Upper Extremity Upper Extremity TraumaTrauma
M4 Student ClerkshipM4 Student Clerkship
UNMC Orthopedic SurgeryUNMC Orthopedic Surgery
Department of Orthopaedic Surgeryand Rehabilitation
TopicsTopics
ClavicleClavicle Shoulder DislocationShoulder Dislocation HumerusHumerus ElbowElbow ForearmForearm Distal RadiusDistal Radius
Clavicle FracturesClavicle Fractures
Clavicle FracturesClavicle Fractures
MechanismMechanism– Fall onto shoulder Fall onto shoulder
(87%)(87%)– Direct blow (7%)Direct blow (7%)– Fall onto outstretched Fall onto outstretched
hand (6%)hand (6%) Trimodal distributionTrimodal distribution
0
10
20
30
40
50
60
70
80
Group I(13yrs)
Group 2(47yrs)
Group 3(59yrs)
Percent
The clavicle is the last ossification
center to complete (sternal end) at about 22-25yo.
Clavicle FracturesClavicle Fractures
Clinical EvaluationClinical Evaluation– Inspect and palpate for deformity/abnormal Inspect and palpate for deformity/abnormal
motionmotion– Thorough distal neurovascular examThorough distal neurovascular exam– Auscultate the chest for the possibility of lung Auscultate the chest for the possibility of lung
injury or pneumothoraxinjury or pneumothorax Radiographic ExamRadiographic Exam
– AP chest radiographs.AP chest radiographs.– Clavicular 45deg A/P oblique X-raysClavicular 45deg A/P oblique X-rays– Traction pictures may be used as wellTraction pictures may be used as well
Clavicle FracturesClavicle Fractures Allman Classification of Clavicle FracturesAllman Classification of Clavicle Fractures
– Type IType I Middle Third (80%)Middle Third (80%)– Type IIType II Distal Third (15%)Distal Third (15%)
Differentiate whether ligaments Differentiate whether ligaments attached to lateral or medial fragmentattached to lateral or medial fragment
– Type IIIType III Medial Third (5%)Medial Third (5%)
Clavicle FractureClavicle Fracture
Closed TreatmentClosed Treatment– Sling immobilization for usually 3-4 weeks with Sling immobilization for usually 3-4 weeks with
early ROM encouragedearly ROM encouraged Operative interventionOperative intervention
– Fractures with neurovascular injuryFractures with neurovascular injury– Fractures with severe associated chest injuriesFractures with severe associated chest injuries– Open fracturesOpen fractures– Group II, type II fracturesGroup II, type II fractures– Cosmetic reasons, uncontrolled deformityCosmetic reasons, uncontrolled deformity– NonunionNonunion
Associated InjuriesAssociated Injuries– Brachial Plexus InjuriesBrachial Plexus Injuries
Contusions most common, penetrating Contusions most common, penetrating (rare)(rare)
– Vascular InjuryVascular Injury– Rib Fractures Rib Fractures – Scapula FracturesScapula Fractures– PneumothoraxPneumothorax
Clavicle FracturesClavicle Fractures
Shoulder DislocationsShoulder Dislocations
Shoulder DislocationsShoulder Dislocations
EpidemiologyEpidemiology– Anterior: Most commonAnterior: Most common– Posterior: Uncommon, 10%, Think Posterior: Uncommon, 10%, Think
Electrocutions & SeizuresElectrocutions & Seizures– Inferior (Luxatio Erecta): Rare, hyperabduction Inferior (Luxatio Erecta): Rare, hyperabduction
injuryinjury
Shoulder DislocationsShoulder Dislocations
Clinical EvaluationClinical Evaluation– Examine axillary nerve (deltoid function, not Examine axillary nerve (deltoid function, not
sensation over lateral shoulder)sensation over lateral shoulder)– Examine M/C nerve (biceps function and Examine M/C nerve (biceps function and
anterolateral forearm sensation)anterolateral forearm sensation) Radiographic EvaluationRadiographic Evaluation
– True AP shoulderTrue AP shoulder– Axillary LateralAxillary Lateral– Scapular YScapular Y– Stryker Notch View (Bony Bankart)Stryker Notch View (Bony Bankart)
Shoulder DislocationsShoulder Dislocations
Anterior Dislocation Recurrence RateAnterior Dislocation Recurrence Rate– Age 20: 80-92%Age 20: 80-92%– Age 30: 60%Age 30: 60%– > Age 40: 10-15%> Age 40: 10-15%
Look for Concomitant InjuriesLook for Concomitant Injuries– Bony:Bony: Bankart, Hill-Sachs Lesion, Glenoid Bankart, Hill-Sachs Lesion, Glenoid
Fracture, Greater Tuberosity FractureFracture, Greater Tuberosity Fracture– Soft Tissue: Soft Tissue: Subscapularis Tear, RCT (older Subscapularis Tear, RCT (older
pts with dislocation)pts with dislocation)– Vascular:Vascular: Axillary artery injury (older pts with Axillary artery injury (older pts with
