Finger Common Fractures MALLET FINGER( Baseball Finger)

Diane L. Gorgas, MD Associate Professor & Residency Director Department of Emergency Medicine • Avulsion of Extensor Digitorum Communis (EDC) Tendon from DIP joint The Ohio State University PITFALL – get the films • Can be associated with Avulsion Fracture

Common Fractures Finger ƒ Distal Upper Extremity MALLET FINGER – Fingers, Hand, Wrist • Mechanism of Injury: • Direct jam ƒ Proximal Upper Extremity • Forced flexion – Humerus, Shoulder, Clavicle • Dorsal dislocation of PIP ƒ Proximal Lower Extremity • Laceration – Hip, Femur • Splint ƒ Distal Lower extremity • Slight hyperextension for 6 weeks – Knees, Ankle, Feet • Night splint for additional 6 weeks • Best results if treated early

1 Jersey Finger Finger JERSEY FINGER • Avulsion injury of Flexor Digitorum Profundus (FDP) from volar base of distal phalanx • Examination: •FDP test - blocked flexion of DIP • Treatment - early surgical repair • Permanent disability if missed

Jersey Finger Neuro Hand Sensation • A pop or rip felt in the finger at the time of the injury ulnar • -Painwhen moving the injured finger and the inability to bend the last tjit joint radial • - Tenderness, swelling and warmth of the injured finger median • - Bruising after 48 hours • - Occasionally a lump felt in the palm of the finger

2 Neuro Hand Strength Boxer’s Fracture DEFINITION ulnar • Distal neck fx of 5th metacarpal • Volar displacement acceptable to 45 degrees for office casting +/- closed reduction • Rotation deformity radial • Referral median • More than minimal valgus or varus displacement • Referral • PITFALLS – missing a fight bite

Boxer’s Fracture Boxer’s Fracture

3 Metacarpal Bones Thumb Immobilization BENNETT’S FRACTURE • Thumb Spica Splinting • Intra-articular fx at base of 1st metacarpal • Wide displacement due to pull of FPL • Fragment held in place by strong ligament

Wrist & Hand Injuries

• Scapholunate Ligament Injury – Most common and most crucial ligament injury of wrist. – Often leads to chronic pain and/or functional instability. PITFALL – Only looking for fractures

4 Scapholunate Ligament Injury Wrist Injuries • Scaphoid fractures – Most common carpal bone injury of wrist. – Can be radiographically occult – PITFALL - splint – Can lead to avascular necrosis of scaphoid if unrecognized.

Terry Thomas/David Wrist Injuries Letterman • Triquetral Fractures – Second most common fracture – PITFALL – not looking at Lateral film

5 “Wrist” Injuries Supracondylar Fracture

• Distal radius/ulna • Mechanism: fall injury patterns on flexed elbow Colle’sfractures s fractures • PITFALL; Smith’s fractures – median nerve (reverse Colle’s) injury PITFALL- R,M,U – Brachial disruption 8% artery injury

Elbow Fractures Humerus Fractures

• Radial Head Fracture – Sail Sign – PITFALL- – No boney abnormality, no fracture

6 Humerus Fractures Clavicle Fracture • PITFALL - Radial Nerve • PITFALLS • Transection ƒ CHECKING FOR VASCULAR • Neuropraxia INTEGRITY ƒ ASSOCIATED INJURIES ƒ SKIN TENTING

Clavicle Fracture Shoulder Dislocations

7 Shoulder Dislocations Knee Injuries • Anterior ƒ Most common •Scaphoid deformity •Flexed and adducted • Posterior ƒ Seizures ƒ PITFALL – not controlling seizures • Inferior/Thoracic

Hip Fractures Knee Injuries

• PITFALLS ƒ Recognizing • Patella Alta - PITFALL Occult • Patellar fractures – fractures PITFALL – check ƒ Addressing extensor mechanism high morbidity

