FRACTURE FRACTURE PATTERNS

● defined as a disruption in the integrity of a living bone, ● Transverse, oblique, spiral

involving injury to the bone marrow, periosteum, and ● Comminuted, segmental, Impacted, avulsion,
adjacent soft tissues compression, pathologic
● described radiographically and clinically ● Greenstick and buckle (torus) fracture in Children
o Anatomy, articular involvement, angulation, FRACTURE PATTERNS
displacement, rotation, shortening, fragmentation
o Soft tissue involvement
▪ (open fracture or closed fracture)
FRACTURE

COMPLETE VS. INCOMPLETE FRACTURE

Complete Fracture Incomplete Fracture Torus Fracture

ETIOLOGY
● Occur when the force applied to the bone exceeds the
strength of the involved bone
INTRINSIC FACTOR EXTRINSIC FACTOR
•Bone's energy absorbing capacity •Rate of load INCOMPLETE FRACTURE
•Modulus of elasticity •Duration, direction, ● Torus or Buckle Fracture
magnitude of force •injuries without a cortical break either lead to plastic
•Fatigue deformation through microfracture or to a 'kink' within
•Strength the long bone, described as a 'buckle' or 'torus' fracture.
•Density ● Greenstick Fracture
DIRECT TRAUMA INDIRECT TRAUMA • Greenstick Fracture partial thickness fracture where
• crushing • compression, only cortex and periosteum are interrupted on one side
• penetrating injuries • traction, of the bone, while they remain uninterrupted on the
• rotational forces other side.
FRACTURE SITES AND DISPLACEMENT CLOSED VS. OPEN
● Initial evaluation: determine the location of the fracture Open Fracture
o The degree of associated soft tissue injury
o The degree of displacement
● Potential sites: diaphysis and metaphysis
● Displacement: Non-displaced or displaced
o Displaced: angulation, rotation, change in length or
translation
Closed Fracture
FRACTURE SITES AND DISPLACEMENT
● Initial eval: determine the location of fracture
o The degree of associated soft tissue injury.
o The degree of displacement
● Potential sites: diaphysis and metaphysis
● Displacement: Non-displaced or displaced
o Displaced: angulation, rotation, change in length or
translation
OPEN FRACTURE:1984 GUSTILO ANDERSON CLASSIFICATION

