Orthopedics High Yield Points

MONTEGGIA FRACTURE DISLOCATION

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MONTEGGIA FRACTURE DISLOCATION

• This is a fracture of the upper-third of the ulna with dislocation of the head of the radius.
• It is caused by a fall on an out-stretched hand (hyperpronation injury).
• May also result from a direct blow on the back of the upper forearm.
• Fractures b/w the proximal third of the ulna and the base of olecranon combined with ananterior dislocation of the proximal radio ulnar joint.

Epidemiology:

• rare in adults
• more common in children with peak incidence between 4 and 10 years of age

TYPES

• 2 main categories depending upon the angulation of the ulna fracture – extension andflexion type.
• The extension type, is the commoner of the two, where theulna fracture  angulates  anteriorly (extends) and the radial head  dislocates anteriorly.
• The flexion type is where theulna fracture angulates posteriorly (flexes) and the radial head dislocates posteriorly.

Bado’s classification of Monteggia Fracture 

Type	Direction of radialhead dislocation	Direction of apex of ulnar shaft fracture angulation
I (M/common)	Anterior	Anterior
II	Posterior	Posterior
Ill	Lateral	Lateral
IV	Anterior	Fracture of both radius & ulnaRadius is fractured in proximal third below the bicepital groove

• Posterior interosseous nerve – most commonly injured nerve in forearm fractures, particularly in Monteggia fracture dislocation.
• Treatment: Rigid anatomical fixation by plating (DCP/LCDCP) is the method of choice.

Exam Important

• Monteggia fracture is fracture of the proximal third of the ulna with radial head dislocation.
• In Monteggia fracture  Both ulnar fracture and head of radius is displaced anteriorly.
• Posterior interosseous nerve is injured in Monteggia fracture dislocation.

PERIARTHRITIS SHOULDER (‘FROZEN’ SHOULDER)

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PERIARTHRITIS SHOULDER (‘FROZEN’ SHOULDER)

Also known as:

1. Adhesive capsulitis
2. Frozen shoulder

• Also referred to as the ‘shoulder of fifties’because the condition is very common around that age.
• Gleno-humeral joint becomes painful and stiff.
• Inflammatory degeneration of the shoulder joint capsule and the soft tissues surrounding it, resulting in adhesions.
• It is common in diabetics.

Clinical Features

1. Pain of insidious onset.
2. Worse at night. Increases on movement.
3. Gradual onset of painful limitation of all the movements, abduction and external rotationin particular.
4. Tenderness all round the shoulder with more than one tender spot.

X-ray shows:

• Rarefaction of the head of the humerus.
• Degenerative changes may be seen in acromioclavicular joint.

Treatment

1. Anti-inflammatory drugs.
2. Gradual and active mobilization of the shoulder.
3. Physiotherapeutic application of moist heat therapy, ultrasound therapy, etc.
4. Manipulation under anesthesia followed by exercise therapy.
5. Infiltration with corticosteroids.

• Natural course of the disease: Slow recovery occurs in 2 years.

Exam Important

PERIARTHRITIS SHOULDER (‘FROZEN’ SHOULDER)

Also known as:

1. Adhesive capsulitis
2. Frozen shoulder

• Gleno-humeral joint becomes painful and stiff.
• Inflammatory degeneration of the shoulder joint capsule and the soft tissues surrounding it, resulting in adhesions.
• Gradual onset of painful limitation of all the movements, abduction and external rotation in particular.

It is common in diabetics. 

