1. COLLES' FRACTURE

Definition

Classic Features

• Dinner fork deformity - wrist has dorsiflexion deformity resembling an upside-down fork
• Occurs mostly in elderly women (osteoporotic bone)
• May be associated with: dorsal comminution, intra-articular extension into radiocarpal/radioulnar joints, and ulnar styloid fracture (which may indicate triangular fibrocartilage complex (TFCC) injury)
• Median nerve compression may present as palmar paresthesias

Radiological Features

• PA view: shortened radius, possible intra-articular extension, associated ulnar styloid fracture
• Lateral view: dorsal angulation and displacement, loss of normal volar tilt of distal radial articular surface

Signs of Instability (requiring surgery)

• Dorsal angulation >20 degrees
• Intra-articular involvement
• Marked comminution
• Radial shortening >1 cm

Management

Stable fractures

• Compression dressing and splint; orthopedic follow-up in 7-10 days

Unstable fractures - Closed Reduction

• Hematoma block: 22-gauge needle into dorsum of distal radius, aspirate hematoma, instill 5-10 mL of 1% or 2% lidocaine
• IV regional anesthesia (Bier block)
• Regional nerve blocks (median, radial, ulnar, brachial plexus)
• Procedural sedation

1. Apply finger traps to relax deforming muscle spasm
2. Apply traction with finger traps
3. Push fragment distal and palmar while holding the forearm firmly
4. Restore volar tilt (minimum neutral/zero degrees acceptable)

Operative Indications

• Open fractures
• Neurovascular compromise
• Unstable/severely comminuted/intra-articular fractures
• Failed closed reduction

Complications

2. ANTERIOR SHOULDER DISLOCATION

Overview

Reduction Maneuvers

A. Stimson Maneuver (Gravity-assisted)

• Patient lies prone with arm hanging off the edge of the stretcher
• 5 kg weights are attached to the wrist/forearm
• Gravity pulls the humeral head inferiorly for 20-30 minutes
• Scapular manipulation or gentle ER/IR rotation can be added to aid reduction
• Safe, requires no force, but slow

B. Scapular Manipulation

• Can be done with patient prone (combined with Stimson) or seated
• Rotate the inferior tip of the scapula medially and dorsally toward the spine using thumbs
• If seated: assistant applies traction on the arm while countertraction is on the ipsilateral clavicle

C. "Best of Both" Technique

• Patient seated sideways with unaffected shoulder and hip against stretcher head
• Operator applies downward force on patient's flexed forearm with gentle IR/ER rotation
• Assistant simultaneously performs scapular manipulation

D. External Rotation Method (Hennepin Technique)

• Fully adduct the arm, flex elbow to 90 degrees
• Hold the patient's wrist and guide the arm into slow, gentle external rotation
• Pause momentarily if patient experiences pain
• Continue until forearm is lying on the bed (full ER)
• No traction applied - very gentle, low force

E. Milch Technique

• Start with arm at 10-20 degrees of flexion and slight abduction
• Slowly elevate (abduct) the arm overhead with gentle distal traction
• Once overhead, apply gentle direct pressure on the humeral head to guide it into the glenoid
• If reduction does not occur, bring arm through a full lateral downward arc with outward traction

F. Traction-Countertraction Method

• One sheet wrapped around affected axilla and assistant's waist (countertraction)
• Another sheet around patient's flexed arm and operator's waist (traction)
• Both lean back simultaneously
• Can adduct the arm after traction is applied and apply lateral traction on the humerus

G. Spaso Technique

• Patient supine; operator lifts the arm toward the ceiling applying gentle vertical traction
• Assistant applies countertraction at the shoulder
• Gentle external rotation applied during the procedure
• Single-operator technique; 87.5% success rate reported; comparable efficacy to external rotation method but faster

H. Hippocratic Technique (Historical only - NOT recommended)

• Operator places foot against chest wall for countertraction
• No longer recommended due to serious neurovascular trauma risk

Management

Pre-reduction

• X-ray to confirm direction of dislocation and check for fractures (AP + axillary/scapular Y view)
• Analgesia and muscle relaxation (procedural sedation, intra-articular lidocaine, or IV opioids)
• Neurovascular exam (axillary nerve - test deltoid sensation and motor function)