GUSTILO ANDERSON CLASSIFICATION
● Type I open fracture. Wound less than 1 cm, without
contamination and minimal injury of soft tissue.
● Type Il open fracture. Wound between 1 and 10 cm, mild
contamination, extensive soft tissue damage and minimal
to moderate crushing component.  ● May lead to growth complications
● Type Ill-A open fracture. Wound larger than 10 cm,
severe contamination and severe crushing component.  complications
● Type Ill-B open fracture. Wound larger than 10 cm, severe
contamination and severe loss of tissues.
● Type Ill-C open fracture. Wound larger than 10 cm, severe
contamination and neurovascular injury.
● Gun Shot Wounds (GSW)
o Low Velocity < 2,000 ft./sec.
o High Velocity > 2,000 ft./sec. 
OTHER TYPES OF FRACTURES
PATHOLOGIC FRACTURES STRESS FRACTURES
• Fx. through bone cyst • Stress Fx. 3rd metatarsal
SALTER-HARRIS FRACTURES
● Epiphyseal growth plate is weaker than supporting
ligaments
o Growth Plate (Physis) is made up of cartilage cells that
are weaker than the supporting ligaments
● Salter-Harris fractures are fractures involving long bones
in children and involve the growth plate or joint surface
o Most common in children 10-16 (80%)
o More common in males due to delayed skeletal
maturation and increased physical activity compared
with females of same age
SALTER-HARRIS FRACTURES
o Blood supply to the growth plate comes through the
epiphysis and the worse the injury to the epiphysis, the
greater the likelihood of growth disturbances
● Fractures are categorized on scale 1-5 and increasing
number indicates increasing potential for growth
SALTER-HARRIS CLASSIFICATION
TYPE 1 = FRACTURE THROUGH EPIPHYSEAL PLATE
● Results in separation of epiphysis
● Good Prognosis
TYPE 2 = FRACTURE OF METAPHYSIS WITH EXTENSION
THROUGH EPIPHYSEAL PLATE
● Most common type in children > 10 y/o
● Good Prognosis
TYPE 3 = FRACTURE OF THE EPIPHYSIS WITH EXTENSION
INTO THE EPIPHYSEAL PLATE
● Totally Intra-articular fracture
● Open reduction necessary
TYPE 4 = FRACTURE THROUGH EPIPHYSIS, METAPHYSIS AND
EPIPHYSEAL PLATE
● Complete intra-articular fracture
● Open reduction necessary
● Growth disturbance likely if not perfect reduction
TYPE 5 = CRUSH FRACTURE OF THE EPIPHYSEAL PLATE
● Most common in knee and ankle
● X-ray can be deceptively normal looking
● Poor prognosis because blood supply to epiphysis is
disrupted
SALTER-HARRIS CLASSIFICATION ● Repairs must, therefore depends to great extent on the
•S = Slip through the growth plate formation of internal callus. (Primary fracture healing).
•A = Above the level of the growth plate INITIAL MANAGEMENT OF FRACTURES
•L = Lower than the growth plate ● Splinting
•T = Through the growth plate ● Assessment of neurovascular function
•R = Ram the growth plate ● Management of Open Fractures
o Hemostasis
o Tetanus prophylaxis
o Antibiotic Prophylaxis
o Urgent irrigation and Debridement
GENERAL PRINCIPLE OF FRACTURE HEALING
● Fracture Healing requires an adequate vascular supply,
minimal necrosis, anatomic reduction, immobilization,
the presence of physiologic stress and the absence of
infection.

TREATMENT PRINCIPLES
FRACTURE HEALING
● Medical management
Five stages of fracture healing:
● Casting
1. Stage of hematoma
● Traction
2. Stage of cellular proliferation: Start within 8 hours (mid
● Surgical management
canal, periosteum)
o Internal fixation
3. Stage of callus: Woven bone, first radiological sign of
o External fixation
fracture healing, take 2 to 3 weeks
4. Stage of consolidation: Mature lamellar bone, take months
5. Stage of remodeling: Bone will come back to original shape,
may take years, less in adult and rotation deformity do not
remodel.
● Must be protected until stage of consolidation.

PATIENT FACTORS THAT INFLUENCE FRACTURE HEALING

FACTORS AFFECTING FRACTURE HEALING

● Age of patient — rule of thumb of immobilization
o <3 weeks for upper limb in child
o <3 x 2 weeks for lower limb in child, upper limb in
FRACTURE HEALING adult
External Callus o <3 x 2 x 2 weeks for lower limb in adult
•The callus that develops around the outer aspects of the ● Type of bone
opposing ends of the bone fragments. o Flat and cancellous > long or cortical
•It is formed by periosteum. ● Pattern of fracture
Internal Callus o Oblique/spiral fracture unite faster than transvers
•The callus that forms between the bone ends or medullary fracture
callus. It is formed by endosteum. It is the chief source of o Comminuted fracture takes longer to unite
union between the fragments. ● Pathoanatomy of fracture
● When fractures are treated by open operation at which o Soft tissue interposition
the fragments are joined firmly together by some o Avascularity
metallic device until the fracture heals, little or no ● Presence of compounding
external callus forms. ● Type of reduction
● Immobilization ▪ Fever, tachycardia and mental confusion
● Compression at fracture site ▪ Petechiae
o Electronegativity at fracture site enhances union ● Infection
CAUSES OF EXCESS CALLUS FORMATION o Contamination of open fracture
o Head injury o Osteomyelitis
o Steroid therapy/ cushing's syndrome o Gas Gangrene (Clostridium perfringens)
o Non-accidental injury SPINAL FRACTURE
o Renal osteodystrophy OCCIPITAL CONDYLE FRACTURES
o Paralytic states Type I Impaction fracture from axial loading
o Neuropathic arthritis Type Il Basilar skull fracture from direct blow
o Osteogenesis imperfecta Type Ill Avulsion fracture from rotation or lateral bending
o Multiple myeloma

