Dr. Dan Regev

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Dr. Dan Regev
Plastic Surgery Department
Rabin Medical Center

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BACKGROUND
•Forearm fractures- common limb fractures
•Upper, middle, lower shaft
MECHANISM OF INJURY
•Direct blow: fall + hyperextension / flexion
•Compression, shearing forces & avulsion
EPIDEMIOLOGY (USA)
•Upper limb fractures = 50% overall
•Forearm fractures = 1/3 of upper limb (distal = 17%)
2mm
Radiio-ulnar
inclination
20%
80%
axial load
ANATOMY
23º radial inclination
11º (lateral view)
anteversion
Epiphysis with slits
Metaphysis spongiotic
Thin cortices
BIARTICULAR
Scaphoid
fossa
Lunate
fossa
BICONCAVE

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EPIDEMIOLOGY
•Gender: Infants 2y boys
Adults women (osteoporosis)
•Race: less in blacks (less osteoporosis)
CAUSES
•Sports: skating, skateboarding, mountain
biking and contact sports
•Trauma: automobile collisions, blows with a
blunt object and child abuse
HISTORY
•Direct blow usually
PHYSICAL EXAMINATION
•Local pain, tenderness,
swelling
•Any wound over the
fracture = open fracture
(2 nd most common after
open tibial fractures)
Smith open fractures classification
I
II
III
IIIa
IIIb
Type Description
Clean wound

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NEUROLOGICAL EVALUATION
TPD / MTPD
5mm - OK
Ulnar
sensory
Radial
sensory
Median
ensory
*Misleading:
muscle & tendon
entrapment etc.
Radial Ulnar Median
VASCULAR EXAM
Allen test Capillary refilling
test

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PHYSICAL EXAM
Radial head #
Ulnar styloid #
Dorsal ulnar prominence
IMAGING
A-P
Lateral
Oblique
Post operatively
Also (completion)
3D: high velocity (young)
2D: extra articular

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Descriptive (symptomes & Rx):
Castaing, Frykman
Extension-compression:
Type Description
I Colles: 4cm prox. To palm; dorsal
fragmentation, angulation and
displacement + Radius shortening
II Partial = marginals
III T (frontal, saggital)
IV Composite = ex. articular
CLASSIFICATION
CASTAING CLASSIFICATION
Therapeutic:
Universal, Melone

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Flexion-compression:
Type Description
Smith I ex. art. ; palmar angulation
II int. art. ; palmar prox. Displace.
III ex. art. ; palmar displace.
Marginals Palmar = as Smith II
Dorsal = Barton’s
Medial = Die punch
Lateral = Backfire
Extra-articular
Radio-carpal
CASTAING CLASSIFICATION
FRYKMAN CLASSIFICATION
Lunate load #
Axial compression
& Lunate dorsal depression
Radio-ulnar
Radio-carpal-ulnar

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* Die punch
principle
I
II
III
IV
UNIVERSAL CLASSIFICATION
Type Description
Ex. art. , stable, for ex. reduction
Ex. art. , unstable, not for ex. reduct.
Articular, stable
IV a Artic. , stable, for ex. reduction
IV b Artic. , unstable, not for ex. reduct.
* Fracture reducibility
I
MELONE CLASSIFICATION
Type Description
Undisplaced = universal type III
II II a Stable, for external reduction
(50%)
Involved
lunate
III
(5%)
IV
V
(dorsal / palmar compression)
II b Unstable, 15% not for external reduction
(double die punch; fragmented radius)
Articular ant. displacement: neural &
vascular compression, cortical tear
180º rotation of articular fragments
Complicated reduction
Burst of diaphysis-metaphysis-epiphysis
Conservative treatment

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SPECIAL FRACTURES
Galeazzi fracture: # dist. 1/3rd Radius + Dislocation of RadioUlnar Joint
(DRUJ) = “reversed Monteggia” (x3 common)
When DRUJ overlooked – higher morbidity
1) Radius shortening by 5mm
2) # of ulnar styloid
3) Widening DRUJ space by 2mm
- or DRUJ subluxation
* Compare to other wrist; keep exact position!
Essex-Lopresti fracture: # dist. head of Radius + Radioulnar dislocation
with partial / complete tear of radioulnal
interosseous membrane
TREATMENT
Emergency: 1) Neurovascular compromise
2) Severe displacement
3) Tenting of the skin
Principles: 1) Articular anatomy restoration
2) Stability of wrist joint
3) Early mobilization

