ANATOMY:
🔹 Injury from direct trauma called “night stick”
fracture
🔹 Wrist joints:
◦ distal radio ulnar
🔹 Dislocation of radial epiphysis:
“fracture of ulna associated with anterior
◦ radiocarpal
🔹
◦ intercarpal
Hand joints:
dislocation of the radial head” Monteggia, 1814
anatomy 🔹
◦ CM: ◦ MP: condyloid ◦ IP: hinge
Strong ligaments:
Dorsal= DISI
2)Posterior or posterolateral 1)Anterior dislocation of radial head and
dislocation of radial head and fracture of
ulnar disphysis with posterior angulation
fracture of ulnar diaphysis with anterior
angulation 🔹
Volar=VISI
Muscles:
•control wrist & finger motion
•carpal tunnels
•Flexor & extensor retinacula
anatomy
4)Anterior dislocation of radial head and
1🔹monteggia farcture 1)Flexor retinaculum
2)Median nerve
fracture of proximal third of radius and ulna 3)Median nerve
4)Muscular br. of median n. to thenar muscles
3)Lateral or anterolateral
dislocation of radial head 🔹 Mechanism
5)Proper palmar digital nerves to the thumb
6)Proper palmar digital nerve to index
and fracture of ulnar
metaphsysis
Fractures 🔹
Repetitive flexion/extension
Signs and Symptoms
Tingling
7)Common palmar digital nerves
8)Common palmar digital nerves
9)Palmar digital branches of ulnar n.
pain 10)Palmar digital branches of ulnar d.n.
Parasthesia
Carpal tunnel syndrome (CTS)
🔹GALLIAZI FRACTURE 🔹
🔹result from repetitive stress to tissue
Night p
Radial shaft fracture, with distal radioulnar joint. 2
🔹
🔹
64% of work injuries
Compressive neuropathy
Ulnar impaction syndrome ( gymnastics
Ulnar Variance
🔹Wrist flexion/ext and finger movements
Risk factors:
wrist injuries ) •exertion
🔹 Difference in length between ulna and radius •repetitive stress
🔹
Progressive degeneration of the triangular fibrocartilage
•posture
🔹
complex and ulnar carpus
Ulnar impaction syndrome in a 41-year-old man with positive 🔹
Same length (within 1 mm) UV = 0
Longer ulna -> UV is positive
localized contact Which is more pronounced:?
🔹
variance and chronic ulnar-sided wrist pain
Extensive chondromalacia and subchondral degenerative
🔹 Longer radius ->UV is negative 🔹
•cold
Repetitive motions cause inflammation and
Sensory Deficits or Motor Function
deficit
sclerosis involving the ulnar aspect of the lunate bone and the
Ulnar Variance potential cause 🔹
edema
Increased pressure in the confined space
radial aspect of the triquetral bone (arrowheads)
🔹When upper extremity is used for weight-bearing, 🔹
compresses the median nerve
64% of all new occupational illnesses in
symptoms
🔹 Tasks require a large variety of wrist motions
radius accepts approximately 80% of load
🔹Repetitive compressive loading + skeletally immature Ulnar 🔹
1996
60% of all new occupational illnesses in 🔹
E.g. assembly line vs. typing vs. guitar vs. hammering
Symptoms are associated with specific
person -> premature closure of radial growth plate ->
positive UV
2004
🔹
movement patterns
Two risk factors
•Force
🔹 Mechanism of injury
🔺
•Repetition
two
Repetition is the more important factor of the
🔹
Fall on dorsiflexed and ulnar deviated wrist
Axial load with forearm in hyperpronation
Patient c/o ulnar sided wrist pain, swelling, loss of grip TREATMENT
conservative
strength
Wrist operative
Radiography
🔹
EXAMINATION
🔹
🔹
Thickened pad of connective tissue that functions as a Compressive load on hyperextended wrist
🔹
Plain films
🔹
cushion for ulnar axial loads Scaphoid and lunate commonly fractured
🔹
Positive ulnar variance (ulna 1-5 mm longer Tenderness just distal to ulnar styloid •Articulate with radius, which bears 80% of load
🔹