CLAY SHOVELER'S FRACTURE

COMPLICATIONS OF FRACTURE ● an oblique fracture of a lower cervical spinous process,
● Rule of 3 commonly C7.
o Death in 3 hours = hypovolemic shock ● It results from hyperflexion, commonly from shoveling
o 3 days = fat embolism snow, although it was originally named for those who
o 3 weeks = DVT with pulmonary embolism were mining clay.
MALUNION ● This is a stable injury.
● Clinically obvious fracture union in non-anatomical
position
● Malalignment of > 15 0 in any plane asymmetrical joint
loading

JEFFERSON FRACTURE (Cl ATLAS FRACTURE)

FRACTURE COMPLICATIONS
● Bone Healing Abnormalities
o Delayed Union : 3—4 months after injury
o Non-Union : > 6 months after injury
o Malunion — unacceptable position
o Avascular Necrosis
● Neurovascular Injuries
o Arterial injuries — repair in 6 hrs.
o Radial nerve palsy
o Sciatic nerve palsy
● Compartment Syndrome
o occurs when there is increased pressure within a
closed osteofascial compartment, resulting in
impaired local circulation
o Increase intracompartmental pressure
o Pain is the earliest and most reliable indicator
▪ Occurs with passive stretch of muscles Pressures >
30 mmHg or within 10 to 30 mmHg of the diastolic
pressure requires
o FASCIOTOMY
● Pulmonary Complications
o Adult Respiratory Distress Syndrome (ARDS)
▪ Characterized by sudden onset of respiratory
problems (usually within 72 hrs.)
▪ Extreme arterial hypoxia (p02 <60)
● consists of a fracture of the Cl ring.
● This results from an axial loading injury to the head with
compression force to Cl (typically from diving).
● The fracture consists of unilateral or bilateral fractures of
the anterior and posterior arches of Cl .
● This is an unstable injury.
HALO ORTHOSES
● For 3 months post SCI
● For unstable cervical fracture and postoperative patients
● To be worn for 3 months
Complications:
o Site Infection
o Pin loosening
o Slippage
o Pressure sore
● Crutchfield tong — worn before Halo; has traction
DENS FRACTURE (ODONTOID FRACTURE)
● Results from rotational forces across the cervical spine.
● Flexion (80%) most common mechanism
● Anderson and D'Alonzo classification:
 o Type I - an avulsion fracture arising from the tip of the ▪ This column acts as the tension band and resists
dens at the site of the alar ligaments distractive loads.
o Type Il - is a fracture at the base without extension to ▪ It is the posterior column that is most important in
the body of C2 providing stability to the spine
o Type Ill - is a fracture through the body VERTEBRAL COMPRESSION FRACTURE: ALTERED LOAD
HANGMAN'S FRACTURE (C2 ISTHMUS FRACTURE) BEARING PHYSICS
● Bilateral pedicle or pars fractures involving the C2
vertebral body.
● Associated with this fracture is anterior subluxation or
dislocation of the C2 vertebral body.
● It results from a severe extension injury such as from an
automobile accident where the face forcibly strikes the
dashboard or from hanging.
● Injury occurs by Hyperextension +Axial load + Rebound THORACIC AND LUMBAR FRACTURES
Flexion ● This commonly occurs within the spinal transition zone of
WHIPLASH INJURY Kyphosis to Lordosis
● The Thoracic (Tl -T9 ) levels are usually stable unless
there are multiple rib fractures.
● Most (60%) thoracic and lumbar fractures occur from T
11 to Ll junction, owing to lack of ribs and the facet
orientation change from frontal to sagittal
C3-C7 FACET JOINT INJURIES
● Goal: To maintain neurologic function, minimize further
● occurs by flexion or distraction Facet Joints + rotation
injury, restore spinal stability and alignment.
● Unilateral facet dislocation have less than 50% translation
TYPES OF SPINAL FRACTURE
● Bilateral facet dislocations Intervertebral disk have
greater than 50% translation
● Most common location for dislocations occur at C5-C6
and C6-C7
C3-C7 COMPRESSION FRACTURES
● Anterior wedge fracture is due to flexion forces
● Commonly occurs at C4C5 and C5-C6 levels
● These fractures are stable and treated with a rigid
orthosis for 8-12 wks
C3- C7 BURST FRACTURES
● Often caused by compression – flexion or vertical axial
load
TWO VS THREE COLUMN CONCEPT

