palpable step deformity between distal clavicle and acromion (with dislocation) i.e. piano key sign

•limited ROM

Investigations

•x-rays: bilateral AP, Zanca view (10-15° cephalic tilt), axillary

Treatment

•non-operative

sling 1-3 wk, ice, analgesia,early ROM, and rehabilitation

•operative

» indication: Rockwood Class IV-VI (111 if labourer or high level athlete)

• number of different approaches involving AC/CC ligament reconstruction or screw/hook plate

insertion

Table 11. Rockwood Classification of Acromioclavicular Joint Separation

Grade Features Treatment

I Joint sprain,absence of complete tear of eitherligament Non-operative

Complete tear of AC ligament,incomplete tear of CC Non-operative

ligament,without marked elevation oflateral clavicular

head

II

Complete tear of AC and CC ligaments,>5 mm elevation Most non-operative,operative iflabourer or high level

at AC joint,superior aspect of acromion is below the

inferior aspect of the clavicle

athlete

Will heal with step deformity,although most fully

funcbonalin 4-6 mo

Based on the anatomical structure the displaced clavicle Operative in most cases

is in proximity to (posterior,very superior,inferior)

IV-VI

Grade AC Ligament CC Ligament Reducible Treatment

I Sprained Normal N,A Non-operative

Non-operative

Most non-operative,

operativeif labourer or

high-level athlete

Will heal withstep

deformity.alLhough most

fully functional in 4-6 mo

Operativein mostcases

II lorn Sprained Yes

III lorn Torn Yes

IV-VI lorn Torn No

Rockwood separations IV-VI are determinedbased on direction ot displacement

IV:Distal clavicle displaced posteriorly into trapezius (seen on axillary XR)

V:Distal clavicle herniated through dellotrapezial fascia into subcutaneous tissue

VI:Distal davide displaced interior to acromion or coracoid under conjoined tendon (rare)

Opea iedictioiaidlitenalFiiati:a vs.

iMsirgicalTreataeitiiDisplacedMidshaft

Qavide Fradares:A Meta-dialysis

J(topIrac=a 203J2(7)a2)5-e2!3

Purpose:Compare c.icotes frpn DBF ard»-

eperane treaheeats aispacednd-shaft dander

fradires.

Methods Keta aa'ysisittSKIsreportag

xpuini

.toctxuai outcomes,and ssbsegoei:

surgeres patedsolderthasKyr.

Destlts: 9 ia:dp=zed ditaltrialsniI02)ata

patents iere ".ded.OJLF lasassocated•a

sgahcadly loaer toe®

*

rate ofLTV compared

toH5'

«

‘

or aeMt-ope-avre teat-ect gtozps (M

0.8.95% CL 0.0S-0-31).Fatctozal ooicaces.rated

by ether DASH or Coestadsetres.mere s 3 cScacty

betteritOlf gp to 6 wo.lieseidodegelectre

pate reoovaL derate ot szbsegsett szrger es«s

sgaScaatly loweri«ieODD cohort(Aftis.W%.

M0-36.95% C10.2A-0.5SL

Coidisiots OBf isassocatediisgtocao:

redochoos«ootswesaadeerier fsscboual

octtoses n dspaced -dstaftdatdi-fradres.

Clavicle Fracture

• incidence: proximal (5%), middle (80%), or distal (15%) third of clavicle

• common in children (unites rapidly without complications)

Mechanism

• fall on shoulder (87%), direct trauma to clavicle (7%),100SH (6%)

Clinical Features

• pain and tenting of skin

• arm is clasped to chest to splint shoulder and prevent movement

Investigations

• evaluate N VS of entire upper limb

• x-ray:AF, 45" cephalic tilt (superior/inferior displacement), 45° caudal tilt (AP displacement)

• Cl : useful for medial physeal fractures and sternoclavicular injury

+

Activate Windows

Goto JClli1

0R17 Orthopaedic Surgery Toronto Notes 2023

Treatment

• medial and middle-third clavicle fractures

• for nondisplaced fractures,simple sling for I -2 wk pm

early ROM and strengthening once pain subsides

» if fracture is shortened >2 cm, consider ORIF

• distal

-third clavicle fractures

• undisplaced (with ligaments intact):sling for 1-2 wk

• displaced (CC ligament injury):ORIF

Specific Complications (see General FractureComplications,OR7 )

• cosmetic bump (most common complication)

• shoulder stiffness, weakness with repetitive activity

• pneumothorax, brachial plexus injuries,and subclavian vessel (all very rare)

