4. Lisfranc Fracture Second metatarsal acts as stabilizing force of the metatarsal-tarsal complex Divided into homolateral and divergent Normally medial aspect of middle cuneiform in line with medical aspect of second metatarsal Emergent orthopedic referral
6. Calcaneus Fracture Multiple types, with 10 percent associated with compression fractures of the lumbar spine Bohler’s angle is angle formed by line from posterior tuberosity and apex of the posterior facet, and line form apex of posterior facet to the apex of the anterior process (angle of less than 20 degrees suggests compression fracture) Immobilization in bulky compressive dressing with early orthopedic consultation
8. Jones fracture Transverse fracture through the base of the 5th metatarsal 10-20mm distal to the proximal part of the metatarsal Nonunion/malunion is a complication NWB cast for 6 weeks
12. March Fracture Stress fracture of the metatarsals Third metatarsal is most common Initial radiographs often “negative” Later radiographs show callous formation Symptomatic relief with crutches, and possibly walking cast
14. Distal Phalanx Fracture Classified as extra-articular or intra-articular fractures Must look for associated nail bed injuries, subungal hematomas Dorsal or hairpin splint with follow up
16. Middle Phalanx Fracture Both the flexor digitorum superficialis and extensor digitorum insert here Splint in position of function Degree of angulation and displacement will determine urgency of orthopedic referral
18. Proximal Phalanx Fracture No tendons attach to proximal phalanx Splint in position of function Degree of angulation and displacement will determine urgency of orthopedic referral
20. Boxer’s Fracture Up to 40 degrees of angulation is acceptable for 5th metacarpal fractures Up to 15 degrees of angulation is acceptable for 4th metacarpal fractures Accurate anatomic reduction is essential for 2nd and 3rd metacarpal fractures Reduce, splint, with orthopedic follow-up
22. Bennett’s Fracture Fracture combined with subluxation or dislocation of the metacarpal joint CT often necessary to evaluate carpometacarpal joint Immobilize (thumb abducted and MCP joint should not be hyperexteded) Emergent orthopedic referral (possible percutanous wiring)
24. Rolando Fracture Second type of intraarticular 1st metacarpal fracture T or Y fracture involving joint surface Splint with orthopedic referral Has poor prognosis, and is dependent on degree of comminution
26. Scaphoid Fracture Most commonly fractured carpal bone No direct blood supply to proximal portion, so susceptible to avascular necrosis The more proximal the fracture, the higher the risk of avascular necrosis Check for “snuff box tenderness” and pain with axial loading of thumb Splint all fractures and suspected fractures, and prompt orthopedic follow-up
28. Pisiform Fracture Caused by direct blow or FOOSH Deep branch of ulnar nerve and artery pass in close proximity Flexor carpi ulnaris attaches to volar surface Splint with orthopedic follow-up Will need short arm cast
30. Hamate Fracture Fractures of the body normally seen with routine radiographs Hamate hook fractures may require carpal tunnel view or CT Ulnar nerve and artery injuries frequently occur Splint with orthopedic referral
32. Colles Fracture Extension fracture of distal radius 60% associated with fracture of ulnar styloid Most common cause is FOOSH Must check for median and ulnar nerve involvement Reduce, splint (sugar tong with 15 degrees of flexion and ulnar deviation) Urgent orthopedic referral Joint involvement requires emergent orthopedic referral
36. Smith Fracture Often called “reverse colles” Uncommon fracture, and rarely involves radioulnar joint Emergent orthopedic referral if available Reduce and long arm splint Barton’s fracture is push-off dorsal rim fracture of radius Hutchinson’s fracture is push-off fracture of radial styloid
38. Nightstick Fracture Isolated fracture of the ulna Often caused by a direct blow (hence the name) Non-displaced factures can be splinted with orthopedic follow-up Displaced fractures may require ORIF
40. Olecranon Fracture Assume intra-articular involvement, so near perfect reduction is necessary for regaining full range of motion Must document ulnar nerve function Non-displaced fractures can be placed in long arm splint at 90 degrees flexion Displaced fractures will need emergent orthopedic referral for possible ORIF
42. Radial Head Fracture Fairly common injury FOOSH is most common cause Pain to palpation over radial head Presence of posterior fat pad or bulging anterior fat pad may be seen Radiocapitellar line (line through center of radius should pass through middle of capitellum) may be only sign in children Long arm splint with urgency of referral based on displacement
44. Coronoid Process Fracture Rarely seen as isolated injury More often seen with posterior dislocation of elbow Tenderness over antecubital fossa Treatment based on associated injury ie: posterior elbow dislocation