atherosclerosis)atherosclerosis)– Nerve:Nerve: Axillary nerve neuropraxia Axillary nerve neuropraxia
Anterior DislocationAnterior Dislocation– TraumaticTraumatic– Atraumatic Atraumatic
(Congenital Laxity)(Congenital Laxity)– Acquired Acquired
(Repeated (Repeated Microtrauma)Microtrauma)
Shoulder DislocationsShoulder Dislocations
Posterior DislocationPosterior Dislocation– Adduction/Flexion/IR at time of Adduction/Flexion/IR at time of
injuryinjury– Electrocution and Seizures Electrocution and Seizures
cause overpull of subscapularis cause overpull of subscapularis and latissimus dorsiand latissimus dorsi
– Look for “lightbulb sign” and Look for “lightbulb sign” and “vacant glenoid” sign“vacant glenoid” sign
– Reduce with traction and gentle Reduce with traction and gentle anterior translation (Avoid ER anterior translation (Avoid ER arm arm Fx) Fx)
Shoulder DislocationsShoulder Dislocations
Inferior DislocationsInferior DislocationsLuxatio ErectaLuxatio Erecta– Hyperabduction injuryHyperabduction injury– Arm presents in a flexed Arm presents in a flexed
“asking a question” posture“asking a question” posture– High rate of nerve and High rate of nerve and
vascular injuryvascular injury– Reduce with in-line traction Reduce with in-line traction
and gentle adductionand gentle adduction
Shoulder DislocationsShoulder Dislocations
Shoulder DislocationShoulder Dislocation TreatmentTreatment
– Nonoperative treatmentNonoperative treatment Closed reduction should be performed after adequate Closed reduction should be performed after adequate
clinical evaluation and appropriate sedationclinical evaluation and appropriate sedation
– Reduction Techniques:Reduction Techniques: Traction/countertraction- Generally used with a sheet Traction/countertraction- Generally used with a sheet
wrapped around the patient and one wrapped around the wrapped around the patient and one wrapped around the reducer.reducer.
Hippocratic technique- Effective for one person. One foot Hippocratic technique- Effective for one person. One foot placed across the axillary folds and onto the chest wall placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial then using gentle internal and external rotation with axial tractiontraction
Stimson technique- Patient placed prone with the affected Stimson technique- Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be extremity allowed to hang free. Gentle traction may be usedused
Milch Technique- Arm is abducted and externally rotated Milch Technique- Arm is abducted and externally rotated with thumb pressure applied to the humeral headwith thumb pressure applied to the humeral head
Scapular manipulationScapular manipulation
Shoulder DislocationsShoulder Dislocations
PostreductionPostreduction– Post reduction films are a must to confirm the Post reduction films are a must to confirm the
position of the humeral headposition of the humeral head– Pain controlPain control– Immobilization for 7-10 days then begin Immobilization for 7-10 days then begin
progressive ROMprogressive ROM Operative IndicationsOperative Indications
– Irreducible shoulder (soft tissue interposition)Irreducible shoulder (soft tissue interposition)– Displaced greater tuberosity fracturesDisplaced greater tuberosity fractures– Glenoid rim fractures bigger than 5 mmGlenoid rim fractures bigger than 5 mm– Elective repair for younger patientsElective repair for younger patients
Proximal Humerus FracturesProximal Humerus Fractures
Proximal Humerus FracturesProximal Humerus Fractures
EpidemiologyEpidemiology– Most common fracture of the humerusMost common fracture of the humerus– Higher incidence in the elderly, thought to be Higher incidence in the elderly, thought to be
related to osteoporosisrelated to osteoporosis– Females 2:1 greater incidence than malesFemales 2:1 greater incidence than males
Mechanism of InjuryMechanism of Injury– Most commonly a fall onto an outstretched arm Most commonly a fall onto an outstretched arm
from standing heightfrom standing height– Younger patient typically present after high Younger patient typically present after high
energy trauma such as MVAenergy trauma such as MVA
Proximal Humerus FracturesProximal Humerus Fractures
Clinical EvaluationClinical Evaluation– Patients typically present with Patients typically present with