Associated Injuries with Clavicle

Fractures

• Up to 9% ol clavicle fractures are

associated with other fractures (most

commonly rib fractures)

• Majority of brachial plexus injuries

are associated with proximal third

fractures

Frozen Shoulder (Adhesive Capsulitis)

•disorder characterized by progressive pain and stiffness of the shoulder, usually resolving

spontaneously within 18 mo

Stages of Adhesive Capsulitis

1. Freezing phase:gradual onset,diffuse

pain (lasts 6-9mo)

2. Frozen phase:decreased ROM

impacts function (lasts 4-9 mo)

3. Thawing phase:gradual return of

motion (lasts 5-26 mo)

Mechanism

•primary adhesive capsulitis

idiopathic, often associated with DM

usually resolves spontaneously in 9-18 mo

•secondary adhesive capsulitis

• due to prolonged immobilization

• shoulder-hand syndrome:CRPS/RSD characterized by arm and shoulder pain, decreased motion,

and diffuse swelling

• following Ml,stroke,shoulder trauma

• poorer outcomes

Clinical Features ft

•gradual onset (weeks to months) of diffuse shoulder pain with:

• decreased active AND passive ROM

• pain worse at night and often preventssleeping on affected side

increased stiffness as pain subsides: continuesfor 6-12 mo after pain has disappeared

Conditions Associated with an

Increased Incidence of Adhesive

Capsulitis

• Prolonged immobilization (most

significant)

• Female gender

• Age >49

• DM (Sx)

• Cervical disc disease

• Hyperthyroidism

. Stroke

- Ml

• Trauma and surgery

• Autoimmune disease

Investigations

•x-ray:AP (neutral, internal/external rotation),scapular Y, and axillary views of the shoulder

may be normal, or may show demineralization from disease

Treatment

•freezing phase

maintenance of active and passive ROM (physiotherapy)

NSAlDs and steroid injections if limited by pain

•thawing phase

aggressive physiotherapy, possible manipulation under anesthesia and early physiotherapy

• arthroscopy for debridement/decompression

Humerus

Proximal Humeral Fracture

Mechanism

• young: high energy trauma (MVC)

• elderly: l

'

OOSH from standing height in osteoporotic individuals

Clinical Features

• proximal humeral tenderness, deformity with severe fracture,swelling, painful ROM, bruising

extends down arm and chest

• physical exam usually reveals diminished forward elevation, with or without disuse atrophy of deltoid

and periscapular musculature

Necr Classification

Based on 4 parts of humerus

• Greater tuberosity

• Lesser tuberosity

• Humeral head

- Shaft

One-part fracture: any of the 4 parts

withnone displaced

Two-part fracture:any of the 4 parts

with1displaced

Three-part fracture:displaced fracture

of surgical neck + displaced greater

tuberosity or lesser tuberosity

Four-part fracture:displaced fracture

of surgical neck + both tuberosities

n

L J

Investigations

• test axillary nerve function (deltoid contraction and skin over deltoid)

• x-rays:AP, trans-scapular, and axillary- views of the shoulder are essential

• CT’

scan:to evaluate for tuberosity or articular involvement and fracture displacement, and if the

diagnosis of non-union is unclear

+

Activate Windows

Go to Settings to activate Window:

OR18 Orthopaedic Surgery Toronto Notes 2023

Classification

• Neer classification is based on 4 fracture locations or‘parts'

• displaced: displacement >1 cm and/or angulation >45°

• the Neer system regards the number of displaced fractures, not the fracture line, in determining

classification

• ± dislocated/subluxed: humeral head dislocated/subluxcd from glenoid

Treatment

• assess for and treat osteoporosis if needed

• non-operative

nondisplaced and minimally displaced (85% of patients): broad arm sling immobilization, begin

ROM within 14 d to prevent stiffness

• most displaced fractures in low-demand elderly patients

• operative

• OR1F (anatomic neck fractures,displaced, associated irreducible glenohumeral joint dislocation)

or 1M nail (surgical neck)

hemiarthroplasty or reverse TSA may be necessary, especially in elderly

minimally invasive percutaneous pinning and intramedullary nail fixation are indicated in rare

instances

Specific Complications (seeGeneral FractureComplications,OR7)

• AVN, nerve palsy (45%; typically axillary nerve),malunion, post-traumatic arthritis, persistent pain

and weakness, frozen shoulder '

Greater tuberosity

Lesser tuberosity

Humeral Shaft Fracture v

11 Mechanism

• young: high energy trauma (direct blows/M VC)

• elderly: FOOSH, twisting injuries, mctastascs

Clinical Features

• pain,swelling, weakness ± shortening, motion/crepitus at fracture site

• must test radial nerve function before and after treatment: look for drop wrist,sensory impairment in

dorsum of hand

'Anatomical neck

Surgical neck

t 1

.