● Holdsworth initially described the two-column concept of COMPRESSION FRACTURE

the spine.
o The anterior column comprises the anterior half of
the vertebral body. This column resists compressive
loads.
o The posterior column comprises the facet joints and
the interspinous ligaments.
● Compression fractures of the spine are common in
elderly and osteoporotic patients.
● They result from axial load with flexion or lateral bending
moment.
● The typical appearance is loss of height of the anterior
aspect of the vertebral body with preservation of the
 posterior elements and generally the posterior aspect of •Fall on outstretched arm
the vertebral body.
o Most common fracture pattern.
o Tx: Hyperextension brace or TLSO
JEWETT BRACE CRUCIFORM ANTERIOR SPINAL

HYPEREXTENSION (CASH)BRACE

CLINICAL FEATURES
BURST FRACTURES 
● Pain over the back side of the shoulder
● This is a continuum of compression fractures with more
● Shoulder pain inc with abd of the arm
axial loading
Imaging
● Fractures are unstable:
● Routine shoulder x-rays will demonstrate most scapular
o More than 50’60% ant compression
fractures
o 20-25 deg of kyphosis
● Axillary lat view – helpful w/ fractures of glenoid fossa,
o More than 50% canal compromise
acromion, coracoid process
o Post column injury
● CXR to r/o associated lung or pulmo injury
FLEXION DISTRACTION FRACTURES
Treatment
● Defined by position of fracture fulcrum,
● Sling immobilization x2 wks, early range of ROM exercises
● these fractures occur either anterior to or within the
● Orthopedic referral for ORIF for severely displaced or
vertebral body
angulated fratures
● Chance Fractures have the fulcrum anteriorly and
PROXIMAL HUMERU FRACTURES
distraction occurs through the bone
● Classification = Neer Classification System
● Seat Belt Fractures have the fulcrum within the vertebral
•Classification by amount of displacement of four segments
body, with anterior column compression and distraction
•Displacement = separation > 1 cm or angulation >
through posterior column
45deg
FLEXION DISTRACTION FRACTURES
•Anatomic Neck
•Surgical Neck
•Greater Tuberosity
•Lesser Tuberosity
Major Categories
•One part fracture — No displacement (80-85%) of fractures
•Two part fracture — Displacement of one fragment
•Three part fracture — Displacement of two individual
UPPER EXTREMITY FRACTURE fragments from remaining humerus
CLAVICLE FRACTURE •Four part fracture — Displacement of all four segments
● Clavicular fractures are common fractures usually Mechanism of Injury
resulting from direct trauma. ● Fall on outstretched arm (most common)
● The middle third of the bone is injured 80 % of the time. ● Direct blow to lateral aspect of arm
● Adjacent vessels and nerves are often injured as well. Clinical Presentation
● These injuries commonly result from seatbelt use in a ● Upper arm and shoulder pain after fall
frontal collision. ● Most commonly seen in elderly
● Treatment: Arm sling, Clavicle strap for 3 to 4 wks. Imaging
SCAPULAR FRACTURÈ ● Plain film x-ray imaging
● High Energy Mechanism Treatment
•Look for associated injuries •One part fractures
● Classification (by location of fracture) •Immobilization with shoulder immobilizer sling and swath,
•Body Analgesia, Ortho follow-up
•Neck •Two/Three/Four Part fractures
•Glenoid •Immobilize and emergent orthopedic referral
● Mechanism of Injury •Many will require surgical repair
•Direct blow to the scapula Complications
•Trauma to the shoulder •Adhesive capsulitis = Frozen Shoulder = Most
Common — Prevent with early mobilization
•Neurovascular Injuries = Axillary nerve and artery, brachial
plexus
•Posterior Dislocations = Will frequently accompany lesser
tuberosity fractures
•Avascular necrosis of humeral head especially with anatomic
neck fractures