arm held close to chest by arm held close to chest by contralateral hand. Pain and contralateral hand. Pain and crepitus detected on palpationcrepitus detected on palpation
– Careful NV exam is essential, Careful NV exam is essential, particularly with regards to the particularly with regards to the axillary nerve. Test sensation axillary nerve. Test sensation over the deltoid. Deltoid atony over the deltoid. Deltoid atony does not necessarily confirm does not necessarily confirm an axillary nerve injuryan axillary nerve injury
Proximal Humerus FracturesProximal Humerus Fractures
Neer ClassificationNeer Classification– Four partsFour parts
Greater and lesser Greater and lesser tuberosities, tuberosities,
Humeral shaftHumeral shaft Humeral headHumeral head
– A part is displaced if A part is displaced if >1 cm displacement >1 cm displacement or >45 degrees of or >45 degrees of angulation is seenangulation is seen
Proximal Humerus FracturesProximal Humerus Fractures TreatmentTreatment
– Minimally displaced fractures- Sling immobilization, early Minimally displaced fractures- Sling immobilization, early motionmotion
– Two-part fractures- Two-part fractures- Anatomic neck fractures likely require ORIF. High incidence Anatomic neck fractures likely require ORIF. High incidence
of osteonecrosisof osteonecrosis Surgical neck fractures that are minimally displaced can be Surgical neck fractures that are minimally displaced can be
treated conservatively. Displacement usually requires ORIFtreated conservatively. Displacement usually requires ORIF– Three-part fracturesThree-part fractures
Due to disruption of opposing muscle forces, these are Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement unstable so closed treatment is difficult. Displacement requires ORIF. requires ORIF.
– Four-part fracturesFour-part fractures In general for displacement or unstable injuries ORIF in the In general for displacement or unstable injuries ORIF in the
young and hemiarthroplasty in the elderly and those with young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%)severe comminution. High rate of AVN (13-34%)
Humeral Shaft FracturesHumeral Shaft Fractures
Humeral Shaft FracturesHumeral Shaft Fractures
Mechanism of InjuryMechanism of Injury– Direct trauma is the most common especially Direct trauma is the most common especially
MVAMVA– Indirect trauma such as fall on an outstretched Indirect trauma such as fall on an outstretched
handhand– Fracture pattern depends on stress appliedFracture pattern depends on stress applied
Compressive- proximal or distal humerusCompressive- proximal or distal humerus Bending- transverse fracture of the shaftBending- transverse fracture of the shaft Torsional- spiral fracture of the shaftTorsional- spiral fracture of the shaft Torsion and bending- oblique fracture usually Torsion and bending- oblique fracture usually
associated with a butterfly fragmentassociated with a butterfly fragment
Humeral Shaft FracturesHumeral Shaft Fractures
Clinical evaluationClinical evaluation– Thorough history and Thorough history and
physicalphysical– Patients typically Patients typically
present with pain, present with pain, swelling, and deformity swelling, and deformity of the upper armof the upper arm
– Careful NV exam Careful NV exam important as the radial important as the radial nerve is in close nerve is in close proximity to the proximity to the humerus and can be humerus and can be injuredinjured
Humeral Shaft FracturesHumeral Shaft Fractures
Radiographic evaluationRadiographic evaluation– AP and lateral views of the humerus AP and lateral views of the humerus – Traction radiographs may be indicated Traction radiographs may be indicated
for hard to classify secondary to severe for hard to classify secondary to severe displacement or a lot of comminutiondisplacement or a lot of comminution
Humeral Shaft FracturesHumeral Shaft Fractures Conservative TreatmentConservative Treatment
– Goal of treatment is to Goal of treatment is to establish union with establish union with acceptable alignmentacceptable alignment
– >90% of humeral shaft >90% of humeral shaft fractures heal with fractures heal with nonsurgical managementnonsurgical management 20 degrees of anterior 20 degrees of anterior
angulation, 30 degrees of varus angulation, 30 degrees of varus angulation and up to 3 cm of angulation and up to 3 cm of shortening are acceptableshortening are acceptable