;

Investigations

• x-ray: AP and lateral views of the humerus, including the shoulder and elbow joints

Figure 15. Fractures of the proximal

Treatment humerus

• in general, humeralshaft fractures are treated non-operatively

• non-operative

± reduction; can accept deformity due to compensatory ROM ofshoulder

hanging cast (weight of arm in cast providestraction acrossfracture site) with collar and cuff

sling immobilization untilswelling subsides, then Sarmiento functional brace, followed by ROM

Acceptable Humeral Shaft Deformities

for Non-Operative Treatment

• <20° anterior angulation

• <30° varus angulation

•

<3cm of shortening

• operative

indications:see NO CAST sidebar,OR6, pathological fracture, “floating elbow” (simultaneous

unstable humeral and forearm fractures)

ORIF: plating (most common), IM rod insertion, external fixation (rare)

Specific Complications (seeGeneral Iracture Complications, OR7)

(§

>

• failure of functional bracing (seen in up to 30% of patients)

• radial nerve palsy: expect spontaneous recovery in 3-4 mo, otherwise send for EMli

• non-union: most frequently seen in middle 1/3

• decreased ROM

• compartment syndrome

Risk of radial nerve and brachial artery

Injury

Distal Humeral Fracture

The anterior humeral line refersto an

imaginary line drawn along the anterior

surface of the humeral cortex that

passesthrough the middle third of the

capitellum when extended interiorly.

In subtle supracondylar fractures, the

anterior humeral line is disrupted,

typically passing through the anterior

third of the capitellum

Mechanism

• young: high energy trauma (MVC)

• elderly:lower energy falls in patients with osteoporotic bone

Clinical Features

• elbow pain and swelling

• assess brachial artery (ecchymosis over anteromedial forearm issuggestive of brachial artery injury)

r T

L J

+

Activate Windows

<3cFto Settings to activate Windows

0R19 Orthopaedic Surgery Toronto Notes 2023

Investigations

• x-ray:AP and lateral views of the humerus and elbow

• Clscan:helpful when suspecting shear fracture of capitulum or trochlea, and for preoperative

planning

• assess NVS:radial, ulnar, and median nerve

Classification

• supracondylar, distal single column, distal bicolumnar, and coronal shear fractures

Treatment

• goal is to restore a functional ROM of at least 30-130°flexion (unsatisfactory outcomes in 25%)

• non-operative (paediatric patients and elderly patients with medical comorbidities)

cast immobilization (in supination for lateral condyle fracture; pronation for medial condyle

fractures):short immobilization and early range of motion

• operative

• indications: displaced,supracondylar, bicolumnar

• closed reduction and percutaneous pinning (children);OKU'

; total elbow arthroplasty (complex

bicolumnar in elderly)

adult fractures are almost always treated operatively due to risk of elbow stiffness with nonoperative management

Elbow

Supracondylar Fracture

•subclass of distal humerusfracture:extra-articular,fracture proximal to capitulum and trochlea,

usually transverse

•most common in paediatric population (peak age ~7 yr),rarely seen in adults

•AIN (median nerve) injury commonly associated with extension type

Mechanism

•>96% are extension injuries via 1

'

OOSH (e.g.fall off monkey bars); <4% are flexion injuries

Clinical Features

•pain,swelling, point tenderness

•neurovascular injury: median and radial nerves, radial artery

Three Joints at the Elbow

Humeroradial joint

Humeroulnar joint

Radioulnar joint

Normal carrying angle of elbow is ~10°

of valgus

Humera

Investigations

•x-ray: AR and lateral views of the elbow

disruption of anterior humeral line suggests supracondylar fracture

• fat pad sign: a sign of effusion and can be indicative of occult fracture

assess NVS:median and radial nerves, radial artery

Treatment

•non-operative

• nondisplaced (paediatric): closed reduction with long arm plaster slab in 90°flexion x 3 wk

•operative

• indications:see NO CAST sidebar, OR6; displaced >50%, vascular injury, open fracture

requires closed reduction plus percutaneous pinning followed by limb cast with elbow flexed <90°

in adults,OK1F is necessary

Specific Complications (see General Fracture Complications,OR7)