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1) Closed reduction:
- longitudinal traction
- palmar flexion
- ulnar inclination
METHODS
2) Direct nailing (ORIF):
- lowering consolidation time
and immobilization time (6-8w)
- for radial styloid, posteromedial fragments
and stbilizing the radio-ulna joint (pronosupination)
METHODS
3) Direct osteosynthesis (internal fixation):
- includes special plates and screws
- Anterior / posterior approach (if palmar large
bone loss)
- Can include bone graft (Radius, Iliac crest)
to stabilize fragments
4) External fixation:
- nesscitates preliminar closed reduction
- ligamentotaxis
- duration of 3-8w; if consolidates enough- remove & cast 2w
afterwards mobile cast
- technique: reduction under Rx vision
longitudinal traction -> neutralize articulation
palmar flexion?
mild extension (8º)
Stable fractures
No displacement
CI to surgery
Unstable
Few large
fragments
Unstable
Multiple fragments
Melone V
Unstable
Multiple fragments

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BACKGROUND
•Carpal fractures- only 25% of wrist fractures
•10% of hand injuries
MECHANISM OF INJURY
•Axial compression + wrist hyperextension
(fall with outstretched hand)
EPIDEMIOLOGY
•Common in adolescents
BASIC FUNCTIONS
1) Positioning
2) Regulating forces
3) Transmitting forces
ANATOMY
Metacarpals
Dist. row
Prox. row

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GREATER ARC:
Perilunate carpal bones
LESSER ARC:
Disruption of ligaments
* follows lunate contour
TRADITIONAL
CONCEPT
Two rows
(distal as one unit)
Scaphoid bridging
Between them
VULNERABILITY ZONES
BIOMECHANICAL MODELS
NAVARRO
TALEISNIK
Central = flex.-extens.
(radio-lunate, luno-capitate)
Lateral = radial dev. = volar rot.
ulnar dev. = neutral
Medial = pronation - supination
radial dev. = high pos.
ulnar dev. = low pos.
*Pisiform not included

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BIOMECHANICAL MODELS
LICHTMAN’S OVAL
RING CONCEPT
Two rows = one ring
Scapho-trapezial link
Triquatrio-hamatum link
Any disruption possible
WRIST KINEMATICS
•Wrist joint = three articular
•Proximal row with intracarpal motion (scaphoid – lunate)
•Distal row moves as one unit
•Pisiform does not contribute and not included
FLEXION / EXTENSION
Radio-carpal & mid-carpal joints
Rows angulate
Lunate moves the list; scaphoid – the most
RADIAL & ULNAR DEVIATION
Proximal row rotates in the sggital plane
Distal row angulates radial / ulnar
PRONATION & SUPINATION
Forearm bones function
Pron. - palmar RadioScaphoCapitate Lig.
Supin. - palmar UlnoLunate Lig.
dorsal RadioTriquetral Lig.
WEBER’S VIEW
Radial column – force bearing
Ulnar column – wrist control
(lunate position vs stable capitate)
PALMAR DORSAL
Radial Ulnar deviation
Prox. row – volar dorsiflex. flex.
Dist. row – dorsal volar flex.

