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Showing posts with label Musculoskeletal. Show all posts
Showing posts with label Musculoskeletal. Show all posts

Thursday, April 29, 2021

HUMERAL SHAFT FRACTURES

HUMERAL SHAFT FRACTURES


HUMERAL SHAFT FRACTURES
Injury To The Upper Arm
Whenever a patient presents with a possible humeral fracture, inspect the upper arm for swelling, ecchymosis, deformity, and open wounds. Palpate the area of maximal tenderness, and assess the joint above (shoulder) and below (elbow) for injury. Always perform a thorough distal neurovascular examination. After a fracture of the humeral shaft, the arm should be supported and immobilized.
When gross fracture angulation occurs, emergency care personnel should restore overall alignment of the arm by applying longitudinal traction. This is best accomplished with conscious sedation of the patient to avoid patient guarding and muscle spasm that may prevent adequate reduction of the fracture. Once the fracture is reduced, someone must maintain alignment of the fracture manually while a well-padded splint is applied to the arm to provide stability and maintain the reduction. For humeral shaft fractures, a coaptation splint typically works best. The entire injured limb can then be placed in a sling for added comfort.


HUMERAL SHAFT FRACTURES

Fracture Of Shaft Of Humerus
Fractures of the humeral shaft are generally due to direct trauma and can present as different fracture patterns, such as transverse, spiral or oblique, and comminuted. Nonsurgical treatment is acceptable in most instances, but the choice of treatment is based on the type and location of the fracture, concomitant injuries, and age and condition of the patient. For closed fractures, a coaptation splint or a collar and a lightweight, hanging arm cast may be placed initially. About 10 days after injury, when the initial swelling has subsided, the patient is fitted with a fracture brace, which allows the patient to exercise the hand, wrist, elbow, and shoulder while maintaining fracture alignment.
INJURY TO THE ELBOW

INJURY TO THE ELBOW


INJURY TO THE ELBOW
Injuries of the elbow range from nondisplaced fractures to complex fracture-dislocations. When a patient presents with an elbow injury, inspect the elbow and forearm for swelling, ecchymosis, deformity, and wounds such as abrasions or lacerations that could raise concern for an open injury. Palpate the area of maximal tenderness, and assess the joint above (shoulder) and below (wrist) for additional areas of tenderness that could suggest other injuries.
INJURY TO THE ELBOW

Palpation can also be utilized to detect for the presence of a joint effusion associated with the injury. An effusion is, again, most easily noted by palpation over the posterolateral “soft spot” of the elbow. Elbow range of motion may be limited after an acute injury owing to pain or because of the presence of a fracture or dislocation. A thorough distal neurovascular examination is mandatory to determine if damage has occurred to any neurovascular structures from the injury. After an elbow fracture, the elbow show be supported and immobilized with a well-padded posterior elbow splint incorporating both the upper arm and forearm. The entire injured limb can then be placed in a sling for added comfort.
FRACTURE OF DISTAL HUMERUS

FRACTURE OF DISTAL HUMERUS


FRACTURE OF DISTAL HUMERUS
In adults, fractures of the distal humerus often require surgical fixation because they are usually caused by a high-energy injury and frequently are comminuted and/or intra-articular in location. Fracture patterns include supracondylar, transcondylar, intercondylar (T or Y), lateral or medial condyle, or epicondyle and isolated capitellar or trochlear fractures. Intra-articular fractures may be difficult to adequately assess on plain radiographs; therefore, CT scans may be needed.
Surgical fixation can be with plates and screws, or screws alone, depending on the particular fracture pattern. Joint replacement has also become an option for distal humerus fractures that may be too comminuted to be stabilized with plates and screws.
FRACTURE OF DISTAL HUMERUS

Complex Intra-articular Fractures
Comminuted intra-articular fractures of the distal humerus are among the more challenging orthopedic injuries, and their reconstruction requires considerable surgical skill (see Plate 2-21). The major complications include restricted elbow motion and early degenerative joint disease.
FRACTURE OF HEAD AND NECK OF RADIUS

FRACTURE OF HEAD AND NECK OF RADIUS


FRACTURE OF HEAD AND NECK OF RADIUS
Fractures of the radial head occur primarily in adults, whereas fractures of the radial neck are more common in children. The usual causes of these injuries are indirect trauma, such as a fall on the outstretched hand, and, less commonly, a direct blow to the elbow. Radial head and neck fractures are generally classified into four groups. In type I fractures, the fracture is nondisplaced or minimally displaced. Type II fractures refer to displaced fractures of the joint margin or neck with a single fracture line. Type III fractures are comminuted fractures of the head or neck. Type IV fractures are associated with dislocation of the elbow.
RADIAL HEAD AND NECK FRACTURES

Diagnosis of a radial or neck head fracture may be difficult. Pain, effusion in the elbow, and tenderness to palpation directly over the radial head or neck are the typical manifestations. If the fracture is displaced, a “click” or crepitus over the radial head or neck is detected during forearm supination or pronation. Radiographic findings in nondisplaced fractures are minimal, and the radiograph often shows only swelling in the elbow with a fat pad sign. Any radiographic evidence of fat pad displacement accompanied by tenderness over the radial head or neck strongly suggests a fracture.
FRACTURE OF OLECRANON