•stiffnessis most common

•brachial artery injury (kinking can occur if displaced fracture), median or ulnar nerve injury,

compartment syndrome (leads to Volkmann's ischemic contracture), malalignment cubitus varus

(distal fragment tilted into varus)

Figure 16. X-ray of transverse

displaced supracondylar fracture of

humerus with elbow dislocation

[/

Anterior Humeral Line

apitellum

Radio-Capitellar Line

• i

uv

-m

*

j

Radial Head

©Oasmond Ballance 2006

Figure 17. Lateral view of elbow

ri

L J

Capitellum moves posteriorly to the

anterior humeral line in extension type

fractures and anteriorly in fhxion type

fractures

+

Activate Windows

TSo to Settings to activate Windows,

OR20 Orthopaedic Surgery Toronto Notes 2023

Radial Head Fracture

• a common fracture of the upper limb in young adults (85% occur between 30-60 yr)

Mechanism

• FOOSH with elbow extended and forearm pronated

Clinical Features

• marked local tenderness on palpation over radial head (lateral elbow)

• decreased ROM at elbow, ± mechanical block to forearm pronation and supination

• pain on pronation/supination

Terrible Triad

Radial head fracture

Coronoid fracture

Elbow dislocation

Investigations

• x-ray:AF and lateral views of the elbow

• enlarged anterior fat pad ("sail sign”) or the presence of a posterior fat pad on lateral view

indicates effusion, which could occur with occult radial head fractures

Table 12. Classification and Treatment of Radial Head Fractures

Mason Class Radiographic Description Treatment

Elbow slab or sling x 3-5 d withearly ROM

ORIf if:angulation >30",involves >1/3 of Iheradial head,or if

>3 nun of joint incongruity exists,block to forearm rotation

Radial head excision t prosthesis (if ORIF not feasible)

Comminuted fracture with posterior elbow dislocation Radial head ORIF or radial head excision with prosthesis

Nondisplaced fracture (< 2 mm)

Displaced fracture|>2mm)

1

Figure 18.Lateral x-ray of elbow with

effusion (“sail sign”)

2

3 Comminuted fracture

4

To avoid stiffness,do not immobilize

elbow joint >2-3 wk

Treatment

the gold standard in management

• arthroscopic repair can be considered:offers improved visualization and enhances soft tissue

preservation of the joint

• ORIF remains

Specific Complications (seeGenera/ FractureComplications,OR7)

• myositis ossificans - calcification of muscle

• recurrent instability (if MCL injured and radial head excised)

Olecranon Fracture

Mechanism

• direct blow:fall onto point of elbow (posterior aspect)

• indirect blow:FOOSH (typically transverse/oblique fracture)

Clinical Features

• localized pain, palpable defect

• ± loss of active extension due to avulsion of triceps tendon

Investigations

• x-ray: AF and lateral (require true lateral to determine fracture pattern)

Treatment

• non-operative

• non-displaced (<2 mm,stable):cast x 2-3 wk (elbow in 90° flexion, often in full elbow extension),

then gentle ROM

• operative

displaced ± non-intact extensor mechanism

Elbow Dislocation

• third most common joint dislocation after shoulder and patella

• simple: dislocation with no associated features

• complex:dislocation with associate features (fracture along with anterior capsule and/or collateral

ligaments disrupted)

Mechanism

• elbow hyperextension via FOOSH or valgus/supinalion stress during elbow flexion

• usually the radius and ulna are dislocated together, alternatively the radial head dislocates in isolation

and the ulna is fractured (see Monteggia Fracture, OR22 )

• 80% are posterior/posterolateral, anterior are rare and usually devastating +

Activate Windows

Go to Settings to activate Windows.

0R21 Orthopaedic Surgery Toronto Notes 2023

Clinical Features

• elbow pain,swelling, deformity

• flexion contracture

• ± absent radial or ulnar pulses

Investigations

• x-ray: AP and lateral views of the elbow

• assess N VS:brachial artery, median and ulnar nerves

Elbow Dislocation

The radio-capitellar line refers to an

imaginary line along the longitudinal axis

of the radial neck that passesthrough

the centre of the capitellum, regardless

of the degree of elbow florion. If the

radio-capitellar line does not pass

through Ihe centre of the capitellum a

dislocation should be suspected

Treatment

• non-operative

• closed reduction under conscioussedation (post-reduction x-rays required)

• Parvin’s method: patient lies prone with arm hanging down; apply gentle traction downwards on

wrist; as olecranon slips distallv,gently lift up the arm at elbow to reduce joint