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A WORD ABOUT INSTABILITIES..
•Static (per standard Rx) vs. dynamic (per stress views)
•Lunate position: Dorsal / Volar Intercalated Segmental Instability (DISI / VISI)
•Mayfield classification
DISI: 1) scapho-lunate dissociation; most common instability.
*In radial styloid #
disruption of scapholunate, scaphotrapezoid ligs., FCR floor & radiocarpal lig.
Pain & tenderness in snuffbox / dorsal scapholunate joint + clicks
Watson’s test (+ pain)
Rx: scapholunate space >+3mm (Terry-Thomas sign); scaphoid “cortical ring”
*comparison to other wrist
Tx: arthroscopic tear resection, K-wire pinning (3-4w), ligaments repair
& capsulodesis
2) Scaphoid non-union / mal-union: prox. & dist. Fragments move indipendently
Rx: high resolution CT scan
Tx: correct fusion
A WORD ABOUT INSTABILITIES..
VISI: 1) lunotriquetral dissociation; can lead to synovitis, arthrosis & wrist pain
Rx: may be normal (ulnar sided instabilities?)
*L-T lig. Disruption alone cannot produce VISI
Ulnar sided wrist pain motiom limit
Shear test (+ pain)
Tx: immobilization 4-6w inc. elbow, lig. debridement by arthroscopy
2) Radiocarpal dissociation; in rheumatoid arthritis
Compromise of dorsal radiocarpal capsule (inc. radiotriquetral lig.)
OTHERS: 1) Radiocarpal instabilities; dist. Radius # (DISI), arthritis (ulnar)
*Volar subluxation is rare
2) Perilunate fracture-dislocations: in the lesser arc; can include
greater arc and even distal radiolunate joint

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•Most fractured
•In young male adults
•Mechanism: fall, sport injury, MVA
•Isolated / combined with others
•Wrist extension = distal #
Blood supply: distal = distal pole (1/3)
dorsal = proximal 2/3
*prox. Pole – retrograde flow from
vessels distal to waist
(avascular necrosis – bad prognosis)
SCAPHOID FRACTURES
Trapezium
Trapezoid
articulation
History: radial wrist pain post fall with outstretched hand
Examine: pain in snuffbox, mild swelling
Rx: may be without signs (2%); A-P, Lat., oblique x2
compare to other scaphoid, repeat in 10-14d
SCAPHOID FRACTURES CLASSIFICATIONS
Horizontal
oblique
Russe
Stable
Transverse Vertical
oblique
Herbert
&
Fisher
Base
(tubercle)
Waist
Body
Radius
articulation

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Scaphoid fractures
Nonunion: wide # zone, sclerosis (resorption); shortening,
fragments discrepancy, angulation
Delayed union: wide # zone, NO sclerosis (after 4m)
Unstable: 1) displacement + any step-off v>=1mm
2) angulation
3) motion of fracture
4) association with carpal instability
Treatment: 1) Immobilization – stable & non-displaced
* Thumb spica cast – long, for first 6w, short afterwards
2) Internal fixation – unstable # & displaced
3) Bone grafting: only if severe comminution
Preiser’s disease: idiopathic avascular necrosis; ~40y old, steroid usage
Tx: revascularization / resection + prox. Row carpectomy
LUNATE FRACTURES
Possible #: body, palmar / dorsal
Tx: Cast immobilization (6w)
KienbÖck’s disease: avascular necrosis
From repeated trauma; male workers,
18-40y; short ulna; fragmentation-collapse-
-loss of carpal alignment-carpal arthrosis
TRAPEZIUM FRACTURES
Rare
Direct blows
Rx mostly enough
Closed vs. open reduction
TRAPEZOID FRACTURES
The list frequently injured
Dorsal dislocation by palmar
forces on M2
Anatomic reduction + stabilize.
CAPITATE FRACTURES
Rare
Prox. 2/3 (perilunate injuries)
Non-displaced # - immobilize
fragments – open reduction
TRIQUETRIUM FRACTURES
Common
With ligs. & bony damage
Mostly dorsal cortex chip fractures
Tx: immobilize for 4-6w.

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PISIFORM FRACTURES
Rare
Confines FCU
Immobilize (if needed)
HAMATE FRACTURES
Body #; association with other wrist pathology
Hamulus #; seen in golf, squash, tennis;
Deep ulnar pain, aggrevated by activities
Body exam: tenderness over hamate
painful D5 abduction
Internal fiixation
Often progress to non-union
BACKGROUND
•Most common fractures (10% of all fractures)
•In the US more than 16 million per year
MECHANISM OF INJURY
•Different trauma patterns: fist / open hand, with
associated injuries (wounds, foreign bodies)
EPIDEMIOLOGY
•In all age groups
•In small children – suspect abuse

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HISTORY
Trauma pattern: occured in dirty / clean place
associated crush injuries
hand position at injury
high preesure injection
jewelry on fingers
* fist / open hand
* lacerations (over MCP?)
* fist in mouth
Domiant hand and hobbies
Dist. phalanx
Middle phalanx
Prox. phalanx
Metacarpals
ANATOMY
Thumb-Trapezium free articulation
D4-5 with 20-25º of A-P movement
D2-3 with minimal flex.-ex.

