Upper limb injuries X Rays [PPT]
Download
Report
Transcript Upper limb injuries X Rays [PPT]
UPPER LIMB INJURIES
Dr Abhishek Agarwal
Lecturer
Deptt orthopedics
Upper Limb include
Clavicle
Scapula
Shoulder Joint
Humerus
Elbow Joint
Forearm Bones
Wrist and Hand
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
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Fracture of the clavicle in Adults
Common especially in children and elderly
Commonest site is the middle one third
Mainly due to indirect injury
Direct injury leads to comminuted fracture
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Treatment
Conservative by an arm sling or figure of eight
bandage
Operative fixation is indicated if there is an open
fracture, neurovascular injury or nonunion
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Figure of eight Bandage
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Dislocation of the Shoulder
Mostly Anterior > 95 % of dislocations
Posterior Dislocation occurs < 5 %
True Inferior dislocation (luxatio erecta) occurs < 1%
Habitual Non traumatic dislocation may present as
Multi directional dislocation due to generalized
ligamentous laxity and is Painless
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
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
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Anterior Shoulder dislocation
Usually also inferior
Bankart’s Lesion
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
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
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
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
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
X Ray anterior Dislocation of Shoulder
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
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
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006
Axillary Nerve Injury
Also called circumflex nerve
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Axillary nerve injury
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Hippocrates Method
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Stimpson’s technique
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Kocher’s Technique
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Complications of anterior Shoulder
Dislocation : Early
Neuro vascular injury ( rare )
Axillary nerve injury
Associated Fracture of neck of humerus or greater
or lesser tuberosities
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Complications of anterior shoulder
Dislocation : Late
Avascular necrosis of the head of the Humerus
(high risk with delayed reduction)
Heterotopic calcification ( used to be called
Myositis Ossificans )
Recurrent dislocation
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Fractures of The Humerus
Proximal Humerus (includes surgical and anatomical
neck )
Shaft of Humerus
Distal humerus ( includes Supra Condylar fracture
in children )
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Fracture Proximal Humerus
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Fracture Proximal Humerus : Plating or Rush
Nail insertion
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Intra-medullary K wire fixation
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Fractures Shaft of the Humerus
Commonly Indirect injury
Indirect injury results in Spiral or Oblique fractures
Direct injuries results in transverse or comminuted
fracture
May be associated with Radial Nerve injury
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Fracture shaft of the Humerus
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Radial Nerve Injury
Results in Wrist drop
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Management of Fracture Shaft of
the Humerus
Most of the time is Conservative
Closed Reduction in upright position followed by
application of U shaped Slab of POP or Cylinder
cast
Few weeks later or initially in stable fractures
Functional Brace may be used
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
U Shaped slab of POP
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Functional brace Fracture Shaft of
Humerus
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Plating fracture Shaft of humerus
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Intra- medullary K Wire Fixation
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Supra- condylar Fracture of Humerus
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Pediatric Supra-Condylar Humeral fracture
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Pediatric Supra-condylar fracture
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
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
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Complications Supra-Condylar
Fractures
A.
B.
Early= Compartment syndrome
Brachial Artery injury ( Acute
Volkmann's Ischemia )
Nerve Injury : Median, Ulnar or Radial
Late= Stiffness
Volkmann's Ischemic contracture
Heterotopic Calcification
Mal-Union ( Cubitus Valgus or varus)
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Volkmann's Ischemic Contracture
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Supracondylar fracture.
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
Fracture dislocation
http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity
MONTEGGIA FRACTUREDISLOCATION
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
MONTEGGIA FRACTUREDISLOCATION
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
GALEAZZI FRACTURE-DISLOCATION
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
Distal radius fracture.
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
Distal radius fracture.
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
contd
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
Types of treatment
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
Wrist & Hand Injuries
Carpal tunnel (CTS)
result from repetitive stress to
tissue
64% of work injuries
Compressive neuropathy
Wrist flexion/ext and finger
movements
Risk factors
exertion
repetitive stress
posture
localized contact
cold
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
Wrist & Hand Injuries
Carpal fractures
compressive loads to
hyperextended wrist
hyper flexion
rotation loading against
a fixed wrist
Scaphoid
60-70%
Lunate
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
Wrist & Hand Injuries
Thumb: essential to prehension
Sprain: skiers thumb
fall with thumb in abducted
position
tensile loads on MCL
Hyperextension
Bennets fracture (fighting)
Bowler’s thumb: ulnar digital
nerve trauma
tingling, sensitivity
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.
Wrist & Hand Injuries
Metacarpal &
phalangeal injuries
Fractures
Boxers
Dislocations
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25,
1992.