• long-arm splint with forearm in neutral rotation and elbow in 90° flexion

• early ROM (<2 wk)

• operative

• indications: complex fracture dislocation or persistent instabilitv after closed reduction

• OR1P

Specific Complications (see GeneralFractureComplications.UK7)

• stiffness (loss of extension),intra-articular loose body,neurovascular injury (ulnar nerve, median

nerve, brachial artery), radial head fracture

• recurrent instability uncommon

Epicondylitis

• lateral

the lateral

epicondylitis

epicondyle

= “tennis elbow,

” inflammation of the common extensor tendon as it insertsinto #

• medial epicondylitis = “golfer’

s elbow,

"

inflammation of the common flexor tendon as it inserts into

the medial epicondyle

Tennis Elbow = laTeral epicondylitis; pain

associated with extension of wrist

Mechanism

• repeated orsustained contraction of the forearm musdes/chronic overuse

Clinical Features

• point tenderness over humeral epicondyle and/or distal to it over forearm musculature

• pain upon resisted wrist extension (lateral epicondylitis) or wrist flexion (medial epicondylitis)

• generally a self-limited condition, but may take 6-18 mo to resolve

Treatment

• non-operative (vert'good outcomes)

rest,ice, NSAlDs

use brace/strap

physiotherapy,stretching, and strengthening

activity modification/ergonomics

• corticosteroid injection

• operative

• indication:failed 6-12 mo conservative therapy

• percutaneous or open release of common tendon from epicondyle

Elbow Joint Injection

Inject at the centre of the triangle

formed by the lateral epicondyle, radial

head, and olecranon

Forearm

Radius and Ulna Shaft Fractures

Mechanism

• high-energy direct or indirect (MVA, fall from height,sports) trauma

• fractures usually accompanied by displacement due to high energy mechanism

Clinical Features

• deformity, pain,swelling

• loss of function in hand and forearm

rT

L J

Investigations

• x-ray:AP and lateral of forearm ± oblique of elbow and wrist

• CT if fracture is close to joint +

Activate Windows

Go to Settings to activate Windows.

OR22 Orthopaedic Surgery Toronto Notes 2023

Treatment

• goal is anatomic reduction since imperfect alignment significantly limitsforearm pronation and

supination

• ORIT with plates and screws;closed reduction with immobilization usually yields poor results for

displaced forearm fractures(except in children)

Specific Complications (seeGeneral FractureComplications, OR7)

- compartmentsyndrome

• soft tissue contracture resulting in limited forearm rotation -surgical release of tissue may be

warranted

Monteggia Fracture

• fracture of the proximal ulna with radial head dislocation and proximal radioulnar joint injury

- more common and better prognosisin the paediatric age group when compared to adults

Mechanism

• direct blow to the posterior aspect of the forearm

• hvperpronation

• fall on the hyperextended elbow Figure 19. Monteggia fracture

Clinical Features

• pain,swelling, decreased rotation of forearm ± palpable lump at the radial head

• ulna angled apex anterior and radial head dislocated anteriorly (rarely the reverse deformity occurs)

Investigations

• x-ray:AT and lateral views of the elbow, wrist,and forearm

In all isolated ulna fractures,assess

proximal radiusto rule out a Monteggia

fracture

Treatment

• adults (if stable):splint and early postoperative ROM if elbow completely stable,otherwise

immobilization in plaster with elbow flexed for 2-3wk

• adults (if unstable):OR1F of ulna with indirect reduction of radiocapitellar joint in 90% of patients

(open reduction of radiocapitellar joint if unsuccessful)

• paediatrics:attempt closed reduction and immobilization in plaster with elbow flexed for Bado Type

1-111,surgery for Type IV

Specific Complications ( seeGeneral Fracture Complications, OR7)

• PIN injury: most common nerve injury;observe for 3 mo as most resolve spontaneously

• radial head instabilitv/redislocation

• radioulnar synostosis

Bado Type Classification of Monteggia

Fractures

Based on the direction of displacement

of the dislocated radial head,generally

the same direction astheapexofthe

ulnar fracture

Type b anterior dislocation of radial

head and proximal/middle third ukiar

fracture (60%)

Type II:posterior dislocation of radial

head and proximal/middle third ulnar

fracture (15%)

Type III:lateral dislocation of radial

head and metaphyseal ulnar fracture

(20%)

Type IV-combined: proximal fracture

of the ulna and radius,dislocation of the

radial head in any direction (<5%)

Nightstick Fracture

•isolated fracture of ulna without dislocation of radial head

Mechanism

•direct downward blow to upward block forearm (e.g.holding arm up to protect face)