Reduction

• Choose maneuver based on patient cooperation and operator experience
• External rotation and Spaso techniques work well without sedation
• Stimson and traction-countertraction require more assistance

Post-reduction

• Confirm reduction with post-reduction X-ray
• Repeat neurovascular exam
• Immobilization in a sling:
  • Age <20 years: 3 weeks
  • Age 20-40 years: 1-2 weeks
  • Age >60 years: <1 week (to avoid stiffness)
• Physiotherapy after immobilization with emphasis on internal rotator strengthening
• Avoid external rotation + abduction combined for 3 months

Indications for Surgery

• Irreducible dislocation (rare; may need general anesthesia)
• Associated greater tuberosity fracture displaced >1 cm
• Associated glenoid rim fracture (bony Bankart) with >25% glenoid defect
• Recurrent instability (Bankart repair, Latarjet procedure)

Complications

3. BLOOD SUPPLY OF THE NECK OF FEMUR

Overview

Sources of Blood Supply

1. Medial Femoral Circumflex Artery (MFCA) - MOST IMPORTANT

• Arises from the profunda femoris (deep femoral artery) - occasionally directly from the femoral artery
• Runs posteriorly around the femoral neck
• Provides ~82% of total femoral head blood supply
• At the level of the femoral neck, the MFCA divides into terminal branches called retinacular arteries (also called capsular vessels or capital vessels)
• These retinacular vessels travel along the femoral neck under the synovium (subsynovial intracapsular ring) and penetrate the femoral head at the cervicocephalic junction
• There are 4 groups of retinacular vessels (anterior, medial, lateral - largest contributor, posterior)
• The lateral (superior) retinacular arteries are the most important - they supply the critical weight-bearing area of the femoral head

2. Lateral Femoral Circumflex Artery (LFCA)

• Also from profunda femoris
• Provides ~18% of femoral head blood supply (less important)
• Anastomoses with MFCA to form the extracapsular arterial ring at the base of the femoral neck

3. Artery of the Ligamentum Teres (Foveal Artery)

• Branch of the obturator artery (or MFCA)
• Enters the femoral head through the ligamentum teres at the fovea
• Supplies a small area around the fovea
• NOT sufficient to maintain viability of the entire femoral head if retinacular vessels are disrupted
• In adults, its contribution is variable and generally minor

4. Metaphyseal Vessels (Medullary Vessels)

• Enter via the femoral neck medullary canal
• Also disrupted in displaced neck fractures

Vascular Architecture (Step-by-Step)

Femoral artery / Profunda femoris
        │
        ├── Medial Femoral Circumflex A (MFCA) [posterior route]
        │         │
        │         └── Extracapsular arterial ring
        │                    │
        │                    └── Retinacular arteries (travel under synovium along neck)
        │                               │
        │                               └── Subsynovial intracapsular arterial ring
        │                                          │
        │                                          └── Ascending cervical arteries → Femoral head
        │
        ├── Lateral Femoral Circumflex A (LFCA) [anterior route]
        │         └── Extracapsular arterial ring (minor contribution)
        │
        └── Obturator artery
                  └── Foveal artery (ligamentum teres) → Fovea of femoral head

Key Anatomical Points

• The Retinacula of Weitbrecht are condensations of the hip joint capsule along the femoral neck surface that carry the retinacular vessels
• The hip joint capsule extends to the intertrochanteric line anteriorly, but posteriorly only covers the medial half of the femoral neck - the lateral half of the posterior neck is extracapsular
• The MFCA must be protected in surgical approaches to the hip (e.g., at the level of the piriformis tendon/posterior capsule where it gives its terminal branches)

Why Femoral Neck Fractures Cause AVN

1. The retinacular vessels travel along the surface of the femoral neck inside the capsule
2. A displaced intracapsular fracture (subcapital >> transcervical) shears these vessels
3. The foveal artery alone cannot supply the whole head
4. Loss of blood supply → osteonecrosis of the femoral head (rate: ~15-50% in displaced fractures)

• Garden I & II (undisplaced) - low AVN risk
• Garden III & IV (displaced) - high AVN risk (30-50%)