8 Common Knee Fractures Ankle Fractures • Bi and Tri malleolar fractures • Mortis disruption • Misnomer

Mechanism of Ankle Ankle Fractures Injuury • PITFALL • Inversion + Plantarflexion= 80% sprains – Examining the joint above and – Most commonly involve the Anterior below Talofibular Ligament. • Inversion or Eversion alone • Landing on unsteady object • Change of Direction – Deceleration associated • Manual Twisting – Wrestling injury

9 Proximal 5th Metatarsal Palpation Common Fractures in • Test of 5th Metatarsal Avulsion Orthopedics – Occurs most commonly with inversion – Peroneus Brevis pulls styloid off of Michael Quackenbush, DO 5th Metatarsal Assistant Professor Orthopaedic Trauma – PITFALL - Palpate at styloid for pain. Ohio State University Medical Center • If positive for pain should X-ray.

5th Metatarsal Fractures Adult Common Fractures Objectives

1. Recommend an approach to the • Jones versus evaluation of patients who present with pseudo Jones a fracture 2. Identify operative and non-operative ƒ PITFALL – injuries commonly seen in orthopedics nonreferal of 3. Describe basic surgical treatment options for fractures Jones 4. Understand goals of surgery and what your patients can expect during post operative period

10 Evaluation Clinical Evaluation • Patients age • Need to closely exam the • History soft tissues around the – Time of injury fracture – Mechanism of injury • Look for openings in the – “What hurts hurts” skin – which may • Medical History indicate an “open” • Surgical History fracture • Social Hx (occupation) • Medications • Abrasions? Amount of (anticoagulation) swelling? Presence of • Smoking/Alcohol history fracture blisters?

Physical Examination Clinical Evaluation • Soft tissue care • Look for deformity – Primary goal is to halt • Palpate areas of continuing trauma to the tenderness tissues • Examine the joint – Treatment of fractures first above and below begins with “reducing” the • Detailed neurologic fracture or dislocation and vascular – Immobilizing the fracture examination with a splint or external fixation

11 Clinical Evaluation Imaging Studies • Soft tissue care • Some instances plain x-rays do not define the fracture well – Primary goal is to halt – Joint injuries with multiple fragment continuing trauma to the => CT scan tissues – OltftOccult fractures – Treatment of fractures first begins with “reducing” the fracture or dislocation – Immobilizing the fracture with a splint or external fixation

Imaging studies Special Studies • Elderly patients with hip pain => MRI can • Radiographic assessment of fractures diagnose an occult hip • Begins with plain x-rays fracture – 2 view s at l east • Occult Fractures – AP (anteroposterior) and lateral – Bone Scan views • Sensitivity 100% – Joints above and below as some of @ 72hrs the energy can be absorbed at a site – MRI away from the injury • Sensitive in first 24 hrs

12 Now that we have a diagnosis, Treatment where do we go from here? Options

Non Operative Operative Management Management

Plate External Joint Splint Cast and Nail Fixator Replacement Screws

Treatment Treatment Options Options

Non Non Operative Operative Operative Operative Management Management Management Management

Plate Plate External Joint External Joint Splint Cast and Nail Splint Cast and Nail Fixator Replacement Fixator Replacement Screws Screws

13 Treatment Treatment Options Options

Non Non Operative Operative Operative Operative Management Management Management Management

Plate Plate External Joint External Joint Splint Cast and Nail Splint Cast and Nail Fixator Replacement Fixator Replacement Screws Screws

Treatment Fractures that require Options surgical intervention

• “Open” fractures

Non Operative • Irreducible Operative Management Management fractures or dislocations • Displaced intra- Plate External Joint articular fractures Splint Cast and Nail Fixator Replacement Screws

14 Fracture Healing Goals of Surgery • In general all adult fractures take 6-8 weeks to heal with or without surgical • Decrease pain intervention • Some fractures have longer healing • Fix fracture/Replace with prosthesis times • Early return to function – Open fractures • Early mobility – – Fractures in patients with diabetes PT/Strengthening/ROM – Intra-articular (joint) fractures • Return to work – Fractures in bones with poor blood • Return to life supply (scaphoid, talus, tibia)