Treatment

•non-operative

indication: non-displaced

below elbow cast (x 10 d),followed by forearm brace (~8 wk)

•operative

• indication:significantly displaced

ORIT if >50% shaft displacement or >10°angulation

Galeazzi Fracture Figure 20. Nightstick fracture

•fracture of the distal radial shaft with disruption of the DRU|

•most commonly in the distal 1/3of radius near junction of metaphysis/diaphysis

For all isolated radiusfractures assess

Mechanism DRUJ to rule out a Galeazzi fracture

•FOOSH with axial loading of pronated forearm or direct wrist trauma

•forceful axial loading of radial shaft (e.g. direct trauma to distal 1/3 of radius)

Clinical Features

•pain,swelling, deformity,and point tenderness at fracture site

r h

L J

(§)

Monteggia vs. Galeazzi Fractures

Remember the mnemonic 'MUGGER'

:

Monteggia

Ulnar fracture

Galeazz

Radialfracture

+

Activate Windows

T5o to Settings to activate Windows.

OR23 Orthopaedic Surgery Toronto Notes 2023

Investigations

• x-ray: AP, and lateral views of the elbow, wrist, and forearm

shortening of distal radius >5 mm relative to the distal ulna

• widening of the OKU ) space on AP

• dislocation of radius with respect to ulna on true lateral

Fracluro ol distal radius

Treatment

• all cases are operative (“fracture of necessity")

OR1P of radius; afterwards, assess DRU|stability by balloting distal ulna relative to distal radius

if DRU) is stable and reduced,splint for 10-14 d with early ROM encouraged

if DRU) is unstable, OR1P or percutaneous pinning with long arm cast in supination x 2-3wk

Wrist Dislocation of ulna

Figure 21. Galeazzifracture

Colles’ Fracture

Indications for Direct Surgical

Management of Codes' Fracture

• Displaced intra-articular fracture

• Comminuted

• Severe osteoporosis

• Dorsal angulation >5‘or volar tilt

>20"

• >5 mm radlal shortening

• extra-articular transverse distal radius fracture (~2 cm proximal to the radiocarpal joint) with dorsal

displacement ± ulnar styloid fracture

• most common fracture in those >40 yr, especially in women and those with osteoporotic bone

Mechanism

. KOOSH

Clinical Features

• “dinner fork" deformity

• swelling, ecchymosis, tenderness Features of Inadequate Closed

Reduction that Require ORIF

- Radial shortening >3 mm or

- Dorsal tilt >10“ or

- Intra-articular displacement/step-off

>2mm

Investigations

• x-ray:AP and lateral ± oblique views of wrist

Treatment

• goal is to restore radial height (13 mm), radial inclination (22°), volar tilt (11°), as well as DRU)

stability 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:traction with extension (exaggerate injury); traction with ulnar deviation,

pronation, flexion (of distal fragment- not at wrist)

• dorsal slab/below elbow cast for 5-6 wk

obtain post

-reduction Aims immediately; repeat reduction if necessary

• x-ray at 1 wk, 3 wk, and at cessation of immobilization to ensure reduction is maintained

• operative

indication: failed closed reduction,or loss of reduction

percutaneous pinning, external fixation, or ORIF

Lateral View

Smith’s Fracture

• volar displacement of the distal radius(i.e.reverseColies’fracture)

AP View

Mechanism 1. Dorsal tilt

• fall onto the back of the flexed hand 2. Dorsal displacement

3.Radial shortening

4. Ulnar styl

5 Radial tilt

old fracture Investigations

• x-ray: AP and lateral ± oblique views of wrist

Treatment

• if non-displaced/stable: closed reduction and splinting in wrist extension with hematoma or regional

nerve block;long arm cast in supination x6 wk

• if displaced/unstable: ORIF

6. Radial displacement

Figure 22. Colles’ fracture and

associated bony deformity

+

Activate Windows

Go to Settings to activate Windows.