Most treatment begins with Most treatment begins with application of a coaptation spint application of a coaptation spint or a hanging arm cast followed or a hanging arm cast followed by placement of a fracture brace by placement of a fracture brace
Humeral Shaft FracturesHumeral Shaft Fractures
TreatmentTreatment– Operative TreatmentOperative Treatment
Indications for operative Indications for operative treatment include treatment include inadequate reduction, inadequate reduction, nonunion, associated nonunion, associated injuries, open fractures, injuries, open fractures, segmental fractures, segmental fractures, associated vascular or associated vascular or nerve injuriesnerve injuries
Most commonly treated Most commonly treated with plates and screws with plates and screws but also IM nailsbut also IM nails
Humeral Shaft FracturesHumeral Shaft Fractures
Holstein-Lewis FracturesHolstein-Lewis Fractures– Distal 1/3 fracturesDistal 1/3 fractures– May entrap or lacerate radial nerve as the May entrap or lacerate radial nerve as the
fracture passes through the intermuscular fracture passes through the intermuscular septumseptum
Elbow Fracture/DislocationsElbow Fracture/Dislocations
Elbow DislocationsElbow Dislocations EpidemiologyEpidemiology
– Accounts for 11-28% of injuries to the elbowAccounts for 11-28% of injuries to the elbow– Posterior dislocations most commonPosterior dislocations most common– Highest incidence in the young 10-20 years and Highest incidence in the young 10-20 years and
usually sports injuriesusually sports injuries Mechanism of injuryMechanism of injury
– Most commonly due to fall on outstretched hand Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the or elbow resulting in force to unlock the olecranon from the trochleaolecranon from the trochlea
– Posterior dislocation following hyperextension, Posterior dislocation following hyperextension, valgus stress, arm abduction, and forearm valgus stress, arm abduction, and forearm supinationsupination
– Anterior dislocation ensuing from direct force to Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexedthe posterior forearm with elbow flexed
Elbow DislocationsElbow Dislocations
Clinical EvaluationClinical Evaluation– Patients typically present guarding the injured Patients typically present guarding the injured
extremityextremity– Usually has gross deformity and swellingUsually has gross deformity and swelling– Careful NV exam in important and should be Careful NV exam in important and should be
done prior to radiographs or manipulationdone prior to radiographs or manipulation– Repeat after reductionRepeat after reduction
Radiographic EvaluationRadiographic Evaluation– AP and lateral elbow films should be obtained AP and lateral elbow films should be obtained
both pre and post reductionboth pre and post reduction– Careful examination for associated fracturesCareful examination for associated fractures
Elbow Fracture/DislocationsElbow Fracture/Dislocations TreatmentTreatment
– Posterior DislocationPosterior Dislocation Closed reduction under sedationClosed reduction under sedation Reduction should be performed with the elbow flexed Reduction should be performed with the elbow flexed
while providing distal tractionwhile providing distal traction Post reduction management includes a posterior Post reduction management includes a posterior
splint with the elbow at 90 degreessplint with the elbow at 90 degrees Open reduciton for severe soft tissue injuries or bony Open reduciton for severe soft tissue injuries or bony
entrapmententrapment– Anterior DislocationAnterior Dislocation
Closed reduction under sedationClosed reduction under sedation Distal traction to the flexed forearm followed by Distal traction to the flexed forearm followed by
dorsally direct pressure on the volar forearm with dorsally direct pressure on the volar forearm with anterior pressure on the humerusanterior pressure on the humerus
Elbow DislocationsElbow Dislocations
Associated injuriesAssociated injuries– Radial head fx (5-Radial head fx (5-
11%)11%)– TreatmentTreatment
Type I- ConservativeType I- Conservative Type II/III- Attempt Type II/III- Attempt
ORIF vs. radial head ORIF vs. radial head replacementreplacement
No role for solely No role for solely excision of radial head excision of radial head in 2006.in 2006.