Love

Periarthritis Shoulder (‘Froen’ Shoulder)

Question  54-year-old female with decreased range of motion and right shoulder pain increasing over the last 2 months. Identify the Underlying disorder by shown in Photograph . In both the images,left side is a normal picture to compare with the abnormal right side. A. Fracture head humerus B. Rotator cuff injury…

Painful arc syndrome

Galeazzi fracture

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Galeazzi fracture

• Galeazzi fracture is fracture of the distal third of the radius with dislocation of the distal radio-ulnar joint
• Galeazzi fracture is fracture of Lower end of radius
• Galeazzi fracture is Fracture of the distal radius with inferior radio ulnar joint dislocation
• Fracture distal 1/3 radius with DRUJ subluxation

Exam Question 

• Galeazzi fracture is fracture of the distal third of the radius with dislocation of the distal radio-ulnar joint
• Galeazzi fracture is fracture of Lower end of radius
• Galeazzi fracture is Fracture of the distal radius with inferior radio ulnar joint dislocation
• Fracture distal 1/3 radius with DRUJ subluxation

Galeazzi fracture

Monteggia fracture Dislocaton

Monteggia fracture Dislocaton

FRACTURES OF THE TALUS

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FRACTURES OF THE TALUS

• Talus also known as‘Astragalus’.
• Unique bone, has no muscle or tendon attachments.
• Held in place mainly by bony and ligamentous support.

Blood Supply

1. Posterior tibial artery→ through calcaneal branches
2. Anterior tibial artery→ through anterolateral/ anteromedial malleolar branches or through medial tarsal artery
3. Peroneal artery→ through perforating branches
4. Artery of the tarsal canal, a branch of posterior tibial artery
5. Artery of the sinus tarsi, a branch of dorsalis pedis artery

MECHANISM

• Fracture of the neck of the talus results from forced dorsiflexion of the ankle.
• Classification of the Fractures/Dislocations and Fracture→Dislocations of the Talus

Following injuries are seen in the talus:

1. Talar neck fracture
2. Talar body fracture
3. Talar head fracture (rare)
4. Subtalar dislocation
5. Total talar dislocation

Classification of talar neck fracture

Based on Hawkins’ classification(1970) it is classified as follows:

• Undisplaced vertical fracture.
• Displaced fracture with subtalar joint subluxation/ dislocation.
• Displaced fracture with both subtalar and ankle dislocation.
• Displaced fracture with subtalar, ankle and talonavicular dislocation. 

Classification of talar body fractures

Based on Sneppen classification(1977) they are classified as follows:

1. Osteochondral dome fractures
2. Coronal, sagittal, horizontal shear fractures
3. Posterior process fractures
4. Lateral process fractures (Snowboarder’s fracture)
5. Crush fractures

• Talar head fractures are rare and generally associated with talonavicular dislocation/subluxation.

Complications

1. Osteochondral fracture may cause loose body inside the joint which results in persistent pain and limitation of movement.
2. Nonunion in fracture neck of the talus.
3. Avascular necrosis of the body of the talus.
4. Degenerative arthritis of the ankle.

Hawkins’ sign:

• This is a sign seen at the end of 6-8 weeks which indicates presence of good vascularity.
• This can be clearly visualized in a mortise view as a subchondral radiolucent band in the dome of the talus.

Treatment

1. Nonoperative:

• Fractures which are undisplaced/ displaced less than 1 mm are immobilized in plaster cast.

2. Operative:

a) Internal fixation: 

• Displaced fractures such as Types II, III and IV neck fractures;
• coronal, sagittal and horizontal shear fractures of the body are openly reduced and internally fixed.

b) Arthroscopy:

• Arthroscopic procedures are done for removal of loose body,
• management of osteochondral lesions and in early degenerative arthritis of ankle.

c) Arthrodesis:

• Indicated in secondary complication of nonunion, avascular necrosis and degenerative arthritis 

d) Total joint arthroplasty:

• Indicated in secondary degene rative arthritis (without AVN).

e) Talectomy or Astragalectomy:

• Rarely done as it renders the ankle highly unstable.

COMPLICATIONS

1. Avascular necrosis and non-union
2. Osteoarthritis

Exam Important

• Ligament supporting the talus is Spring ligament.
• Ligament supporting the head of talus is Plantar calcaneonavicular ligament.
• Most common complication of talus fracture is Avascular necrosis.
• Fracture of talus without displacement in x-ray would lead to Osteoarthritis of ankle & Avascular necrosis of body of talus.

Fractures of the Talus

February 1, 2019

Arterial supply of the lower limb

In “Module”

Avascular Necrosis