Fractures Dislocations of the Upper Limb Dr Munir
Fractures & Dislocations of the Upper Limb Dr Munir Saadeddin, FRCSE
Upper Limb include l Clavicle l Scapula l Shoulder Joint l Humerus l Elbow Joint l Forearm Bones l Wrist Joint l Scaphoid Bone
Mechanism of Injuries of the Upper Limb l Mostly Indirect l Commonly described as “ a fall on outstretched hand “ l Type of injury depends on position of the upper limb at the time of impact : Flexed, Extended, adducted, abducted, pronated or supinated
Mechanism of Injury
Splintage & Elevation in Upper Limb The Hand has to be Higher than the Elbow l Simplest splint is the triangular splint which can be made of any piece of cloth l Commonest splint used is the Collar & cuff splint l Strapping the upper limb to the trunk is one method of Immobilisation of shoulder and humerus l
Fractures of the Clavicle l. A common injury in all ages l Most fractures are in the Middle third l Usually it is the result of Indirect injury l Direct injuries are more serious ( possible injury to neuro vascular structures ) l In children it may be a Green stick fracture l Fracture site can be identified easily because clavicle is a subcutaneous bone
? Fracture of the Clavicle
? Fracture of the clavicle l. A child with sudden painful swelling over left clavicle l History of a fall injury few days ago l The swelling is over mid clavicle and is tender l Initial x rays do not show a fracture l The Answer is to repeat the X ray two weeks later
Fracture of the clavicle 2 weeks later
Fracture of the clavicle in Adults
Fracture of the clavicle in Adults l Usually displaced with deformity l May be comminuted l mostly heal with a degree of Mal-Union l Delayed union or Non union are less common l Usually is treated conservatively l Open reduction gives satisfactory alignment but results in unsightly scar
Figure of eight Bandage
Figure of Eight bandage l It is the common way for treating fractures of clavicle conservatively l Simple to apply in Emergency room l It helps to reduce overlap of fracture ends l It should not be applied very tight or it may compress the neuro vascular structures at axilla
Union of Fracture of the clavicle l l Early union occurs in 1 -2 weeks in children In adults early union occurs in 3 weeks , union in 6 weeks and consolidation in 12 weeks l Callus formation can be visible and palpable l Mal united overlap of fracture can be treated by trimming some bone after union of fracture l Non Union is treated by compression Plating and bone grafting
Dislocation of the Shoulder l Mostly Anterior > 95 % of dislocations l Posterior Dislocation occurs < 5 % l True Inferior dislocation ( Luxato Inferno ) occurs < 1% l Habitual Non traumatic dislocation may present as Posterior dislocation or Multi directional dislocation due to ligament laxity and is Painless
Mechanism of anterior shoulder dislocation l Usually Indirect fall on Abducted and extended shoulder l May be direct when there is a blow on the shoulder from behind
Anterior Shoulder dislocation Usually also inferior l There is damage ( Overstretching ) to the shoulder capsule and subscapularis muscle l Commonly there is avulsion to the antero inferior part of the Glenoid labrum with adjacent periosteom on the neck of scapula = Bankart’s Lesion l
Clinical Picture l l Patient is in pain Holds the injured limb with other hand close to the trunk The shoulder is abducted and the elbow is kept flexed There is loss of the normal contour of the shoulder
Clinical Picture l Loss of the contour of the shoulder may appear as a step l Anterior bulge of head of humerus may be visible or palpable l A gap can be palpated above the dislocated head of the humerus
X Ray anterior Dislocation of Shoulder
Associated injuries of anterior Shoulder Dislocation l Injury to the neuro vascular bundle in axilla ( rare ) l Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) l Associated fracture
Axillary or Circumflex Nerve Injury It is a branch from posterior cord of Brachial plexus l It hooks close round neck of humerus from posterior to anterior l It pierces the deep surface of deltoid and supply it and the part of skin over it l
Axillary or circumflex nerve injury
Management Of Anterior Shoulder dislocation l Is an Emergency l It should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerus l Following reduction the shoulder should be immobilised strapped to the trunk for 3 -4 weeks and rested in a collar and cuff
Methods of Reduction of anterior shoulder Dislocation l Hippocrates Method ( A form of anesthesia or pain abolishing is required ) l Stimpson’s technique ( some sedation and analgesia are used but No anesthesia is required ) l Kocher’s technique is the method used in hospitals under general anesthesia and muscle relaxation
Hippocrates Method
Stimpson’s technique
Kocher’s Technique
Complications of anterior Shoulder Dislocation : Early l Neuro vascular injury ( rare ) l Axillary or Circumflex nerve injury l Associated Fracture of neck of humerus or greater or lesser tuberosities
Complications of anterior shoulder Dislocation : Late l Avascular necrosis of the head of the Humerus ( may be delayed up to 2 years and only following delayed reduction ) l Heterotopic calcification ( used to be called Myositis Ossificans ) l Recurrent dislocation
Associated fractures
Fractures of The Humerus l Proximal Humerus (includes surgical and anatomical neck ) l Shaft l Distal of Humerus humerus ( includes Supra Condylar fracture in children )
Fracture Proximal Humerus