0R21Orthopaedic Surgery Toronto Notes 2023

Complications of Wrist Fractures

• most common complications are poor grip strength,stiffness, and radialshortening

• distal radiusfractures in individuals <40 yr of age are frequently high energy/comminuted and are

more likely to require ORU-

'

• 80% have normal function in 6-12 mo

Table 13.Early and Late Complications of Wrist Fractures

Early Late

Difficult reduction tloss olreduction

Compartment syndrome

Extensor pollicis longus tendon rupture

Acute carpal tunnel syndrome

Finger swelling with venous block

Complications ot a tight cast/splinl

Malunion,radial shortening

Painful wrist secondary to ulnar prominence

Froren shoulder (“shoulder-hand syndrome")

Post-traumatic arthritis

Carpal tunnel syndrome

CRPS/RSD

AP view

A.Radial inclination

B.Radial length

Scaphoid Fracture

Epidemiology

• most common carpal bone injured

• common in young men; not common in children or in patients beyond middle age

• may be associated with other carpal or wrist injuries (e.g. Colies’

fracture)

Mechanism

• FOOSH: impaction of scaphoid on distal radius, most commonly resulting in a transverse fracture

through the waist (65%), distal (10%), or proximal (25%)scaphoid

Clinical Features

• pain with resisted pronation

• tenderness in the anatomical “snuffbox”, over scaphoid tubercle, and pain with long axis compression

into scaphoid

• usually nondisplaced

Lateral view

C. Volar tilt

1

o

Effect ol Colics’Iracturo

on distal radius

Figure 23.Normal wrist angles

*

wrist angles in Codes’fracture

Note the relative shortening of the

radius relative to the ulna on AP

view in Codes’fracture

Investigations

• x-ray: AP, lateral, and scaphoid views with wrist extension and ulnar deviation

• ± Q’

or MRI:detect occult fracture and prevent AVN

• bone scan rarely used

• 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 snuffbox 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 MR1

Scaphoid Fracture Special Tests

Tender snuff box:100% sensitivity,but

29%specific,asit is also positive with

many other injuries of radial aspect of

Treatment wrist with FOOSH

• early treatment critical for improving outcomes

• non-operative

• non-displaced (<1 mm displacement/

^

5° angulation): long-arm thumb spica cast x 4 wk, then

short arm cast until radiographic evidence of healing isseen (2-3 mo) The proximal pole of the scaphoid

receives as much as100% of its arterial

blood supply from the radial artery that

enters at the distal pole.A fracture

through the proximal third disrupts

this blood supply and results In a high

incidence of AVN/nonunion

• operative

• displaced: ORIt with headless/countersink compression screw is the mainstay treatment

Specific Complications (seeGeneral FractureComplications,OR7)

• most common: nonunion/malunion (use bone graft from iliac crest or distal radius with fixation to

heal)

• AVN of the proximal fragment

• delayed union (recommend surgical fixation)

• scaphoid nonunion advanced collapse (SNAC) -chronic nonunion leading to advanced collapse and

arthritis of wrist

Prognosis

• proximal pole:proximal fifth fracture,AVN rate 100%; proximal third fracture:AVN rate 33%

• waist:middle of the scaphoid fractures have healing rates of 80-90%

• distal pole:distal third fractures have healing rates close to 100% n

L J

Figure 24. ORIF left scaphoid

+

Activate Windows

Go to Settings to activate Windows.

OR25 Orthopaedic Surgery Toronto Notes 2023

Hand Ulna Radius

'

Scaphoid

Trapezium

•Trapezoid

**Capitate

Lunate

• sec Plastic Surperv. PL24

Triquetrum

Pisiform ^

Hamate

^

Spine

3

; n

Spinous

process Metacarpal

bones(1-5)

.-1

Lamina Transverse

process Pedicle Neural arch Superior

articular

process

u- u

©Hisheva Merci

Figure 25. Carpal bones

1/

/

V- •

V- iVertebral '

y

body

Order of Carpal Bones

So Long To Pinky. HereComes The

Thumb

Proximal Row:Scaphoid. Lunate.

Triquetrum. Pisiform (Lateral to Medial)

Distal Row:Hamate.Capitate.

Trapezoid.Trapezium (Medial to Lateral)

Transverse

-

•

- -ri:

Pedicli

ir

-

1M

Vertebral

foramen

8

Inferior

articular process

Spinous Vertebral

process

s

'J*

.

