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ASHT 2013 Review of Adult Fractures Distal Humerus to Distal Phalanx

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ASHT 2013 Review of Adult Fractures Distal Humerus to Distal Phalanx ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx DISCLOSURE ASHT 36th Annual Meeting REVIEW OF ADULT FRACTURES Emily Altman, PT, DPT, CHT, OCS, CLT DISTAL HUMERUS TO DISTAL PHALANX Physical Therapist Hospital for Special Surgery New York, NY, USA Emily Altman, PT, DPT, CHT, OCS, CLT I have no financial relationships to disclose within the past 12 October 24, 2013 months relevant to my presentation 1 2 THANK YOU! HANDOUTS Robert Hotchkiss, MD Thomas Owen, MD www.handtherapyhub.com Nina Suh, MD Eugene Ek, MD • PDF of Powerpoint Edward Athanasian, MD • Reference List Aaron Daluiski, MD • Fracture Readings Kate Neighbors, PAC Contact: [email protected] Andrew Ghatan, MD 3 4 PROMISED LEARNING OBJECTIVES Ò Describe the fundamental principles of fracture healing Ò Describe the path of deforming forces seen in an Essex-Lopresti fracture Ò Explain to a patient why elbow extension against resistance is not permitted following repair of an olecranon fracture Ò Verbalize why a proximal phalanx fracture assumes an apex volar posture Ò Explain the pathomechanics of a Bennett’s fracture Ò Recognize how to find information regarding orthopedic fractures in relevant, up-to-date literature 5 6 1 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx FRACTURE UNIVERSITY BIG PICTURE OBJECTIVES Ò Educate ourselves about upper extremity Ò Improve our understanding of the physics fractures of fractures É How do fractures behave? Ò Understand the anatomical basis É What do they look like? of what we do Ò Build a knowledge base to guide our Ò Basic x-ray appreciation skills treatment decisions and progressions Ò Create an on-going project Ò Encourage informed communication with referring surgeons 7 8 WHAT THIS IS NOT… Ò A condensed orthopedic residency program Ò A radiology fellowship Ò An orthopedic surgeon’s continuing education course Ò A lecture given by an orthopedic surgeon Ò Learn to fix a fracture in 1.5 hours Ò A review of fixation techniques Ò Decision making for optimal surgical management Ò A comprehensive review Monash University, Victoria, Australia 9 10 BONE HEALING CORTICAL BONE Ò Ò Cortical bone Rupture of periosteum and endosteum Ò Ò Cancellous bone Formation of hematoma Ò Ò Bone under compression Periosteal and endosteal response results in bone deposition that proceeds toward the fracture Ò Collar of callus surrounds fracture Ò Callus=fibrous tissue, blood vessels, cartilage and bone. Remodels over time 11 12 2 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx CANCELLOUS BONE COMPRESSION Ò No callus formation Ò Little or no callus formation Ò Ò Fracture defect is bridged directly by osteogenic Direct osteoblastic bridging cells with little or no periosteal reaction. Ò Need direct contact of fragment ends Ò Vascular channels cross the fracture line directly Ò Intramembranous ossification Ò Immediate remodeling. Bone formation, deposition and resorption occur simultaneously as a result of osteoblastic and osteoclastic activity 13 14 FRACTURE MANAGEMENT PRINCIPLES CLASSIFICATION SYSTEMS Ò Characterize / describe features Ò Anatomic or near-anatomic position / reduction Ò Guide treatment decisions Ò Stability Ò Predict outcome Ò Minimally traumatic operative technique Ò Taxonomy: the naming and categorization of Ò Pain control things. A universal phenomenon Ò Early active motion Ò Hierarchy Ò Inherent variability in human observations 15 16 CURRENT USEFULNESS JUST 4 THINGS, EMILY Ò Useful for describing fractures Ò Open / closed Ò Useful as educational tools Ò Displaced / non-displaced Ò Not so useful for guiding treatment Ò Stable / unstable É Observer variability Ò Extraarticular / intraarticular Ò Not so useful for predicting outcomes 17 18 3 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx DISTAL HUMERUS FRACTURES DISTAL HUMERUS FRACTURES ANATOMY CLASSIFICATION Ò Intra-articular É Single column Ð Very uncommon É Bicolumnar Ð Most injuries of the distal humerus Ð All three limbs involved Ò Extra-articular intracapsular É Fracture exists in the joint capsule É No involvement of articular surface É The more distal the fragment the more difficult to neutralize Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition 19 20 Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition 21 22 Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition Nauth A, et al. Current concepts review: distal humeral 23 fractures in adults. J Bone Joint Surg Am. 2011;93:686-700 24 4 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx CHALLENGES CHALLENGES Ò Blood supply to the distal humerus diaphysis Ò Small , cancellous distal fragmentsà poor is entirely dependent on a single nutrient fixation potential vessel that terminates approximately 3-4 cm Ò Complex osseous anatomy makes plate above the olecranon fossa. contouring difficult Ò Hardware cannot violate articular surfaces of olecranon, coronoid, radial fossae Ò Osteoporotic bone 25 26 EXPOSURE Olecranon ORIF Pollock JW, et al. Distal humerus fractures. Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition Orthop Clin N Am. 2008;39:187-200 27 28 Wolfe SW, et al. Eds. Green’s Operative Hand Pollock JW, et al. Distal humerus fractures. Surgery. 6th Edition Orthop Clin N Am. 2008;39:187-200 29 30 5 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx CAPITELLUM/TROCHLEA Ò Capitellum É Somewhat rare É Type I: Hahn-Steinthal fracture Ð Large portion of bone É Type II: Kocker-Lorenz Ð Chondral surface, little bone Ò Trochlea É Rare in isolation Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition 31 CORONAL SHEAR FRACTURES Type III: multiple fragments Type IV Coronal Shear Fracture Type IV: coronal shear fracture Includes lateral trochlear ridge Double arc sign Wolfe SW, et al. Eds. Green’s Operative Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition Hand Surgery. 6th Edition 6 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx COMPLICATIONS CORONOID FRACTURES Ò Ò Nonunion Anatomy É Inadequate fixation Ò Infection Ò Ulnar neuropathy Ò Stiffness Ò Heterotopic Ossification 37 38 O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect Wolfe SW, et al. Eds. Green’s Operative 2003;52:113-134. Hand Surgery. 6th Edition 39 40 ANATOMY OF ELBOW STABILITY Ò Three primary static constraints É Anterior bundle of the MCL É LCL complex É Ulno humeral articulation Ò Secondary contraints É Radiocapitellar articulation É Common flexor tendon É Common extensor tendon É Capsule 41 42 7 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx TRAUMATIC ELBOW INSTABILITY Ò Valgus Posterolateral rotatory mechanism É As elbow dislocates posteriorly É Radial head +/or coronoid process can fracture as collide with the distal humerus. É Last structure injured is MCL Ò Varus Posteromedial rotatory mechanism É Fx of anteromedial facet of coronoid process with either a LCL injury, a fx of the olecranon or both. Ò Olecranon Fracture Dislocations Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition 43 44 POSTEROLATERAL ROTATORY INSTABILITY DISLOCATION TERMINOLOGY (VALGUS) Ò Dislocation=a complete disruption of the joint with loss of contact between the articulating Ò Results in dislocation of the elbow with or surfaces of adjacent bones. without a fracture of the radial head and coronoid Ò “Fracture Dislocation”=joint dislocation with Ò Fall on outstretched arm, creation of a significant a fracture. Priority is the valgus, axial and posterolateral rotatory force dislocation. Protect health of the articular at the joint cartilage. 45 Elbow dislocation and radial head fracture Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition 8 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx DISLOCATION+RH FX+CORONOID FX Ò Terrible triad Ò Tip of coronoid fracture É Does not extend into sublime tubercle É Anterior capsule attached to fracture fragment Ò Radial head fracture Ò MCL and LCL are usually disrupted Ò Size and location of coronoid fx, comminution of RH and severity of ligamentous disruption Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition 49 50 POSTEROMEDIAL ROTATIONAL INSTABILITY (VARUS) Ò Fall onto outstretched arm that creates a varus, axial and posteromedial rotational stress at the elbow. Ò Fracture of the anteromedial facet of the coronoid and either injury to the LCL or fracture of the olecranon. Ò Less common variant than PLRI Ò Bucholz RW, et al. Eds. Rockwood and May not be true dislocation (relationship of Green’s Fractures in Adults. 7th Edition articular surfaces may be maintained) 52 th Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6th Edition Wolfe SW, et al. Eds. Green’s Operative Hand Surgery. 6 Edition 53 54 9 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx Steinmann SP. Coronoid process fracture. J Am Acad Orthop Surg. 2008;16:519-529. 55 56 OLECRANON FRACTURES MAYO CLASSIFICATION Ò Anatomy Ò Mayo classification: 3 factors É Fracture displacement É Comminution É Ulnohumeral stability Bucholz RW, et al. Eds. Rockwood and Green’s Fractures in Adults. 7th Edition 57 58 59 60 10 ASHT 2013 Review of Adult Fractures Distal 10/22/2013 Humerus to Distal Phalanx RADIAL HEAD FRACTURES Ò Anatomy Ò Most common elbow fracture Ò Mechanism É Fall on outstretched hand Ð Load=axial, valgus, posterolateral rotation É Direct blow Ò Mason classification I-III, later IV 61 62 Wolfe SW, et al.
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