HPI: Middle-aged male s/p MCC.

PE:  Ecchymoses, swelling, and tenderness about ankle. Tender over proximal fibula and pain with squeezing of calf.

Ankle Sprains:
-        Divided into grades
o   I: Minor, no significant ligamentous damage. Able to bear weight.
o   II: Associated with partial ligamentous tear. Significant ecchymoses/swelling. Difficulty bearing weight.
o   III:  Associated with complete ligamentous tear. Significant functional loss and universal inability to bear weight.

-        When should we obtain radiographs?:
o   If pretest clinical suspicion is high based on mechanism of injury or patient cannot be ruled out for fracture based on Ottawa ankle rules:

Syndesmotic injuries (AKA “high” ankle sprains):
o   PE and mechanism:

• Physical exam may have tenderness with calf squeeze, pain in syndesmosis with external rotation and dorsiflexion of foot, and translation of fibula with anterior/posterior force.
  
• If mechanism of injury involves hyper-dorsiflexion or significant eversion of the ankle, and patient has tenderness of the medial malleolus, a maisonneuve fracture (proximal fibular fracture associated with syndesmotic tear and deep deltoid ligament rupture) should be suspected. Order both ankle films as well as tib/fib films.  As in patient above, Ankle film may show widened mortise, indicating joint instability.
  

o   Treatment:

• Non-operative: Patient may be made NWB and placed in a boot, short-leg cast, or posterior short-leg splint + sugar tong splint. 
  
• Indications for non-op management:

                  -   Syndesmotic sprain without diastasis or ankle instability
                  -   Otherwise patient needs syndesmotic screw fixation. Patient can be immobilized and follow-up as an outpatient for surgical fixation

AP showing mild varus angulation    

Lateral film showing significant posterior displacement of distal portion of fracture

Supracondylar Humerus Fractures:
Two categories:
·       Extension: Distal fragment displaced anteriorly (95% of cases).
·       Flexion: Distal fragment displaced posteriorly (5% of cases).

Four Types:
·       I: Nondisplaced: look for posterior fat pad
·       II: Displaced. Posterior cortex intact
·       III: Completely displaced
·       IV: Complete periosteal disruption with instability on flexion and extension.

Presentation:

·       Usually from fall on outstretched hand.
·       Frequently will have neurologic findings:
·       Anterior Interosseus Neuropraxia:
·       Most common neurologic finding. Particularly with extension-type fractures.
·       AIN is a branch of Median nerve.
·       Patient's cannot flex thumb IP joint or index DIP joint (Can't make an “OK” sign).
        Almost all will resolve with conservative management.

       Also have vascular compromise in approximately 1%
       Usually brachial artery compromise
       High collateral flow, so patient may have a pink, but pulseless extremity. Still requires emergent reduction.

Treatment:
       Type I: Immobilization at 90 degrees and ortho follow-up.
       Type II: Closed reduction unless displacement is minimal.
       Adequate reduction: Baumann's angle wnl, anterior humeral line transects capitellum
       Type III: High-risk for neurovascular complications. Get ortho involved. Almost always require closed reduction + pinning vs. open reduction
     Type IV: Open surgical reduction and fixation

       Indications for open reduction:
       1.) Inadequate reduction with closed techniques
       2.) Vascular injury
       3.) open fracture
       4.) Type iv fracture

HPI: Patient punched a wall

Physical exam: Right hand with significant soft tissue swelling dorsally and TTP over third metacarpal.

Metacarpal Fractures:
            General Principles

• Divided into fractures of metacarpal head, neck, and shaft
  
• Treatment is based on which metacarpal is involved and location of fx
  
• Acceptable angulation varies by location (See chart below)
  
• No degree of malrotation is acceptable

Treatment:
            Immobilization: Indications for non-operative immobilization are
1.)    Stable fracture pattern
2.)    Acceptable angulation
3.)    no rotational deformity
4.)    Shortening of less than 5mm

Splinting:
•       Fracture splints should be forearm-based and should allow for motion of the interphalangeal (IP) joints.
•       Splints should extend over the dorsal and palmar aspect of the entire metacarpal being treated.
•       Generally, the wrist should be placed in 20-30° of extension; the metacarpophalangeal (MCP) joints should be immobilized in 70-90° of flexion, with the dorsal aspect of the splint extending to the IP joints; and the volar aspect should end at the distal palmar crease.
•       Buddy taping the fingers of the involved metacarpal can aid in maintaining rotational control.