PATHOLOGIC FRACTURE (HUMERUS)

EXERCISE INTERVENTIONS FOR PROXIMAL HUMERAL
FRACTURE (NON-OPERATIVE)
● result from an underlying abnormality of the bone,
usually either from a primary bone tumor or from
metastatic disease. H
● owever, pathologic fractures may result from metabolic
conditions as well.
● A pathologic fracture results when normal stress is placed
onto abnormal bone.

SUPRACONDYLAR FRACTURES

EXTENSION FRACTURES
HUMERAL SHAFT FRACTURE ● Most Common Type
● Shaft humeral fractures are almost always the result of ● Mechanism of injury = Fall on outstretched arm with
direct trauma (less often due to a fall) elbow in extension
● are either transverse or oblique, and are displaced due to ● Imaging = Distal humerus fractures and humeral
muscular action. fragment displaced posteriorly
● Radial nerve injury is the main complication o Sharp fracture fragments displaced anteriorly with
Treatment: potential for injury of brachial artery and median nerve
● Coaptation or cast brace
● ORIF if:
•Segmental fracture
•Pathologic Fracture
•Distal spiral with Radial n. injury (Holstein-Lewis fracture)
•With forearm fracture (floating elbow
•Obesity

Treatment
● Emergent Orthopedic Consultation
● Non-displaced fracture = Immobilization in posterior
splint
 o May be discharged home with close follow-up
● Displaced fracture = Prompt reduction with
percutaneous pin fixation or internal fixation by
orthopedic surgeon
o If vascular compromise on evaluation, ED physician
should attempt reduction
Complications
● Compartment syndrome of forearm (Volkmann's
ischemia)
● Median Nerve Injury = Weakness of Flexor Muscles of
Hand and loss of two point discrimination of the
fingertips
o Neuropraxias at time of injury should resolve over time
FLEXION FRACTURES
● Mechanism of Injury = Direct blow to posterior aspect of
flexed elbow
● Imaging = Distal humerus fracture displaced anteriorly
Treatment
● Non-displaced fractures are treated with splint
immobilization and early orthopedic follow-up
● Displaced fractures require emergent orthopedic
consultation for reduction and percutaneous pinning
SUPRACONDYLAR FLEXION FRACTURES
Complications
•Fractures are frequently open
•Vascular injury is rare
•Ulnar nerve injury is most common complication  forearm supination or pronation, Outpatient ortho
OLECRANON FRACTURE
● Mechanism = Direct blow to point of Elbow
● Clinical Feature
•Swelling/tenderness over Olecranon
•Inability to extend elbow against gravity
● Associated Injury = Ulnar Nerve
Treatment
•Non-displaced = Elbow immobilization in 30 degrees flexion
•Fractures > 2 mm displacement = Emergent Ortho Referral
•Open reduction with internal fixation
CORONOID PROCESS FRACTURE
•Coronoid process fractures are associated with posterior
elbow dislocations.
•Generally an isolated coronoid process fracture is rare;
● most will have associated radial fractures.
CONDYLAR FRACTURE
● Distal Humerus comprised of medial and lateral condyles,
each with articular and non-articular surface
● Articular Surfaces
•Trochlea (medial condyle)
•Capitellum (lateral condyle)
● Non-articular surface
•Medial and Lateral Epicondyle
● Condylar fractures involve both the articular surface and
the non-articular surface
•Lateral condyle fractures are most common
Treatment
•Nondisplaced or minimally displaced =
Immobilization in 90 degrees elbow flexion with
•Displaced Fractures (> 3 mm) = Surgical Fixation
EPICONDYLAR FRACTURE
● Seen most commonly in children
● Medial Epicondyle
o Avulsion fracture of medial condyle often accompanies
posterior elbow dislocation
o Associated ulnar nerve injury
Treatment
● Nondisplaced = Immobilization
● Displaced (> 3-5 mm or intra-articular) - Orthopedic
referral and surgical reduction
● Lateral Epicondyle
o Rare, typically the result of direct blow
o Most are non-displaced and treated with
immobilization
MEDIAL EPICONDYLE FRACTURE (HUMERUS)
● Resulting from valgus stress, fractures of the medial
epicondyle of the humerus (littleleaguer's elbow) are
really avulsion injuries.
● The medial epicondyle (or apophysis) of the humerus is
injured by repeated violent contractions of the forearm
flexor muscles which arise at this site.
● This is particularly seen in curveball and slider pitches;
these motions result in strong valgus forces being applied
at the medial
 Galeazzi
Radial Fracture
Ulnar Fracture
Monteggia
NIGHTSTICK FRACTÚRE
● Isolated fracture of ulnar shaft
● Mechanism = Direct blow to ulna with patient raising
forearm to protect face
Treatment
•Non-displaced = Immobilization in cast
•Displaced
CAPITELLUM FRACTURE •>10 degrees angulation or displacement > 50% of ulna
● Fractures of the capitellum are the result of direct trauma •Orthopedic referral - ORIF
to the extremity.
● In pediatric patients, this site is the second most common
site of injury about the elbow.