Fracture Proximal Humerus : Plating or Rush Nail insertion
Fracture Proximal Humerus : Intra-medullary K wire fixation
Intra-medullary K wire fixation
Fractures Shaft of the Humerus l Commonly Indirect injury l Indirect injury results in Spiral or Oblique fractures l Direct injuries results in transverse or comminuted ( Butterfly ) fracture l May be associated with Radial Nerve injury
Fracture shaft of the Humerus
Radial Nerve Injury l Results in Drop Wrist l Associated with fracture humerus in up to 12% of fractures l 2/3 ( 8%) of Radial injury are Neuropraxia l 1/3 ( 4%) are nerve lacerations or transection
Management of Radial Nerve Injury l When present in open fractures ; immediate exploration and ± repair l In closed injuries treated conservatively ; initial management is doing Nerve Conduction Studies ( NCS ) and Electromyography ( EMG ) and awaiting for spontaneous recovery
Management of Radial Nerve injury l Recovery usually starts after few days but may take up to 9 months for full recovery l If No spontaneous recovery occurs in 12 weeks confirmed by NCS and EMG ; then exploration of the nerve should be carried out
Exploration Radial Nerve
Management of Fracture Shaft of the Humerus l Preferably Conservative l Closed Reduction in upright position followed by application of U shaped Slap of POP or Cylinder cast l Few weeks later or initially in stable fractures Functional Brace may be used
U Shaped slap of POP
Functional brace Fracture Shaft of Humerus
Indications for ORIF Fracture Shaft of Humerus l Failure to reduce fracture conservatively l Bilateral humeral fractures l Open fracture with radial nerve Injury l Unconscious patient l Delayed-Union, Non-Union and Mal-Union
Plating fracture Shaft of humerus
Intra- medullary K Wire Fixation
Supra- condylar Fracture of Humerus
Supra-Condylar fracture of t Humerus
Supra-condylar fracture of Humerus
Acute Volkmann's Ischemia
Reduction of supra-condylar Fracture l Absolute Emergency l Should de done under G A by experienced doctor as soon as possible l In the past the arm was held in flexed elbow position in back-slab POP after reduction l At present time Percutaneous K wire fixation is ALWAYS carried out after reduction
Reduction Supra-Condylar Fracture
Complications Supra-Condylar Fractures A. Early= Brachial Artery injury ( Acute Volkmann's Ischemia ) Nerve Injury : Median, Ulnar or Radial B. Late= Stiffness Volkmann's Ischemic contracture Heterotopic Calcification Mal-Union ( Cubitus Valgus )
Volkman’s Ischemic contracture
Volkmann's Ischemic Contracture
Mal-Union Supra- condylar fracture l Most commonly results in Cubitus Varus l Less common is Cubitus Valgus or Cubitus Recurvatum l Management is by Corrective Supra. Condylar Osteotomy
Intra- Articular fractures of Elbow l Are sometimes difficult to diagnose exactly l X ray of the other shoulder is helpful in diagnosis l C T may be required in some cases l Non displaced intra- articular fractures can be managed by immobilisation in functional position till union l Displaced fractures require ORIF
Intra-articular Fracture of Elbow
Intra-Articular Fracture of Elbow l This is displaced fracture of capitullum which required ORIF l If not reduced Anatomically it will lead to stiffness, deformity and early OA
ORIF Fracture Cpitullum
Fractures Head of Radius
Displaced Fracture Head of Radius
Displaced Fracture Head of Radius l Displaced fractures Head of Radius require ORIF if possible l When unable to reconstruct articular surface Anatomically we carry out excision of the Head
Excision Comminuted Fracture Head of radius
Montegia Fracture Dislocation It is a fracture of the proximal 1/3 rd of the Ulna with dislocation of head of radius anteriorly. Posterirly or laterally l Head of Radius dislocates same direction as fracture l It requires ORIF or it will redisplace l
Montegia : Lateral displacement
Galliazi Fracture l It is a fracture of distal Radius and dislocation of inferior Radio- Ulnar joint l Like Montegia fracture if treated conservatively it will redisplace l This fracture appeared in acceptable position after reduction and POP
Galliazi Fracture l Fracture redisplaced in POP l This required ORIF
Fracture Both Bones of Forearm
Fractures Around the Wrist A. Extra-Articular : Greenstick fracture distal radius in children Colle’s fracture Smith fracture B. Intra-Articular : Barton’s fracture= volar and dorsal Comminuted Intra-articular fracture
Colles’ Fracture l l l Most common fracture in Osteoporotic bones Extra-Articular : 1 inch of distal Radius Results from a fall on dorsi flexed wrist Typical deformity : Dinner Fork Deformity is : Impaction, dorsal displacement and angulation, radial displacement and angulation and avulsion of ulnar styloid process Management is usually conservative : MUA and forearm POP
Colles’ Fracture
Colles’ Fracture
Smith Fracture
Smith Fracture l Almost the opposite of Colles’ fracture l Much less common compared to colles’ l Results from a fall on palmer flexed wrist l Typical deformity : Garden Spade l Management is conservative : MUA and Above Elbow POP
Volar Barton’s Fracture Dislocation It is Intra-Articular with volar displacement which looks like smith fracture l There is dorsal type which looks like Colles’ fracture l Management is by ORIF l
ORIF Volar Barton’s
Comminuted Intra- Articular fractures
External Fixator for Comminuted Fractures
Scaphoid Bone Fractures
Scaphoid bone Fractures
Scaphoid Bone Fractures
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