than radial articular surface) ass/w TFCC tear
Assess for fracture or ulnar subluxation
Press test
Patient presses arms of chair to lift body off seat
•Scaphoid: 60-70% of all carpal fractures
•Most likely in wrist extension > 95°, radial side
🔹
MRI or Arthrography optional to confirm 100% sensitive loading
FCC load test Triangular Fibrocartilage •Lunate: Compressive F through capitate
Complex (TFCC) Tear
🔹
Pain is a + test
Rule out injury to distal radio-ulnar joint (DRUJ)
•Squeeze radius/ulna together and passively rotate forearm 🔹 Anatomy
Painful in DRUJ injury -Blood supplied from distal pole
No pain in isolated TFCC tear -The more proximal the fracture, the greater the risk of
🔹
avascular necrosis (AVN) or delayed union
Examination
Treatment
🔹 Long arm cast with forearm neutral for
wrist and hand Carpal fractures -Minimal swelling
-Tenderness in snuff box
4-6 weeks injuries 🔹Radiographs
-Pain with axial load
🔹 Referral criteria:
Associated injuries including DRUJ
forearm
•AP
•Lateral
•Oblique
instability Scaphoid Fracture •Scaphoid view
Persistent pain after immobilization 🔹 Mechanism
🔺Normal plain films don’t rule out a scaphoid fracture
Review 🔹
•Falling on outstretched arm
🔹
Signs and Symptoms
🔹 Refer all vertically displaced AC joint sprains
🔹
•Pain in Anatomical Snuff Box
Treatment
🔹
🔹 Refer any displaced, non-middle-third claviclular fractures History
Non-displaced fracture of waist or distal
🔹 Pick and KNOW 1-2 shoulder reduction methods •FOOSH(fall on outstretched hand )
pole
🔹 Conservatively treat non-displaced radial head fractures Dull, deep, ache in radial side of wrist
•Long arm thumb spica cast 6 weeks
🔹 Refer all Skier’s thumb that gap >20°
Treat suspected scaphoid fxs even if xrays neg
Treat TFCC tears with 6 wks long arm cast
•Then, short arm thumb spica cast for 2-6
weeks Referral criteria
-Replace cast/get x-rays Q2 wks to assess •Proximal fractures
🔹 Proximal radial fractures are rare. Why? 🔹
healing
Clinically suspected fracture with normal
•Angulated; displaced >1mm
Scapholunate dissociation
Colles Fracture
🔹
•due to Protection from overlying musculature
Fractures of distal third of radius
Colles’ fractures,
plain films
-Treat as non-displaced fracture
•Presentation > 2 wks
•Early return to play necessary
•Non-union or AVN
Mechanism -“PRICE”
Smith’s fractures, -Short-arm thumb spica cast
Fall on outstretched arm Barton’s fractures
Signs and Symptoms F/U in 10 days for repeat x-rays
Silver Fork Deformity 🔹
(Young males and old females)
Combined fracture
Fall on outstretched arm
-Consider bone scan/MRI if x-rays neg but fx
suspected
Direct blow to dorsolateral side of wrist
2 🔹Shearing fracture 1🔹Bending fracture Typical suspects, all possible because of
•Anterior lip of radial articular surface is sheared
off
•Landing on outstretched arm
•Axial compressive loads cause radial bending with
a fracture pattern showing anterior metaphyseal
🔹
exposure
🔹 Direct impact
Indirect trauma
•(Barton’s fracture)
cortex failure in tension
•(Colles’ Fracture)
RADIAL FRAUCTRES
🔹
Thumb: essential to prehension
Sprain: skiers thumb
•fall with thumb in abducted position
🔹
•tensile loads on MCL
Hyperextension Bennets fracture
(fighting)Bowler’s thumb:
5🔹Combined fracture
High energy combination loading: 4 🔹Avulsion 3🔹Compressive loads
ulnar digital nerve trauma tingling, sensitivity
•Bending •Example: exaggerated torsion creates Pathoanatomy Stener lesion
•Compression high stresses on osteoligamentous •High fall, for example
•Intraarticular fracture of joint surface
Sprain of ulnar collateral ligament of thumb MCP