FRACTURE OF OLECRANON


FRACTURE OF OLECRANON
Olecranon fractures are caused by a direct blow to the elbow or an indirect avulsion injury, such as a fall on an outstretched hand while the triceps is contracting. Nondisplaced fractures of the olecranon can be treated with posterior splinting or a cast, but displaced fractures are best stabilized with open reduction and internal fixation. 
FRACTURE OF OLECRANON

These fractures are typically intra-articular; therefore, care should be taken to appropriately reduce and align the joint surface during surgical fixation, regardless of technique utilized. Fixation with a tension band wire using screws or Kirschner wires is common in more simple fracture patterns. The tension band technique acts to convert the tensile forces through the fracture that are causing displacement into compressive forces that will allow fracture reduction and healing. If the fracture is too comminuted or too distal (extends to the coronoid or proximal ulnar shaft), a tension band technique is typically not adequate for fracture stability. Interfragmentary compression utilizing plate fixation is the preferred method of treatment in this situation. Precontoured plates that match the anatomy of the olecranon are now available and routinely used. The plate is positioned along the subcutaneous border of the ulna, however, and may require removal after fracture healing owing to its very superficial location.
DISLOCATION OF ELBOW JOINT

DISLOCATION OF ELBOW JOINT


DISLOCATION OF ELBOW JOINT
Dislocations of the elbow joint are the most common dislocations after those of the shoulder and finger joints. Swelling, pain, and pseudoparalysis of the arm are acute signs and symptoms of dislocation, and elbow deformity is visible on both clinical and radiographic examinations.
DISLOCATION OF ELBOW JOINT

Acute elbow dislocations are classified as anterior or posterior, with the direction determined by the position of the radius and ulna relative to the humerus. In addition to the anterior or posterior direction of dislocation, the forearm bones can also be displaced medially or laterally. Posterior elbow dislocations are by far the most common type and usually result from a fall on an outstretched hand. The rare, but extensively studied, anterior dislocation of the elbow is usually an open injury and may lacerate the brachial artery. Rarely, the radius and ulna dislocate in different directions, an injury called a “divergent” dislocation.

Monday, April 19, 2021

COMPLICATIONS OF FRACTURE

COMPLICATIONS OF FRACTURE


COMPLICATIONS OF FRACTURE
A major objective in the management of fractures and dislocations is to avoid as many complications as possible. The principles of fracture treatment direct the surgeon to reduce the fracture and immobilize it with a cast/splint or internal/external fixation devices, to allow natural healing to occur. A variety of complications, either as a consequence of the injury itself or as a consequence of treatment, can produce serious and permanent problems. Acute complications such as damage to nerves and blood vessels, adult respiratory distress syndrome, and infection usually arise from the injury itself. Complications also develop during the healing process and may lead to irreparable loss of function. Chronic complications include failure of union, deformities, osteoarthritis, joint stiffness, implant failure, and reflex sympathetic dystrophy.

COMPLICATIONS OF FRACTURE

Neurovascular Injury
Displacement of fracture fragments or bone ends at a dislocated joint often produces compression or laceration of adjacent vessels and nerves. Critical neurovascular structures (e.g., the brachial plexus) lie deep in the limb, close to the skeleton, which protects them from injuries. A fracture or dislocation makes nerves or vessels vulnerable to injury from sharp bone fragments or from entrapment in the fracture site.
ARTHRITIS

ARTHRITIS


ARTHRITIS
Primary osteoarthritis of the elbow is uncommon, unlike in the hip and knee; and the need for joint replacement in the elbow is much less common than the hip, knee, and shoulder. Elbow arthritis often develops in patients who repetitively load the joint, such as heavy laborers or athletes. It more commonly occurs in males and in the dominant extremity. Symptoms typically include pain and loss of motion. Pain typically occurs at the end ranges of motion, particularly terminal extension, from impingement due to osteophytes. Pain through the midrange of elbow motion is much less common but may develop if the articular cartilage loss is severe enough.
Other common causes of elbow arthritis include inflammatory conditions, most commonly rheumatoid arthritis, and trauma, most commonly after an intra-articular fracture. The elbow is a common site of involvement in rheumatoid arthritis, but the pharmacologic advances in treatment of this disease have made the progression of arthritis and symptoms much less severe. Although advances in implants have helped in the surgical treatment of intra-articular elbow fractures, post-traumatic arthritis can still occur.
Nonoperative management of elbow arthritis is the initial treatment and includes activity modification, range-of-motion exercises, use of braces and other support devices, intra-articular cortisone injections, and administration of nonsteroidal anti-inflammatory drugs or disease-modifying antirheumatic drugs.
IMAGING OF OPEN AND ARTHROSCOPIC ELBOW DEBRIDEMENT
IMAGING OF OPEN AND ARTHROSCOPIC ELBOW DEBRIDEMENT

Initial surgical treatments for elbow arthritis include open or arthroscopic debridement procedures (see Plate 2-33). These surgeries are done to improve pain and range of motion, and may include removal of loose bodies, osteophyte resection, capsular release or excision, and synovectomy. Recovery time can be shorter after an arthroscopic debridement, but there is a potential risk of neurovascular injury with this technique.

ANATOMY PHYSIOLOGY

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