Elbow DislocationsElbow Dislocations
Associated Associated injuriesinjuries– Coronoid process Coronoid process
fractures (5-10%)fractures (5-10%)
Elbow DislocationsElbow Dislocations
Associated injuriesAssociated injuries– Medial or lateral epicondylar fx (12-Medial or lateral epicondylar fx (12-
34%)34%)
Elbow DislocationsElbow Dislocations Instability ScaleInstability Scale
– Type IType I Posterolateral rotary Posterolateral rotary
instability, lateral ulnar instability, lateral ulnar collateral ligament disruptedcollateral ligament disrupted
– Type IIType II Perched condyles, varus Perched condyles, varus
instability, ant and post instability, ant and post capsule disruptedcapsule disrupted
– Type IIIType III A: posterior dislocation with A: posterior dislocation with
valgus instability, medial valgus instability, medial collateral ligament disruptioncollateral ligament disruption
B: posterior dislocation, B: posterior dislocation, grossly unstable, lateral, grossly unstable, lateral, medial, anterior, and medial, anterior, and posterior disruptionposterior disruption
Forearm FracturesForearm Fractures
Forearm FracturesForearm Fractures
EpidemiologyEpidemiology– Highest ratio of open to closed than any Highest ratio of open to closed than any
other fracture except the tibiaother fracture except the tibia– More common in males than females, More common in males than females,
most likely secondary mva, contact most likely secondary mva, contact sports, altercations, and fallssports, altercations, and falls
Mechanism of InjuryMechanism of Injury– Commonly associated with mva, direct Commonly associated with mva, direct
trauma missile projectiles, and fallstrauma missile projectiles, and falls
Forearm FracturesForearm Fractures Clinical EvaluationClinical Evaluation
– Patients typically present with gross deformity of Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of the forearm and with pain, swelling, and loss of function at the handfunction at the hand
– Careful exam is essential, with specific Careful exam is essential, with specific assessment of radial, ulnar, and median nerves assessment of radial, ulnar, and median nerves and radial and ulnar pulsesand radial and ulnar pulses
– Tense compartments, unremitting pain, and pain Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for with passive motion should raise suspicion for compartment syndromecompartment syndrome
Radiographic EvaluationRadiographic Evaluation– AP and lateral radiographs of the forearmAP and lateral radiographs of the forearm– Don’t forget to examine and x-ray the elbow and Don’t forget to examine and x-ray the elbow and
wristwrist
Forearm FracturesForearm Fractures Ulna FracturesUlna Fractures
– These include nightstick and Monteggia fracturesThese include nightstick and Monteggia fractures– Monteggia denotes a fracture of the proximal Monteggia denotes a fracture of the proximal
ulna with an associated radial head dislocationulna with an associated radial head dislocation Monteggia fractures classification- BadoMonteggia fractures classification- Bado Type I- Anterior Dislocation of the radial head with Type I- Anterior Dislocation of the radial head with
fracture of ulna at any level- produced by forced fracture of ulna at any level- produced by forced pronationpronation
Type II- Posterior/posterolateral dislocation of the radial Type II- Posterior/posterolateral dislocation of the radial head- produced by axial loading with the forearm flexedhead- produced by axial loading with the forearm flexed
Type III- Lateral/anterolateral dislocation of the radial Type III- Lateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysis- forced head with fracture of the ulnar metaphysis- forced abduction of the elbowabduction of the elbow
Type IV- anterior dislocation of the radial head with Type IV- anterior dislocation of the radial head with fracture of radius and ulna at the same level- forced fracture of radius and ulna at the same level- forced pronation with radial shaft failurepronation with radial shaft failure
Forearm FracturesForearm Fractures Radial Diaphysis FracturesRadial Diaphysis Fractures
– Fractures of the proximal two-thirds can be considered Fractures of the proximal two-thirds can be considered truly isolatedtruly isolated
– Galeazzi or Piedmont fractures refer to fracture of the Galeazzi or Piedmont fractures refer to fracture of the radius with disruption of the distal radial ulnar jointradius with disruption of the distal radial ulnar joint
– A reverse Galeazzi denotes a fracture of the distal ulna A reverse Galeazzi denotes a fracture of the distal ulna with disruption of radioulnar jointwith disruption of radioulnar joint