46. Intercondylar Fracture Usually occur in patients over 50 Actually a supracondylar fracture with vertical component (T or Y) Most often caused by direct blow Neurovascular injuries are not frequently associated Splint, with likely admission (in consult with orthopedics)
48. Supracondylar Fracture Most common in children 3-11 y.o. 25% of these fractures in children are greenstick (making radiographic diagnosis difficult) Need to look at anterior humeral line (line drawn along anterior surface of humerus normally transects the middle third of the capitellum) also look for pathologic fad pads BAM (brachial artery and median nerve) Splint with emergent orthopedic referral Only reduce if there is neurovascular compromise
50. Capitellum Fracture 30% have associated proximal radius fracture Rarely seen in children Splint in hyperflexion Adequate reduction difficult with closed techniques, will often need ORIF
52. Lateral Epicondyle Fracture Caused by direct or indirect mechanisms Lateral epicondylar ossification center appears at age 10-11, but not complete until second decade of life Posterior splint with elbow at 90 degrees and forearm neutral Orthopedic referral
54. Monteggia Fracture Fracture of the proximal one third of the ulnar shaft combined with a radial head dislocation Paralysis of deep branch of radial nerve is frequent (usually due to contusion and returns without treatment) Emergent orthopedic referral
56. Galeazzi Fracture Fracture of the distal one third of the radius with instability of the distal radioulnar joint Should be suspected when there is distal radioulnar joint tenderness or ulnar head prominence Commonly associated with distal radioulnar subluxations which can be acute or delayed Emergent referral for possible ORIF
58. Midshaft Humerus Fracture Location of the fracture will determine the displacement Many neurovascular structures near by (brachial plexus, radial nerve, etc) Non-displaced fractures get coaptation splint and orthopedic referral Displaced/angulated fractures need emergent orthopedic referral
60. Proximal Humerus Fracture Occur commonly in elderly Include all fractures proximal to the surgical neck Neer classification divides proximal humus into 4 parts (grater tuberosity, lesser tuberosity, anatomic neck, surgical neck) 3 and 4 part fractures often associated with dislocation Must assess brachial plexus, axillary nerve/artery 80% of these fractures are one part fractures that only need sling and swath
62. Greater Tuberosity Humeral Fracture Neer 2 part fracture Sling and swath with orthopedic referral Early mobilization associated with better outcomes
64. Hill Sachs Fracture Impaction fracture of the postero-lateral aspect of humeral head Bankart lesion is disruption of lower part of labrum, and is definite if inferior rim of glenoid has fracture
68. Scapula Fracture Relatively uncommon High degree of force needed (look for other injuries) Non-displaced fractures often only get sling Displaced fractures may need defining with CT and require ORIF
70. Pelvic Fracture Another lecture in itself Mortality 5-20% Remember pelvis is a “ring” structure Many associated injuries ie: urogenital Often require CT for better classification and operative planning Emergent orthopedic consultation
72. Acetabular Fracture More pelvic fractures Judet-Letournel classification (post wall, post column, ant wall, ant column, transverse) Follow all lines of the pelvic x-ray for subtle fractures ie: ilioischial and iliopubic lines
74. Proximal Femur Fracture Injury may compromise blood supply to proximal femur Look at Shenton’s line and neck-shaft angle to detect occult fracture Multiple classifications Look for associated injuries Emergent orthopedic consultation with admission
78. Patellar Fracture Three general types are transverse (most common), comminuted (second most common), vertical (10-20%) “Skyline/sunrise view” may be helpful Knee immobilized, long leg posterior splint Orthopedic referral for possible ORIF or patellectomy
80. Tibial Plateau Fracture Caused by violent varus or valgus stress along with axial loading High association with MVC’s May need CT for preoperative planning Splint and orthopedic consultation
82. Osgood-Schlatter Disease Disturbance in development of tibial tuberosity caused by repeated stress Typically seen in girls 8-10 y.o. and boys 10-15 y.o. with males affected 3 times more often Pain and swelling over tibial tuberosity Treat with NSAIDS and reduced activity
84. Fibular Neck Fracture Must suspect significant knee injury Other associated injuries ie: common peroneal nerve Symptomatic relief if all other associated injuries excluded
88. Medial Maleolus Fracture Fractures often associated with ligamentous injury Isolated one part fracture can be splinted with orthopedic referral Danis-Weber classification based on level of the fibular fracture: the more proximal, the greater the risk of syndesmotic disruption and associated instability Unstable 2 or 3 part fractures will necessitate more prompt orthopedic involvement