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FINGER FRACTURE
Intra / extra articular, stable / unstable
Very precise reduction (rotation error)
Closed reduction if possible (tendons & ligs.)
usually with k-wire
For a cast: alignment ±10º
no rotation error
maintan flex.-ex. Balance
no bone tissue loss
normal finger gross appearance
DISTAL PHALANX FRACTURES
•Common d/t crush injury
•Min. displacement – simple splint
•Damage to fingernail : hematoma, laceration
repair lacerations
*clear fractured surface from nailbed tissue
•In children may be through growth plate
Wide epiphysis

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MIDDLE PHALANX FRACTURES
•Condylar #: closed reduction + k-wire
if open reduction: fine screw
•Shaft #: unstable (FDS)
closed reduction + k-wire + splint
PIPJ #: most serious (volar plate)
bad comminution
closed fixation (trans art. Pins)
early mobilization (after 3-4)
PROXIMAL PHALANX FRACTURES
•Unstable
•Most accurate reduction (intra-articular)
•Shaft # (transverse, oblique) - ant. angulation
•MPJ #: nesscitates + stabilization

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METACARPAL FRACTURES
•Shaft #: oblique shortens, trans. angulates & spiral - rotates
•Goals for reduction:
- No rotational error
- less 3mm shortening
- angulation up to 15º
unstable
- surface contact >50% of all bone fragments
•Usually closed reduction
•Neck #: most common D5 neck #
- Reduction by k-wire
•Head fracture: uncommon; Tx as discussed above.
METACARPAL THUMB FRACTURES
Neck #
Bone loss
•Head & shaft #: stable; k-wire debridement after long. traction
•Angulation

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A WORD ABOUT JOINT DISLOCATIONS..
PIPJ: dorsal dislocation; hyperex.+longitudinal compression
Simplecomplex fracture-dislocation (most unstable)
Simple & complex- immobilization 3-4w
Fracture-dislocation (volar plate tear)- immobilization or
K-wire or even open reduction (volar plate arthroplasty)
Lateral dislocation; collat. Lig. rupture & volar plate tear
small rupture – body taping 4-6w; major- surgical repair
Volar dislocation; rare; unstable; extensive trauma, central slip disruption
Central slip repair + immobilization;
Boutonierre deformity sequela
DIPJ: open dislocation is more common (cutaneous anchoring to bone
Debridement, reduction, splinting. Antibiotics; if closed- reduced & stable
A WORD ABOUT JOINT DISLOCATIONS..
MCPJ: dorsal dislocation; forced hyperextension
Simple- reduction by wrist flex. & MCPJ tract. + flex.
Early active motion
Complex- prominence in palm & skin dimpling
Rx: intra articular sesamoid bone (volar plate)
Open redcution (dorsal approach)
Lateral dislocation; forceful adduction / abduction; may not be noticed
Partial tear- buddy taping protection 3w
Complete tear- surgical repair
CMCJ: axial loading
If acute – easy reduction; pinning to maitain reduction
Failure – pain, weakness,degenerative arthritis

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A WORD ABOUT JOINT DISLOCATIONS..
Thumb IPJ: dislocation is rare; lateral (collateral lig.) or dorsal (volar plate)
Immobilization for 3-4w
Thumb MCPJ: ulnar collateral lig. Injuries; common; forced palmar abduct.-ex. (ski)
Swollen & tender MPJ; at dist. origin; examination under local anesthesia
Deviation under stress 20º = severe tear repair / arthrodesis
* Stener lesion- adductor policis between the torn parts
* Gamekeeper thumb- chron. UCL stertching
Radial collateral lig. Injuries; at prox. Origin
immediate repair vs. late arthrodesis
Dorsal dislocation; forced hyperex. + longitudinal compression
Neuropraxia possible;
If simple – closed reduction, immobilization (25º flex.) for 2-3w
If complex tear- of collateral ligs. & volar plates
Thumb CMCJ: rare; can lead to chronicsubluxation