🔹
🔹64% of Grade III injuries
•Shearing
•Avulsion
attachments
•Disruption of the subchondral and cancellous 🔹
Grades I, II, and III
🔹 I = no laxity
🔹Adductor aponeurosis interposed
bone
Thumb Sprain
🔹 Ulnar collateral ligament of first metacarpophalangeal joint
🔹 II = laxity but intact
III = complete tear 🔹Prohibits reattachment of ligament
MRI and arthrogram are sensitive
distal radial
“Skier’s Thumb”Gamekeeper’s Thumb"
fractures •Fall on outstretched hand with abducted thumb Mechanism of injury
Hyperextension of first MCP joint Forced abduction and hyperextension of thumb
FOOSH with thumb caught in extension Examination
•E.g. softball player tagging an opponent sliding into base
🔹 Diagnosis
•Anesthesia (block)
•Valgus stress to MCPJ in extension
COMPLICATION
Thumb Injuries History, •Over 20° opening is probably grade III tear
Radiographs
GENERAL ,LOCAL, SPECIFIC , Physical exam
-Compartmet
-FHL
-CRPS (complex region pain syndrome)
-MALUNION 🔹
Treatment
Grades I & II
Thumb spica splint 2-4 weeks, then
TREATMENT 🔹
Splint or tape 3 months
🔹
1 coller fracture: traction ulnar tilt, ulnar tilt Grade III
•Controversial
🔹
volar angulation
2 smith fracture: traction ,dorsal angulation Metacarpal and Phalangeal •Surgery
•Refer to Ortho
rarely surgical ttt mainly conservative Injuries
Thumb Fracture
by fatema okoff
🔹 “Bennett’s fracture”
Fracture subluxation of trapeziometacarpal joint
Axial force on flexed metacarpal bone
Boxer’s Fracture
Injury to 5th metacarpal
Mallet Finger
Injury to extensor tendon
Flexion deformity
Jersey Finger
Injury to Flexor Digitorum Profundus
Boutonniere Deformity
🔹 Injury from direct trauma called “night stick”
fracture
🔹 Wrist joints:
◦ distal radio ulnar
🔹 Dislocation of radial epiphysis:
“fracture of ulna associated with anterior
◦ radiocarpal
🔹
◦ intercarpal
Hand joints:
dislocation of the radial head” Monteggia, 1814
anatomy 🔹
◦ CM: ◦ MP: condyloid ◦ IP: hinge
Strong ligaments:
Dorsal= DISI
2)Posterior or posterolateral 1)Anterior dislocation of radial head and
dislocation of radial head and fracture of
ulnar disphysis with posterior angulation
fracture of ulnar diaphysis with anterior
angulation 🔹
Volar=VISI
Muscles:
•control wrist & finger motion
•carpal tunnels
•Flexor & extensor retinacula
anatomy
4)Anterior dislocation of radial head and
1🔹monteggia farcture 1)Flexor retinaculum
2)Median nerve
fracture of proximal third of radius and ulna 3)Median nerve
4)Muscular br. of median n. to thenar muscles
3)Lateral or anterolateral
dislocation of radial head 🔹 Mechanism
5)Proper palmar digital nerves to the thumb
6)Proper palmar digital nerve to index
and fracture of ulnar
metaphsysis
Fractures 🔹
Repetitive flexion/extension
Signs and Symptoms
Tingling
7)Common palmar digital nerves
8)Common palmar digital nerves
9)Palmar digital branches of ulnar n.
pain 10)Palmar digital branches of ulnar d.n.
Parasthesia
Carpal tunnel syndrome (CTS)
🔹GALLIAZI FRACTURE 🔹
🔹result from repetitive stress to tissue
Night p
Radial shaft fracture, with distal radioulnar joint. 2
🔹
🔹
64% of work injuries
Compressive neuropathy
Ulnar impaction syndrome ( gymnastics
Ulnar Variance
🔹Wrist flexion/ext and finger movements
Risk factors:
wrist injuries ) •exertion
🔹 Difference in length between ulna and radius •repetitive stress
🔹
Progressive degeneration of the triangular fibrocartilage
•posture
🔹
complex and ulnar carpus
Ulnar impaction syndrome in a 41-year-old man with positive 🔹
Same length (within 1 mm) UV = 0
Longer ulna -> UV is positive
localized contact Which is more pronounced:?