RADIAL HEAD FRACTURE BOTH BONE FOREARM FRACTURE

● Mechanism of Injury = Fall on outstretched hand
● Clinical Finding = Tenderness and swelling over the radial
head
Imaging
● May not be seen on initial x-ray
● Evaluate for anterior or posterior fat pad which suggests
diagnosis
Treatment
● Non-displaced = Sling immobilization, Ortho follow-up
● Comminuted/Displaced Fractures = Immobilization in
post long arm splint
RADIAL HEAD FRACTURE
MONTEGGIA FRACTURE DISLOCATION
● Monteggia fracture-dislocations are classified by the
Bado system.
● Bado type I injuries are characterized by a proximal ulnar
fracture with anterior dislocation of the radial head.
● This is due to a forceful pronation injury of the forearm
and is the most common type.
GALEAZZI'S FRACTURE OF PIEDMONT FRACTURE
● Also called a reverse Monteggia fracture
● a fracture of the radius at the junction of the middle and
distal thirds with distal radioulnar joint dislocation.
● This fracture pattern may be caused by a fall on an
outstretched hand or from a direct trauma to the dorsal
aspect of the wrist.
● Fracture of both ulnar and radius
o Usually displaced fracture
● Mechanism of Injury = Direct blow to forearm
● Associated Injury
o Peripheral Nerve Deficits
o Development of compartment syndrome
Treatment
● Non-displaced (rare) = Immobilization in bivalved cast
● Displaced — ORIF
o Closed reduction may be possible in children
Complications
● Compartment Syndrome
● Malunion
VOLKMANNS ISCHEMIC CONTRACTURE
● Complication of elbow and forearm fractures or casting
that is too tight (compartment syndrome)
● Pressure on Brachial artery results in ischemia of muscles
of forearm, typically flexor compartment
● Results in forearm pronation, flexion of wrist and digits
and paralysis of intrinsic muscles
● Patient complains of pain out of proportion of injury, digit
swelling and paresthesias
● Irreversible damage in 6 hours
● Consider in any patient presenting with pain and
numbness in hand after casting has been performed
Treatment
•Removal of cast
•Surgical decompression with fasciotomy
CHAUFFEUR (BACKFIRE)
● The chauffeur fracture is also called a lorrie or
Hutchinson fracture.
● This fracture results from a direct injury to the thenar
side of the wrist, resulting in intraarticular fracture at the
base of the radial styloid
● This type of fracture resulted from a backfire when a
crank was used to start a motor in automobiles.

