Most (80%) of first metacarpal fractures occur at the base. Fractures at the base of the first metacarpal are often described as intra-articular or extra-articular. Intra-articular fractures usually occur as a result of an axial force to a flexed thumb. Intra-articular fractures are divided into three types: 1. Rolando 2. Bennett 3. Severely comminuted. A Bennett fracture involves a displaced fracture fragment at the volar ulnar portion of the metacarpal base. The strong volar oblique ligament keeps the Bennett fracture fragment in place as the rest of the metacarpal displaces radially and dorsally. Minimally displaced Bennett fractures are treated in a thumb spica cast for 6 weeks. A Bennett fracture with >1mm of intra-articular displacement is associated with a higher risk of post-traumatic arthritis and is an indication for surgical fixation. A Rolando fracture is a Y-shaped intra-articular fracture at the base of the first metacarpal. Bennett fractures can usually be fixed with closed reduction and percutaneous pinning while a Rolando fracture usually requires open reduction and internal fixation due to fracture comminution. Severely comminuted intra-articular base fractures often require placement of an external fixator.

Proximal humerus fractures account for <5% of fractures in children and the peak age of occurrence is 15 years old. Nearly all proximal humerus and midshaft humerus fractures in the pediatric population can be treated nonoperatively with good results. The younger the patient the greater potential for bone remodeling and greater degree of fracture displacement that the body will correct over time. Physeal closure between the humeral head and the shaft occurs at ages 16 to 19 years of age. Once the physis closes remodeling is not likely to occur. There is no widely accepted criteria to what amount of fracture displacement is acceptable for nonoperative treatment. One age dependent guideline allowed for up to 75 degrees of angulation for patients under 7 years old, up to 60 degrees from 8-11 years old, and up to 45 degrees in children over 12 years old. A hanging arm cast is a common treatment modality that allows for passive fracture reduction as gravity provides traction on the humerus. The long arm hanging cast shown below is generally continued for 3-4 weeks or until early healing can be seen on x-ray. In older pediatric patients with significant fracture displacement, closed reduction and percutaneous pinning may be considered as minimally invasive option. 1, 2

References
1.Bahrs C, Zipplies S, Ochs, BG, Rether J, Oehms J, Eingarttner C, Rolauffs B, Weise K. Proximal Humeral Fractures in Children and Adolescents. Journal of Pediatric Orthopaedics. 2009; 29(3):238-242.
2.Baxter MP, Wiley JJ. Fractures of the Proximal Humeral Epiphysis. Journal of Bone and Joint Surgery. 1986; Aug 4:570-573.

Distal radius fractures are the most commonly seen fracture in the emergency room and many are associated with ipsilateral ulnar styloid fractures. Distal radius fractures are treated with a variety of different methods including immobilization, closed reduction and immobilization, percutaneous pinning, and open reduction and internal fixation. The significance of an ulnar styloid fracture with a distal fracture remains unclear. The ulnar styloid is an attachment site for the triangular fibrocartilage complex (TFCC). The TFCC is a cartilage structure that, along with connecting ligaments, support the distal ulna and radius. The TFCC provides stability to the distal radioulnar joint (DRUJ) with grasping and forearm rotation. For this reason, there is a belief that ulnar styloid fractures disrupt the TFCC causing DRUJ instability. However, no long term differences in outcomes have been found between patients with a displaced ulnar styloid fracture and patients who had a distal radius fracture alone. Wrist function after distal radius fracture is not effected by a fracture of the ulnar styloid base. The main reason for this is that restoring distal radius position with open reduction and internal fixation provides distal radioulnar joint stability and the TFCC eventually heals with immobilization. Ulnar styloid fractures often remain displaced well after the distal radius heals. Patients should be advised that most ulnar styloid fractures never reduce but likely scar down and remain inconsequential to functional outcome. 1,2

References
1. Zenke Y, Sakai A, Oshige T, Moritani S, Nakamura T. The effect of an associated ulnar styloid fracture on the outcome after fixation of a fracture of the distal radius. J Bone Joint Surg. 2009;91B:102–107
2. Kwang KJ, Young-do K, Nam-hoon D. Should An Ulnar Styloid Fracture Be Fixed Following Volar Plate Fixation Of A Distal Radial Fracture? JBJs. 2010 – Volume 92 – Issue 1 – p. 1-6.

When examining a baseball player, one can often observe a callus formed over the hypothenar eminence due to the positioning of their hands on the bat. Through a good clinical exam one often finds point tenderness over the hook of the hamate. A carpal tunnel view should be obtained which allows better visualization of the hook of the hamate, capitate, trapezium, triquetrum and pisiform. If no clear fracture line is visualized, a CT scan should be ordered to rule out a hook of hamate fracture.

A supinated oblique view is helpful in evaluating a patient for a pisiform fracture or pisotriquetral osteoarthritis. This view allows for the articular surface and the contour of the pisiform to be visualized clearly.

A Roberts view is an AP of the thumb. Based upon the history of wrist pain, this would not be helpful in evaluating the above patient.

A patient with scaphoid tenderness often presents with tenderness to palpation along the volar radial aspect of the wrist or in the snuffbox.

Reference
Hamate. http://www.wheelessonline.com. Accessed 1/16/15.

The most common cause of an adult acquired flat foot deformity (AAFFD) is posterior tibial tendon dysfunction. As AAFFD progress the midfoot and forefoot abduct and the hindfoot moves into a valgus position. The deltoid ligament becomes incompetent late in the condition as the hindfoot moves further into a valgus position. A tight Achilles tendon can develop and worsen the deformity. Treatment largely depends on whether the flat foot deformity is rigid or flexible. A rigid flatfoot deformity cannot be corrected passively beyond neutral which is a distinguishable feature from a flexible deformity. On exam of a rigid deformity forefoot pronation cannot be corrected passively with the heel in valgus. The rigidity of the tanlonavicular, subtalar, and calcaneocuboid joints leads to fixed hindfoot valgus and midfoot abduction.
Patients with posterior tibial tendon dysfunction, a flat foot deformity, and a flexible hindfoot are candidates for tendon transfers including posterior tibial tendon debridement and flexor digitorum longus (FDL) tendon transfer or FDL tendon transfer to the navicular, spring ligament repair, calcaneal osteotomy, and Achilles lengthening. Patients with rigid hindfoot valgus and forefoot abduction deformities require a fusion procedure, most commonly a triple arthrodesis. A triple arthrodesis involves fusion of the talonavicular, subtalar, and calcaneocuboid joints. The goal of fusion is to create a neutral hindfoot and forefoot.

References
1. Vulcano E, Deland JT, Ellis SJ. Approach and treatment of the adult acquired flatfoot deformity. Curr Rev Musculoskelet Med. 2013 Dec; 6(4): 294–303.
2. Abousayed M, Alley M, Shakked R, Rosenbaum A. Adult-Acquired Flatfoot Deformity: Etiology, Diagnosis, and Management. JBJS Reviews: August 2017 – Volume 5 – Issue 8 – p