🔹
variance and chronic ulnar-sided wrist pain
Extensive chondromalacia and subchondral degenerative
🔹 Longer radius ->UV is negative 🔹
•cold
Repetitive motions cause inflammation and
Sensory Deficits or Motor Function
deficit
sclerosis involving the ulnar aspect of the lunate bone and the
Ulnar Variance potential cause 🔹
edema
Increased pressure in the confined space
radial aspect of the triquetral bone (arrowheads)
🔹When upper extremity is used for weight-bearing, 🔹
compresses the median nerve
64% of all new occupational illnesses in
symptoms
🔹 Tasks require a large variety of wrist motions
radius accepts approximately 80% of load
🔹Repetitive compressive loading + skeletally immature Ulnar 🔹
1996
60% of all new occupational illnesses in 🔹
E.g. assembly line vs. typing vs. guitar vs. hammering
Symptoms are associated with specific
person -> premature closure of radial growth plate ->
positive UV
2004
🔹
movement patterns
Two risk factors
•Force
🔹 Mechanism of injury
🔺
•Repetition
two
Repetition is the more important factor of the
🔹
Fall on dorsiflexed and ulnar deviated wrist
Axial load with forearm in hyperpronation
Patient c/o ulnar sided wrist pain, swelling, loss of grip TREATMENT
conservative
strength
Wrist operative
Radiography
🔹
EXAMINATION
🔹
🔹
Thickened pad of connective tissue that functions as a Compressive load on hyperextended wrist
🔹
Plain films
🔹
cushion for ulnar axial loads Scaphoid and lunate commonly fractured
🔹
Positive ulnar variance (ulna 1-5 mm longer Tenderness just distal to ulnar styloid •Articulate with radius, which bears 80% of load
🔹
than radial articular surface) ass/w TFCC tear
Assess for fracture or ulnar subluxation
Press test
Patient presses arms of chair to lift body off seat
•Scaphoid: 60-70% of all carpal fractures
•Most likely in wrist extension > 95°, radial side
🔹
MRI or Arthrography optional to confirm 100% sensitive loading
FCC load test Triangular Fibrocartilage •Lunate: Compressive F through capitate
Complex (TFCC) Tear
🔹
Pain is a + test
Rule out injury to distal radio-ulnar joint (DRUJ)
•Squeeze radius/ulna together and passively rotate forearm 🔹 Anatomy
Painful in DRUJ injury -Blood supplied from distal pole
No pain in isolated TFCC tear -The more proximal the fracture, the greater the risk of
🔹
avascular necrosis (AVN) or delayed union
Examination
Treatment
🔹 Long arm cast with forearm neutral for
wrist and hand Carpal fractures -Minimal swelling
-Tenderness in snuff box
4-6 weeks injuries 🔹Radiographs
-Pain with axial load
🔹 Referral criteria:
Associated injuries including DRUJ
forearm
•AP
•Lateral
•Oblique
instability Scaphoid Fracture •Scaphoid view
Persistent pain after immobilization 🔹 Mechanism
🔺Normal plain films don’t rule out a scaphoid fracture
Review 🔹
•Falling on outstretched arm
🔹
Signs and Symptoms
🔹 Refer all vertically displaced AC joint sprains
🔹
•Pain in Anatomical Snuff Box
Treatment
🔹
🔹 Refer any displaced, non-middle-third claviclular fractures History
Non-displaced fracture of waist or distal
🔹 Pick and KNOW 1-2 shoulder reduction methods •FOOSH(fall on outstretched hand )
pole
🔹 Conservatively treat non-displaced radial head fractures Dull, deep, ache in radial side of wrist
•Long arm thumb spica cast 6 weeks
🔹 Refer all Skier’s thumb that gap >20°
Treat suspected scaphoid fxs even if xrays neg
Treat TFCC tears with 6 wks long arm cast
•Then, short arm thumb spica cast for 2-6
