Transcript 12- Fractures & Dislocations of the Upper Limb.ppt

Fractures & Dislocations of
the Upper Limb
Dr Munir Saadeddin, FRCSE
Upper Limb include
Clavicle
 Scapula
 Shoulder Joint
 Humerus
 Elbow Joint
 Forearm Bones
 Wrist Joint
 Scaphoid Bone

Mechanism of Injuries of the
Upper Limb

Mostly Indirect

Commonly described as “ a fall on
outstretched hand “

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
 Simplest splint is the triangular splint which can
be made of any piece of
cloth
 Commonest splint used
is the Collar & cuff splint
 Strapping the upper limb
to the trunk is one
method of Immobilisation
of shoulder and humerus

Fractures of the Clavicle
A common injury in all ages
 Most fractures are in the Middle third
 Usually it is the result of Indirect injury
 Direct injuries are more serious ( possible
injury to neuro vascular structures )
 In children it may be a Green stick
fracture
 Fracture site can be identified easily
because clavicle is a subcutaneous bone

? Fracture of the Clavicle
? Fracture of the clavicle
A child with sudden painful swelling over
left clavicle
 History of a fall injury few days ago
 The swelling is over mid clavicle and is
tender
 Initial x rays do not show a fracture
 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
Usually displaced with deformity
 May be comminuted
 mostly heal with a degree of Mal-Union
 Delayed union or Non union are less
common
 Usually is treated conservatively
 Open reduction gives satisfactory
alignment but results in unsightly scar

Figure of eight Bandage
Figure of Eight bandage
It is the common way for treating
fractures of clavicle conservatively
 Simple to apply in Emergency room
 It helps to reduce overlap of fracture ends
 It should not be applied very tight or it
may compress the neuro vascular
structures at axilla

Union of Fracture of the clavicle


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

Callus formation can be visible and palpable

Mal united overlap of fracture can be treated by
trimming some bone after union of fracture

Non Union is treated by compression Plating and
bone grafting
Dislocation of the Shoulder

Mostly Anterior > 95 % of dislocations

Posterior Dislocation occurs < 5 %

True Inferior dislocation ( Luxato Inferno ) occurs <
1%

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

Usually Indirect fall on Abducted and
extended shoulder

May be direct when there is a blow on the
shoulder from behind
Anterior Shoulder dislocation
Usually also inferior
 There is damage
( Overstretching ) to the
shoulder capsule and
subscapularis muscle
 Commonly there is
avulsion to the antero
inferior part of the
Glenoid labrum with
adjacent periosteom on
the neck of scapula =
Bankart’s Lesion

Clinical Picture
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

Loss of the contour of
the shoulder may
appear as a step

Anterior bulge of head
of humerus may be
visible or palpable

A gap can be palpated
above the dislocated
head of the humerus
X Ray anterior Dislocation of
Shoulder
Associated injuries of anterior
Shoulder Dislocation

Injury to the neuro vascular bundle in
axilla ( rare )

Injury of the Axillary or Circumflex
Nerve ( Usually stretching leading to
temporary neuropraxia )

Associated fracture
Axillary or Circumflex Nerve Injury
It is a branch from
posterior cord of
Brachial plexus
 It hooks close round
neck of humerus from
posterior to anterior
 It pierces the deep
surface of deltoid and
supply it and the part
of skin over it

Axillary or circumflex nerve injury
Management Of Anterior Shoulder
dislocation
Is an Emergency
 It should be reduced in less than 24 hours
or there may be Avascular Necrosis of
head of humerus
 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

Hippocrates Method ( A form of
anesthesia or pain abolishing is required )
Stimpson’s technique ( some sedation
and analgesia are used but No anesthesia
is required )
 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

Neuro vascular injury ( rare )

Axillary or Circumflex nerve injury

Associated Fracture of neck of humerus or
greater or lesser tuberosities
Complications of anterior shoulder
Dislocation : Late

Avascular necrosis of the head of the
Humerus ( may be delayed up to 2 years
and only following delayed reduction )

Heterotopic calcification ( used to be
called Myositis Ossificans )

Recurrent dislocation
Associated fractures
Fractures of The Humerus

Proximal Humerus (includes surgical and
anatomical neck )

Shaft of Humerus

Distal 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
Commonly Indirect injury
 Indirect injury results in Spiral or Oblique
fractures
 Direct injuries results in transverse or
comminuted ( Butterfly ) fracture
 May be associated with Radial Nerve
injury

Fracture shaft of the Humerus
Radial Nerve Injury

Results in Drop Wrist

Associated with fracture humerus in up to 12%
of fractures

2/3 ( 8%) of Radial injury are Neuropraxia

1/3 ( 4%) are nerve lacerations or transection
Management of Radial Nerve Injury

When present in open fractures ;
immediate exploration and ± repair

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

Recovery usually starts after few days but
may take up to 9 months for full recovery

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

Preferably Conservative

Closed Reduction in upright position
followed by application of U shaped Slap
of POP or Cylinder cast

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

Failure to reduce fracture conservatively

Bilateral humeral fractures

Open fracture with radial nerve Injury

Unconscious patient

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
Absolute Emergency
 Should de done under G A by experienced
doctor as soon as possible
 In the past the arm was held in flexed
elbow position in back-slab POP after
reduction
 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

Most commonly results in
Cubitus Varus

Less common is Cubitus
Valgus or Cubitus
Recurvatum

Management is by
Corrective SupraCondylar Osteotomy
Intra- Articular fractures of Elbow
Are sometimes difficult to diagnose exactly
 X ray of the other shoulder is helpful in
diagnosis
 C T may be required in some cases
 Non displaced intra- articular fractures can
be managed by immobilisation in
functional position till union
 Displaced fractures require ORIF

Intra-articular Fracture of Elbow
Intra-Articular Fracture of Elbow

This is displaced
fracture of capitullum
which required ORIF

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

Displaced fractures
Head of Radius
require ORIF if
possible

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 1/3rd of the
Ulna with dislocation
of head of radius
anteriorly. Posterirly
or laterally
 Head of Radius
dislocates same
direction as fracture
 It requires ORIF or it
will redisplace

Montegia : Lateral displacement
Galliazi Fracture

It is a fracture of distal
Radius and dislocation of
inferior Radio- Ulnar joint

Like Montegia fracture if
treated conservatively it
will redisplace

This fracture appeared in
acceptable position after
reduction and POP
Galliazi Fracture

Fracture redisplaced in
POP

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






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
Almost the opposite of Colles’ fracture
 Much less common compared to colles’
 Results from a fall on palmer flexed
wrist
 Typical deformity : Garden Spade
 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
 There is dorsal type
which looks like
Colles’ fracture
 Management is by
ORIF

ORIF Volar Barton’s
Comminuted Intra- Articular fractures
External Fixator for Comminuted
Fractures
Scaphoid Bone Fractures
Scaphoid bone Fractures
Scaphoid Bone Fractures