Examples of Common Primary Goals Fractures

• Immobilize (let soft tissues relax) • Pain control • Ice and elevation • Upper extremity – sling • Lower extremity – crutches/walker • Urgent orthopedic follow up

15 Metacarpal Fractures Metacarpal neck fractures • ~3% of all fractures • Extra-articular fxs • >50% work related – Some angulation, shortening accepted (more • Less frequent, MVC, in littl e/ ri ng, l ess w/ recreation, index/long fingers), but household injuries rotation need to be • Border digits most corrected common • “Boxer’s fracture” – ulnar gutter splint 10-14 days

Evaluation Distal Radius Fractures • Physical exam • Common sites of injuries – Range of motion • Most common fx of the UE – Rotational deformity • 8-17% all bony injuries – Associated soft- tissue injury – Neurovascular examination

16 Classification Classification Fracture Pattern Fracture Pattern

Stable Unstable

Amenable to Requires definitive closed reduction fixation to achieve/maintain and casting Radiographic parameters treatment

Classification Fracture Pattern

Stable

Amenable to closed reduction and casting treatment

17 Common Fractures • Clavicle fractures – Vast majority heal with simple immobilization with sling for comfort – Begin early range of motion (1-2 weeks) – 6-8 weeks back to full activities

18 Proximal humerus fractures • 4-5% of all fractures • Most fxs (80-85%) min displaced • Bimodal distribution – Young high energy injury – Older pt, low energy injury, osteoporotic bone

Common Fractures about the hip Displaced or Non-displaced

Femoral neck fracture

Intertrochanteric

Hip fracture

19 Incidence Femoral neck fractures

• 250,000 Hip Fractures/year • Double by 2040 to 500,000

Etiology Femoral neck fractures • Osteoporosis • Low energy fall • 90% >65y/o • Peak @ 80y/o • F>M

• High energy fxs – More rare

20 Femoral neck fractures Intertrochateric Hip Fractures

Intertrochateric Hip Why fix? Fractures • Early mobilization – WBAT POD 1 – Prevents prolonged bedrest – Decreased bed sores – Decreased pneumonia – Decreased pain • Function – 40% Pre-Injury Ambulatory Status

Osteoporos Int. 2000;11(12):1018-23 J Gerontol A Biol Sci Med Sci. 1999 Dec;54(12):M635-40

21 Fractures around the knee Fractures around the knee • Supracondylar / intracondylar – Longer period of distal femur fractures NWB (typically 3 months) • Tibial plateau fractures postoperatively • “Joint” or “intra-articular” due to joint fractures fixation – Recommend surgical – Early range of ORIF for majority of motion to prevent fractures due to joint knee involvement contractures

Fractures around the knee Foot and Ankle Fractures

• Foot and ankle trauma is common • 25% of all traumatic injuries • Significant time loss from work – Foot required for walking

22 Nonoperative Treatment Metatarsal Fractures • Indicated for some • Treatment usually isolated lateral nonoperative malleolus fractures – WBAT in fracture boot • Symptomatic: – Early ROM – Hard shoe exercises / PT – Walking cast – Takes ~6-8 weeks – Elastic bandage to heal

Ankle fractures Lisfranc Injuries • Surgical intervention indicated for • Up to 40% overlooked on – Medial malleolus fractures initial radiographs – Bimalleolar and • High index of trimalleolar fractures suspicion • Patients instructed to be • Xrays may show non-weight bearing for 8 minimal weeks after surgery (longer if associated ligmentous displacement vs injury) complete • 3-6 month recovery time disruption

23 Take Home Points • Begin with thorough clinical evaluation • Obtain appropriate radiographs • Splint/Immobilize • Patients should be prepared for a “long” recovery time • Surgery provides early ROM, predictive healing, better functional outcome

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