M4Lecture3UpperExtremity上肢影像学资料课件

UpperExtremityTraumaM4StudentClerkshipUNMCOrthopedicSurgeryDepartmentofOrthopaedicSurgeryandRehabilitationUpperExtremityTraumaM4StudeTopicsClavicleShoulderDislocationHumerusElbowForearmDistalRadiusTopicsClavicleClavicleFracturesClavicleFracturesClavicleFracturesMechanismFallontoshoulder(87%)Directblow(7%)Fallontooutstretchedhand(6%)TrimodaldistributionTheclavicleisthelastossificationcentertocomplete(sternalend)atabout22-25yo.ClavicleFracturesMechanismTheClavicleFracturesClinicalEvaluationInspectandpalpatefordeformity/abnormalmotionThoroughdistalneurovascularexamAuscultatethechestforthepossibilityoflunginjuryorpneumothoraxRadiographicExamAPchestradiographs.Clavicular45degA/PobliqueX-raysTractionpicturesmaybeusedaswellClavicleFracturesClinicalEvaClavicleFracturesAllmanClassificationofClavicleFracturesTypeI MiddleThird(80%)TypeII DistalThird(15%)DifferentiatewhetherligamentsattachedtolateralormedialfragmentTypeIII MedialThird(5%)ClavicleFracturesAllmanClassClavicleFractureClosedTreatmentSlingimmobilizationforusually3-4weekswithearlyROMencouragedOperativeinterventionFractureswithneurovascularinjuryFractureswithsevereassociatedchestinjuriesOpenfracturesGroupII,typeIIfracturesCosmeticreasons,uncontrolleddeformityNonunionClavicleFractureClosedTreatmAssociatedInjuriesBrachialPlexusInjuriesContusionsmostcommon,penetrating(rare)VascularInjuryRibFracturesScapulaFracturesPneumothoraxClavicleFracturesAssociatedInjuriesClavicleFrShoulderDislocationsShoulderDislocationsShoulderDislocationsEpidemiologyAnterior:MostcommonPosterior:Uncommon,10%,ThinkElectrocutions&SeizuresInferior(LuxatioErecta):Rare,hyperabductioninjuryShoulderDislocationsEpidemiolShoulderDislocationsClinicalEvaluationExamineaxillarynerve(deltoidfunction,notsensationoverlateralshoulder)ExamineM/Cnerve(bicepsfunctionandanterolateralforearmsensation)RadiographicEvaluationTrueAPshoulderAxillaryLateralScapularYStrykerNotchView(BonyBankart)ShoulderDislocationsClinicalShoulderDislocationsAnteriorDislocationRecurrenceRateAge20:80-92%Age30:60%>Age40:10-15%LookforConcomitantInjuriesBony:Bankart,Hill-SachsLesion,GlenoidFracture,GreaterTuberosityFractureSoftTissue:SubscapularisTear,RCT(olderptswithdislocation)Vascular:Axillaryarteryinjury(olderptswithatherosclerosis)Nerve:AxillarynerveneuropraxiaShoulderDislocationsAnteriorAnteriorDislocationTraumaticAtraumatic (CongenitalLaxity)Acquired (RepeatedMicrotrauma)ShoulderDislocationsAnteriorDislocationShoulderDPosteriorDislocationAdduction/Flexion/IRattimeofinjuryElectrocutionandSeizurescauseoverpullofsubscapularisandlatissimusdorsiLookfor“lightbulbsign”and“vacantglenoid”signReducewithtractionandgentleanteriortranslation(AvoidERarmFx)ShoulderDislocationsPosteriorDislocationShoulderInferiorDislocations LuxatioErectaHyperabductioninjuryArmpresentsinaflexed“askingaquestion”postureHighrateofnerveandvascularinjuryReducewithin-linetractionandgentleadductionShoulderDislocationsInferiorDislocationsShoulderShoulderDislocationTreatmentNonoperativetreatmentClosedreductionshouldbeperformedafteradequateclinicalevaluationandappropriatesedationReductionTechniques:Traction/countertraction-Generallyusedwithasheetwrappedaroundthepatientandonewrappedaroundthereducer.Hippocratictechnique-Effectiveforoneperson.OnefootplacedacrosstheaxillaryfoldsandontothechestwallthenusinggentleinternalandexternalrotationwithaxialtractionStimsontechnique-Patientplacedpronewiththeaffectedextremityallowedtohangfree.GentletractionmaybeusedMilchTechnique-ArmisabductedandexternallyrotatedwiththumbpressureappliedtothehumeralheadScapularmanipulationShoulderDislocationTreatmentShoulderDislocationsPostreductionPostreductionfilmsareamusttoconfirmthepositionofthehumeralheadPaincontrolImmobilizationfor7-10daysthenbeginprogressiveROMOperativeIndicationsIrreducibleshoulder(softtissueinterposition)DisplacedgreatertuberosityfracturesGlenoidrimfracturesbiggerthan5mmElectiverepairforyoungerpatientsShoulderDislocationsPostreducProximalHumerusFracturesProximalHumerusFracturesM4Lecture3UpperExtremity上肢影像学资料课件ProximalHumerusFracturesEpidemiologyMostcommonfractureofthehumerusHigherincidenceintheelderly,thoughttoberelatedtoosteoporosisFemales2:1greaterincidencethanmalesMechanismofInjuryMostcommonlyafallontoanoutstretchedarmfromstandingheightYoungerpatienttypicallypresentafterhighenergytraumasuchasMVAProximalHumerusFracturesEpidProximalHumerusFracturesClinicalEvaluationPatientstypicallypresentwitharmheldclosetochestbycontralateralhand.PainandcrepitusdetectedonpalpationCarefulNVexamisessential,particularlywithregardstotheaxillarynerve.Testsensationoverthedeltoid.DeltoidatonydoesnotnecessarilyconfirmanaxillarynerveinjuryProximalHumerusFracturesClinProximalHumerusFracturesNeerClassificationFourpartsGreaterandlessertuberosities,HumeralshaftHumeralheadApartisdisplacedif>1cmdisplacementor>45degreesofangulationisseenProximalHumerusFracturesNeerProximalHumerusFracturesTreatmentMinimallydisplacedfractures-Slingimmobilization,earlymotionTwo-partfractures-AnatomicneckfractureslikelyrequireORIF.HighincidenceofosteonecrosisSurgicalneckfracturesthatareminimallydisplacedcanbetreatedconservatively.DisplacementusuallyrequiresORIFThree-partfracturesDuetodisruptionofopposingmuscleforces,theseareunstablesoclosedtreatmentisdifficult.DisplacementrequiresORIF.Four-partfracturesIngeneralfordisplacementorunstableinjuriesORIFintheyoungandhemiarthroplastyintheelderlyandthosewithseverecomminution.HighrateofAVN(13-34%)ProximalHumerusFracturesTreaHumeralShaftFracturesHumeralShaftFracturesHumeralShaftFracturesMechanismofInjuryDirecttraumaisthemostcommonespeciallyMVAIndirecttraumasuchasfallonanoutstretchedhandFracturepatterndependsonstressappliedCompressive-proximalordistalhumerusBending-transversefractureoftheshaftTorsional-spiralfractureoftheshaftTorsionandbending-obliquefractureusuallyassociatedwithabutterflyfragmentHumeralShaftFracturesMechaniHumeralShaftFracturesClinicalevaluationThoroughhistoryandphysicalPatientstypicallypresentwithpain,swelling,anddeformityoftheupperarmCarefulNVexamimportantastheradialnerveisincloseproximitytothehumerusandcanbeinjuredHumeralShaftFracturesClinicaHumeralShaftFracturesRadiographicevaluationAPandlateralviewsofthehumerusTractionradiographsmaybeindicatedforhardtoclassifysecondarytoseveredisplacementoralotofcomminutionHumeralShaftFracturesRadiogrHumeralShaftFracturesConservativeTreatmentGoaloftreatmentistoestablishunionwithacceptablealignment>90%ofhumeralshaftfractureshealwithnonsurgicalmanagement20degreesofanteriorangulation,30degreesofvarusangulationandupto3cmofshorteningareacceptableMosttreatmentbeginswithapplicationofacoaptationspintorahangingarmcastfollowedbyplacementofafracturebraceHumeralShaftFracturesConservHumeralShaftFracturesTreatmentOperativeTreatmentIndicationsforoperativetreatmentincludeinadequatereduction,nonunion,associatedinjuries,openfractures,segmentalfractures,associatedvascularornerveinjuriesMostcommonlytreatedwithplatesandscrewsbutalsoIMnailsHumeralShaftFracturesTreatmeHumeralShaftFracturesHolstein-LewisFracturesDistal1/3fracturesMayentraporlacerateradialnerveasthefracturepassesthroughtheintermuscularseptumHumeralShaftFracturesHolsteiElbowFracture/DislocationsElbowFracture/DislocationsElbowDislocationsEpidemiologyAccountsfor11-28%ofinjuriestotheelbowPosteriordislocationsmostcommonHighestincidenceintheyoung10-20yearsandusuallysportsinjuriesMechanismofinjuryMostcommonlyduetofallonoutstretchedhandorelbowresultinginforcetounlocktheolecranonfromthetrochleaPosteriordislocationfollowinghyperextension,valgusstress,armabduction,andforearmsupinationAnteriordislocationensuingfromdirectforcetotheposteriorforearmwithelbowflexedElbowDislocationsEpidemiologyElbowDislocationsClinicalEvaluationPatientstypicallypresentguardingtheinjuredextremityUsuallyhasgrossdeformityandswellingCarefulNVexaminimportantandshouldbedonepriortoradiographsormanipulationRepeatafterreductionRadiographicEvaluationAPandlateralelbowfilmsshouldbeobtainedbothpreandpostreductionCarefulexaminationforassociatedfracturesElbowDislocationsClinicalEvaElbowFracture/DislocationsTreatmentPosteriorDislocationClosedreductionundersedationReductionshouldbeperformedwiththeelbowflexedwhileprovidingdistaltractionPostreductionmanagementincludesaposteriorsplintwiththeelbowat90degreesOpenreducitonforseveresofttissueinjuriesorbonyentrapmentAnteriorDislocationClosedreductionundersedationDistaltractiontotheflexedforearmfollowedbydorsallydirectpressureonthevolarforearmwithanteriorpressureonthehumerusElbowFracture/DislocationsTreElbowDislocationsAssociatedinjuriesRadialheadfx(5-11%)TreatmentTypeI-ConservativeTypeII/III-AttemptORIFvs.radialheadreplacementNoroleforsolelyexcisionofradialheadin2006.ElbowDislocationsAssociatediElbowDislocationsAssociatedinjuriesCoronoidprocessfractures(5-10%)ElbowDislocationsAssociatediElbowDislocationsAssociatedinjuriesMedialorlateralepicondylarfx(12-34%)ElbowDislocationsAssociatediElbowDislocationsInstabilityScaleTypeIPosterolateralrotaryinstability,lateralulnarcollateralligamentdisruptedTypeIIPerchedcondyles,varusinstability,antandpostcapsuledisruptedTypeIIIA:posteriordislocationwithvalgusinstability,medialcollateralligamentdisruptionB:posteriordislocation,grosslyunstable,lateral,medial,anterior,andposteriordisruptionElbowDislocationsInstabilityForearmFracturesForearmFracturesForearmFracturesEpidemiologyHighestratioofopentoclosedthananyotherfractureexceptthetibiaMorecommoninmalesthanfemales,mostlikelysecondarymva,contactsports,altercations,andfallsMechanismofInjuryCommonlyassociatedwithmva,directtraumamissileprojectiles,andfallsForearmFracturesEpidemiologyForearmFracturesClinicalEvaluationPatientstypicallypresentwithgrossdeformityoftheforearmandwithpain,swelling,andlossoffunctionatthehandCarefulexamisessential,withspecificassessmentofradial,ulnar,andmediannervesandradialandulnarpulsesTensecompartments,unremittingpain,andpainwithpassivemotionshouldraisesuspicionforcompartmentsyndromeRadiographicEvaluationAPandlateralradiographsoftheforearmDon’tforgettoexamineandx-raytheelbowandwristForearmFracturesClinicalEvalForearmFracturesUlnaFracturesTheseincludenightstickandMonteggiafracturesMonteggiadenotesafractureoftheproximalulnawithanassociatedradialheaddislocationMonteggiafracturesclassification-BadoTypeI-AnteriorDislocationoftheradialheadwithfractureofulnaatanylevel-producedbyforcedpronationTypeII-Posterior/posterolateraldislocationoftheradialhead-producedbyaxialloadingwiththeforearmflexedTypeIII-Lateral/anterolateraldislocationoftheradialheadwithfractureoftheulnarmetaphysis-forcedabductionoftheelbowTypeIV-anteriordislocationoftheradialheadwithfractureofradiusandulnaatthesamelevel-forcedpronationwithradialshaftfailureForearmFracturesUlnaFractureForearmFracturesRadialDiaphysisFracturesFracturesoftheproximaltwo-thirdscanbeconsideredtrulyisolatedGaleazziorPiedmontfracturesrefertofractureoftheradiuswithdisruptionofthedistalradialulnarjointAreverseGaleazzidenotesafractureofthedistalulnawithdisruptionofradioulnarjointMechanismUsuallycausedbydirectorindirecttrauma,suchasfallontooutstretchedhandGaleazzifracturesmayresultfromdirecttraumatothewrist,typicallyonthedorsolateralaspect,orfallontooutstretchedhandwithpronationReverseGaleazziresultsfromfallwithhandinsupinationForearmFracturesRadialDiaphyDistalRadiusFracturesDistalRadiusFracturesDistalRadiusFracturesEpidemiologyMostcommonfracturesoftheupperextremityCommoninyoungerandolderpatients.UsuallyaresultofdirecttraumasuchasfallonoutstretchedhandIncreasingincidenceduetoagingpopulationMechanismofInjuryMostcommonlyafallonanoutstretchedextremitywiththewristindorsiflexionHighenergyinjuriesmayresultinsignificantlydisplaced,highlyunstablefracturesDistalRadiusFracturesEpidemiDistalRadiusFracturesClinicalEvaluationPatientstypicallypresentwithgrossdeformityofthewristwithvariabledisplacementofthehandinrelationtothewrist.TypicallyswollenwithpainfulROMIpsila