MechanismMechanism– Usually caused by direct or indirect trauma, such as fall Usually caused by direct or indirect trauma, such as fall
onto outstretched handonto outstretched hand– Galeazzi fractures may result from direct trauma to the Galeazzi fractures may result from direct trauma to the
wrist, typically on the dorsolateral aspect, or fall onto wrist, typically on the dorsolateral aspect, or fall onto outstretched hand with pronationoutstretched hand with pronation
– Reverse Galeazzi results from fall with hand in supinationReverse Galeazzi results from fall with hand in supination
Distal Radius FracturesDistal Radius Fractures
Distal Radius FracturesDistal Radius Fractures
EpidemiologyEpidemiology– Most common fractures of the upper extremityMost common fractures of the upper extremity– Common in younger and older patients. Usually Common in younger and older patients. Usually
a result of direct trauma such as fall on out a result of direct trauma such as fall on out stretched handstretched hand
– Increasing incidence due to aging populationIncreasing incidence due to aging population Mechanism of InjuryMechanism of Injury
– Most commonly a fall on an outstretched Most commonly a fall on an outstretched extremity with the wrist in dorsiflexionextremity with the wrist in dorsiflexion
– High energy injuries may result in significantly High energy injuries may result in significantly displaced, highly unstable fracturesdisplaced, highly unstable fractures
Distal Radius FracturesDistal Radius Fractures
Clinical EvaluationClinical Evaluation– Patients typically present with gross Patients typically present with gross
deformity of the wrist with variable deformity of the wrist with variable displacement of the hand in relation to the displacement of the hand in relation to the wrist. Typically swollen with painful ROMwrist. Typically swollen with painful ROM
– Ipsilateral shoulder and elbow must be Ipsilateral shoulder and elbow must be examinedexamined
– NV exam including specifically median NV exam including specifically median nerve for acute carpal tunnel compression nerve for acute carpal tunnel compression syndromesyndrome
Radiographic EvaluationRadiographic Evaluation
3 view of the wrist including AP, Lat, 3 view of the wrist including AP, Lat, and Obliqueand Oblique– Normal RelationshipsNormal Relationships
23 Deg
11 mm
11 Deg
Distal Radius FracturesDistal Radius Fractures EponymsEponyms
– Colles FractureColles Fracture Combination of intra and extra articular fractures of the distal Combination of intra and extra articular fractures of the distal
radius with dorsal angulation (apex volar), dorsal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortentingdisplacement, radial shift, and radial shortenting
Most common distal radius fracture caused by fall on Most common distal radius fracture caused by fall on outstretched handoutstretched hand
– Smith Fracture (Reverse Colles)Smith Fracture (Reverse Colles) Fracture with volar angulation (apex dorsal) from a fall on a Fracture with volar angulation (apex dorsal) from a fall on a
flexed wristflexed wrist– Barton FractureBarton Fracture
Fracture with dorsal or volar rim displaced with the hand and Fracture with dorsal or volar rim displaced with the hand and carpuscarpus
– Radial Styloid Fracture (Chauffeur Fracture)Radial Styloid Fracture (Chauffeur Fracture) Avulsion fracture with extrinsic ligaments attached to the Avulsion fracture with extrinsic ligaments attached to the
fragmentfragment Mechanism of injury is compression of the scaphoid against Mechanism of injury is compression of the scaphoid against
the styloidthe styloid
Distal Radius FracturesDistal Radius Fractures
TreatmentTreatment– Displaced fractures require and attempt at Displaced fractures require and attempt at
reduction.reduction. Hematoma block-10ccs of lidocaine or a mix of lidocaine Hematoma block-10ccs of lidocaine or a mix of lidocaine
and marcaine in the fracture siteand marcaine in the fracture site Hang the wrist in fingertraps with a traction weightHang the wrist in fingertraps with a traction weight Reproduce the fracture mechanism and reduce the Reproduce the fracture mechanism and reduce the
fracturefracture Place in sugar tong splintPlace in sugar tong splint
– Operative ManagementOperative Management For the treatment of intraarticular, unstable, malreduced For the treatment of intraarticular, unstable, malreduced
fractures.fractures. As always, open fractures must go to the OR.As always, open fractures must go to the OR.