weeks Referral criteria
-Replace cast/get x-rays Q2 wks to assess •Proximal fractures
🔹 Proximal radial fractures are rare. Why? 🔹
healing
Clinically suspected fracture with normal
•Angulated; displaced >1mm
Scapholunate dissociation
Colles Fracture
🔹
•due to Protection from overlying musculature
Fractures of distal third of radius
Colles’ fractures,
plain films
-Treat as non-displaced fracture
•Presentation > 2 wks
•Early return to play necessary
•Non-union or AVN
Mechanism -“PRICE”
Smith’s fractures, -Short-arm thumb spica cast
Fall on outstretched arm Barton’s fractures
Signs and Symptoms F/U in 10 days for repeat x-rays
Silver Fork Deformity 🔹
(Young males and old females)
Combined fracture
Fall on outstretched arm
-Consider bone scan/MRI if x-rays neg but fx
suspected
Direct blow to dorsolateral side of wrist
2 🔹Shearing fracture 1🔹Bending fracture Typical suspects, all possible because of
•Anterior lip of radial articular surface is sheared
off
•Landing on outstretched arm
•Axial compressive loads cause radial bending with
a fracture pattern showing anterior metaphyseal
🔹
exposure
🔹 Direct impact
Indirect trauma
•(Barton’s fracture)
cortex failure in tension
•(Colles’ Fracture)
RADIAL FRAUCTRES
🔹
Thumb: essential to prehension
Sprain: skiers thumb
•fall with thumb in abducted position
🔹
•tensile loads on MCL
Hyperextension Bennets fracture
(fighting)Bowler’s thumb:
5🔹Combined fracture
High energy combination loading: 4 🔹Avulsion 3🔹Compressive loads
ulnar digital nerve trauma tingling, sensitivity
•Bending •Example: exaggerated torsion creates Pathoanatomy Stener lesion
•Compression high stresses on osteoligamentous •High fall, for example
•Intraarticular fracture of joint surface
Sprain of ulnar collateral ligament of thumb MCP
🔹
🔹64% of Grade III injuries
•Shearing
•Avulsion
attachments
•Disruption of the subchondral and cancellous 🔹
Grades I, II, and III
🔹 I = no laxity
🔹Adductor aponeurosis interposed
bone
Thumb Sprain
🔹 Ulnar collateral ligament of first metacarpophalangeal joint
🔹 II = laxity but intact
III = complete tear 🔹Prohibits reattachment of ligament
MRI and arthrogram are sensitive
distal radial
“Skier’s Thumb”Gamekeeper’s Thumb"
fractures •Fall on outstretched hand with abducted thumb Mechanism of injury
Hyperextension of first MCP joint Forced abduction and hyperextension of thumb
FOOSH with thumb caught in extension Examination
•E.g. softball player tagging an opponent sliding into base
🔹 Diagnosis
•Anesthesia (block)
•Valgus stress to MCPJ in extension
COMPLICATION
Thumb Injuries History, •Over 20° opening is probably grade III tear
Radiographs
GENERAL ,LOCAL, SPECIFIC , Physical exam
-Compartmet
-FHL
-CRPS (complex region pain syndrome)
-MALUNION 🔹
Treatment
Grades I & II
Thumb spica splint 2-4 weeks, then
TREATMENT 🔹
Splint or tape 3 months
🔹
1 coller fracture: traction ulnar tilt, ulnar tilt Grade III
•Controversial
🔹
volar angulation
2 smith fracture: traction ,dorsal angulation Metacarpal and Phalangeal •Surgery
•Refer to Ortho
rarely surgical ttt mainly conservative Injuries
Thumb Fracture
by fatema okoff
🔹 “Bennett’s fracture”
Fracture subluxation of trapeziometacarpal joint
Axial force on flexed metacarpal bone
Boxer’s Fracture
Injury to 5th metacarpal
Mallet Finger
Injury to extensor tendon
Flexion deformity
Jersey Finger
Injury to Flexor Digitorum Profundus
Boutonniere Deformity
