Dafydd Loughran FY2 Wrexham Maelor

13/5/14

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* Understand the relevant anatomy

* Build confidence using management principles

* Recognise common fracture patterns

* Competently describe radiographs

* The Mnemonic…

Some Lovers Try Positions That They Cant Handle

Scaphoid, Lunate, Triquetrium, Pisiform, Trapezium, Trapezoid, Capitate, Hamate.

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* Nerves – Median, Ulnar, & Radial nerves

* Muscles – As determined by nerve function

* Vessels – Radial & Ulnar arteries, & assess for compartment syndrome

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* Median Nerve – At carpal tunnel in Forearm #

In antecubital fossa in Supracondylar # of Humerus

* Ulnar Nerve - # of Medial epicondyle of humerus

* Radial Nerve – Radial neck #

(Humeral shaft #)

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* Each nerve has an area that is solely provided by that nerve and so sensation should be checked here:

* Median nerve: Volar aspect of index finger

* Ulnar nerve: Volar aspect of little finger

* Radial nerve: Dorsum of first web space

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* Median nerve (flexors and LOAF muscles): Test Abductor pollicis brevis by asking patient to resist pushing thumb into palm

Anterior interosseous nerve (branch of median nerve arising at elbow) tested by ‘OK sign’ – tests Flexor pollicis longus, and is crucial to test especially in supracondylar fractures

* Ulnar nerve (intrinsic muscles of hand, flexor carpi ulnaris & half of

flexor digitorum profundus): Test finger abduction by patient resisting pushing fingers together

* Radial nerve (extensors): Test by finger extension and wrist extension against resistance

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* Palpate radial and ulnar nerve * Is the hand warm & well perfused? * Is there good capillary refill (<2sec)?

* Is there a risk of compartment syndrome? Predominantly clinical diagnosis requiring prompt management. High index of suspicion if increasing pain, or if pain exacerbated by passive stretch of the muscles •  Immediate senior involvement •  Split cast if already casted •  Decision to be made re fasciotomy

* ATLS Protocol • ABCDE

Neurovascular status • Autogenous zones • Focused muscle power testing • Pulses / Perfusion / Compartment syndrome

Open / Closed fracture • IV antibiotics (Co-amoxiclav) • Check tetanus status – booster if in doubt • Remove large debris then photograph and cover until formal washout & closure

Definitive fracture management +/- Medical optimisation • ?Conservative • ?Operative • Decisions depend of fracture pattern but vary depending on comminution, translation, angulation & rotation

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!  Colles #

!  Smith’s #

!  Barton’s #

!  Chauffer’s #

! Scaphoid #

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* Fracture of distal radius with dorsal displacement of hand * Usually from fall on outstretched hand (FOOSH) * Named after Abraham Colles, Irish Surgeon, who

recognised the classic deformity before the existence of Xrays * Instability criteria which increases the likelihood for

requiring operative management: 1.  Dorsal tilt > 20deg 2.  Comminuted #

3.  Abruption of ulnar styloid process 4.  Intra-articular displacement >1mm 5.  Loss of radial height >2mm

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* Fracture of distal radius with volar displacement. * Fall onto flexed wrist * Named after Robert William Smith, also an

Irishman, who got involved in an academic argument with Colles regarding the position of the so called Colles #. (Also described neurofibromatosis 33years before von Recklinghausen did so and named it after himself.) * Simplified management principles:

•  Undisplaced = Cast • Mild angulation/displacement = Attempted closed

reduction •  Significant angulation / displacement = ORIF

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* Intra-articular fracture of distal radius with dislocation of the radiocarpal joint (these are the 2 features distinguishing from Colles/Smith)

* Can be either volar Barton (more common) or dorsal Barton

* Management is usually ORIF

* For a change he was an American

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* Intra-articular Radial styloid process #

* Due to compression of scaphoid against the styloid process of radius

* Name originates due to hand crank on old fashioned cars backfiring from drivers grasp and striking back of wrist

* Now more commonly after FOOSH

* *  Commonest Carpal #

*  Pain in anatomical snuffbox

*  # often not visible initially – if clinical suspicion then cast & reimage at 10 days.

*  Risk of avascular necrosis (AVN) as it receives supply from lateral & distal branches of radial artery that then flow retrograde to proximal pole.

*  Risk of AVN much greater (30%) if proximal pole #.

*  Management:

•  Conservative if: Less than 1mm displacement waist (mid-part)

Immobilise in cast for 9-12/52

•  Internal fixation if: Displaced >1mm, or radiolunate angle >15deg, or scapholunate angle >60deg

•  Internal fixation if: Open Fracture

•  Internal fixation if: Perilunate dislocation

•  Internal fixation if: Proximal pole fracture

* * 28yr male attends following high velocity RTA

* Frontal impact to chest and abdomen then ejected from car

* Severe right arm pain, increasingly SOB

* Obs on arrival: T37.2C, HR 115, BP115/80, RR27, SpO2 90% on Air

Describe your step by step management plan…

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* Know the anatomy and use it to think what might be at risk.

* Follow structured management principles

* Always consider associated injuries and follow ATLS protocols

* Thoroughly assess neurovascular status and be vigilant of compartment syndrome

* Recognise the common fracture patterns so that anticipating definitive management plans is easier

Any questions?