1a.

body

Left Lateral View Superior View

Figure 27. Schematic diagram of vertebral anatomy

Adapted fron:Moore KL Agi.r AMR.Essential Clinical Anatomy,3rd ed. Philadelphia:Lippincott Williams and Wilkins.2007.p274

Fractures of the Spine

• see Neurosurgery. NS39

Compression Cervical Spine

General Principles

• Cl (atlas): no vertebral body, no spinous process

• C2 (axis):odontoid = dens

• 7 cervical vertebrae; 8 cervical nerve roots

• nerve root exits above vertebra (i.e. C4 nerve root exits above C4 vertebra), C8 nerve root exits below

C7 vertebra

• radiculopathy = impingement of nerve root

• myelopathy = impingement of spinal cord Burst

Special Testing

• compression test: pressure on head worsens radicular pain

• distraction test: traction on head relieves radicular symptoms

• Valsalva test: Valsalva maneuver increases intrathecal pressure and causes radicular pain

• Lhermitte Sign: electric shock sensation radiating to back upon forward flexion of the neck,some

etiologies include multiple sclerosis, cervical myelopathy, and B12 deficiency

• occiput-wall distance (OW'

D):patient stands against a wall with erect posture and distance between

the occiput and the wall is measured, value greater than 2 cm is abnormal, indicative of thoracic

hyper-kvphosis

Fracture-dislocation

Figure 26. Compression, burst, and

dislocation fractures of the spine

Table 14. Cervical Radiculopathy/Neuropathy

Root C5 C6 a C8

Deltoid

Biceps

Biceps

Brachioradialis

Wrist extension

triceps

Wrist flexion

Finger extension

Index and middle finger Bing and little finger

Motor Interossei

Digital flexors

Sensory Axillary nerve (patch over thumb

lateral deltoid)

Reflex Biceps Biceps

Brachioradialis

triceps Finger jerk

+

Activate Windows

TJO to Settings TO activate Windows.

OR26 Orthopaedic Surgery Toronto Notes 2023

X-Rays for C-Spine

• AP spine:alignment

• AP odontoid:atlantoaxial articulation

• lateral

vertebral alignment: posterior vertebral bodiesshould be aligned (translation >3.5 mm is

abnormal)

• angulation:between adjacent vertebral bodies(>11° is abnormal)

disc or facet joint widening

anterior soft tissue space (at C3 should be S3 mm:at C4 should be <8-10 mm)

• oblique:evaluate pedicles and intervertebral foramen

• ± swimmer’

s view:lateral view with arm abducted 180“ to evaluate C7-T1 junction if lateral view is

inadequate

• ± lateral flexion/extension view: evaluate subluxation of cervical vertebrae

Differential Diagnosis of C-Spine Pain

• neck muscle strain, cervical spondylosis, cervical stenosis, RA (spondylitis), traumatic injury,

whiplash, myofascial pain syndrome, acute discogenic nerve root entrapment, infection, fracture,

neoplasm, pain from soft tissue structure

C-SPINE INJURY

• see Neurosurgery. NS38

Thoracolumbar Spine

General Principles

• spinal cord terminates at conus medullaris (Ll /2)

• individual nerve roots exit below pedicle of vertebra (i.e. L4 nerve root exits below L4 pedicle)

Special Tests

• straight leg raise: passive lifting of leg (30-70“

) reproduces radicular symptoms of pain radiating down

posterior/lateral leg to knee ± into foot

• Lasegue maneuver: dorsillexion of foot during straight leg raise makessymptoms worse, or if leg is

less elevated, dorsillexion will bring on symptoms

• femoral stretch test: with patient prone. Hexing the knee of the affected side and passively extending

the hip results in radicular symptoms of unilateral pain in anterior thigh

Table 15. Lumbar Radiculopathy/Neuropathy

Root L4 L5 S1

Motor Ouadnceps (knee extension hip

adduction)

Tibialis anterior (ankle Inversion •

dorsillexion)

Medial malleolus

Squat and rise

Knee (patellar)

Femoralstretch

Extensor hallucis longus

Gluteus medlus(hip abduction)

Peroneuslongus brevis (ankle eversion)

Gastrocnemius soleus (plantar (lesion)

Sensory

Screening Test

Reflex

lateral foot

Walking on toes

Ankle (Achilles)

Straight leg raise

1st dorsal webspace and lateral leg

Heel walking

Medial hamstring*

Test Straight leg raise

Differential Diagnosis of Back Pain

1.mechanical or nerve compression (>90%)

• degenerative (disc,facet,ligament)

• nerve root compression (e.g. disc herniation)

spinal stenosis (congenital, osteophyte, central disc)

2.others(<10%)

• neoplastic (primary, metastatic, multiple myeloma)

• infectious(osteomyelitis,TB)

• metabolic (osteoporosis)

traumatic fracture (compression,distraction, translation,rotation)

• spondyloarthropathies (ankylosing spondylitis)

referred (aorta,renal,ureter, pancreas)

DEGENERATIVE DISC DISEASE

• loss of vertebral disc height with age resulting in:

bulging and tears of annulusfibrosus

change in alignment of facet joints

osteophyte formation

n

c j