COLLES FRACTURE
● This is a common fracture in elderly patients,
● consisting of a transverse fracture of the distal radial
metaphysis proximal to the of the distal fragment and
volar dislocation.
● It results from a fall on an outstretched hand. The ulnar
styloid is commonly fractured as well.
SMITH FRACTURE
● Also called a reverse Colles fracture,
● the Smith fracture is a transverse fracture of the distal
radial metaphysis with palmar displacement of the distal
fracture fragment.
● This fracture results from a backward fall onto the
outstretched hand.
COLLES vs SMITH Fracture
BARTON FRACTURE
● intraarticular fracture of the dorsal margin of the distal
radius.
● The fracture line is oblique and extends to the
radiocarpal joint.
● The fracture results from a fall on an outstretched hand.
REVERSE OR VOLAR BARTON FRACTURE
● intraarticular fracture through the distal radius.
● The reverse Barton fracture involves the volar rim of the
radius while the conventional Barton fracture involves
the dorsal rim.
● The fracture is caused by direct trauma.
SCAPHOID FRACTURES
● Scaphoid fractures are the most common carpal fractures
● resulting from a fall on an outstretched hand.
● 70 % of these occur at the waist, 20 % at the proximal
pole, and 10 % at the distal pole.
● Blood supply for the proximal pole enters at the waist.
● If this blood supply is interrupted due to fracture, the
proximal pole is at risk for avascular necrosis
TRIQUETRUM DORSAL CHIP FRACTURE
● 2nd most common
● Mechanism = Fall on outstretched hand
● Exam = Tenderness on palpation distal to ulnar styloid on
dorsal aspect of wrist, painful flexion
● Best visualized on lateral view of wrist
● Treatment = Volar splint
LUNATE FRACTURE
● Mechanism = Fall on outstretched hand
● Exam = Pain over mid-dorsum of wrist increased with
axial loading of 3rd digit
● Plain x-rays are often normal
● Treatment = Immobilization in thumb spica splint,
orthopedic referral
Complications
● Kienbock's disease = Avascular necrosis of proximal
segment
METACARPAL FRACTURES
● Neck (Most common)
● Mechanism = Direct impaction force
● Boxer's fracture = 5th MC neck fracture DISTAL PHALANX FRACTURES
● Fractures are typically unstable with volar angulation ● 15-30% of hand fractures
and/or rotation ● Mechanism is typically crush or shearing forces
● Rotation Exam = Look for malalignment of plane of ● Classified as Tuft, Shaft or Intraarticular fractures
fingernails in flexed position ● Fractures at base may be associated with flexor or tendon
treatment injuries
● Anatomic reduction if unacceptable angulation or ● Treatment is typically protective splinting (hairpin splint
rotational deformity or finger splint)
● Splint with wrist in 20 degree extension and MP flexed at BASEBALL FINGER (MALLET FINGER)
90 d e g rees ● Also called a dropped finger, this injury results from
hyperflexion to the distal interphalangeal joint.
● There is a dorsal avulsion fracture of the base of the
distal phalanx.
● This indicates that the common extensor tendon remains
attached to this avulsed fragment.
BOXER'S FRACTUREPHYSICAL ● The injury is typical at the second digit as the result of
forced hyperflexion (catching a ball).

BASE OF THE THUMB FRACTURES

BENNETT'S FRACTURE
•Intra-articular fracture of thumb base with subluxation or
dislocation of MC joint
•Axial loading injury with hand closed
ROLANDO'S FRACTURE
•Comminuted T or Y shaped fracture involving the joint
surface
•Axial loading injury with hand closed
•Worse prognosis

PROXIMAL AND MIDDLE PHALANX

● No tendon attachments
Mechanism
•Direct blow = transverse or comminuted fracture
•Twisting Mechanism = Spiral fracture
● Fractures are typically stable
SHOULDER ARTHROPLASTY SURGICAL PROCEDURES
REHAB PRINCIPLES FOR REVERSE TOTAL SHOULDER ARTHROP.