fractures and dislocations of the upper limb33333

8/14/2019 Fractures and Dislocations of the Upper Limb33333

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PREPARE- M. ALISAWEPREPARE- M. ALISAWE

FRACTURE OF UPPERFRACTURE OF UPPER

LIMBLIMB


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Upper Limb includeUpper Limb include

Clavicle

Scapula

Shoulder Joint

Humerus

Elbow Joint

Forearm Bones

Wrist Joint Scaphoid Bone


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FRACTUREFRACTURE

Definition : is a structural break in thenormal continuity of a bone

It is caused by trauma

It may be complete or incomplete or

fissure fracture


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ContCont

Dislocation is total disruption of a joint with

no intact between the articular surfaces


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Aetiology of fractureAetiology of fracture

1. Traumatic fracture :

a. Direct trauma : The bone breaks

transversely at the site of trauma,double bone break at the same level .

b. Indirect trauma : the bone breaks

obliquely at the weakness point.c. Avulsion fracture [muscle violence] :

due to muscle contraction


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ContCont

2.pathological fracture :

a. By minor trauma[ which would not

fracture normal bone]due to generalized

or localized bone disease .


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Types of fractureTypes of fracture

1. Simple : without an external wound

2. Compound : with an external wound


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Shape of fractureShape of fracture

1. Transverse[ direct trauma]

2. Oblique [indirect]

3. spiral[ [indirect]4. Comminuted [sever compression]

5. Green stick [in children]

6. Wedge [vertebral fracture]


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Clinical features and diagnosis ofClinical features and diagnosis of

fracturefracture

1. History of trauma.

2. Loss of function [loss of movement.

3. Pain due to friction between bone ends .4. Swelling due to fracture bone , oedema,

haematoma .

5. Deformity;described according to theposition distal fragment

6. Tenderness ; maximum over the fracture line


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ContCont

7.abnormal mobility .

8. x-ray :

a. At the time of fracture : for diagnosisb. after fixation :to know good or bad

reduction

C. at the end of treatment : before removingthe plaster cast to know the type of union [

good or bad union]


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Mechanism of injuryMechanism of injury

MostlyIndirect :

Commonly described as a fall onoutstretched hand

Type of injury depends onposition of theupper limb at the time of impact : Flexed,

Extended, adducted, abducted, pronatedor supinated


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Fracture of clavicleFracture of clavicle

Fracture of the middle third [shaft ] (80%)

This is the commonest fracture in the whole body

Trauma and morbid anatomy :

Clavicular shaft fracture is usually due to a fall on theoutstretched hand and less commonly due to direct

blow or to a fall on the point of the shoulder .


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ContCont

The fracture almost always occurs in the

middle third because it is the thinnest part

of the bone which is further weakened by

the junction of the two main curves of theshaft .

The potential deforming forces are the

weight of the arm that lead downward andinward displacement of the outer fragment-


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ContCont

-And the pull of the sternomastoid muscle

that lead to upward displacement of the

proximal fragment

In children the fracture is often of the

greenstick varity .


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Clinical featuresClinical features

The shoulder is dropped and deformity

and the pt support the elbow with the

opposite hand and bend his head to the

affected side to relax the sternomastoid

muscle .


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DiagnosisDiagnosis

history of injury

clinical features

symptoms : pain with the motion of shoulderjoint , swelling, ecchymosis,

sign: deformity , tenderness , bony crepitus

x-ray


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CCC fracture of middle third of clavicleCCC fracture of middle third of clavicle

.


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TreatmentTreatment

Conservative by an broad arm sling for 3

weeks and analgesics or figure of eight

bandage.

Internal fixation is rarely needed .


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Figure of eight BandageFigure of eight Bandage


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IIndications of open reduction andndications of open reduction and

internal fixationinternal fixation

Nonunion: the most frequent indication.

Neurovascular involvement . A persistent wide separation of the

.fragments with interposition of soft tissue.


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Fracture of the distal end with torn of

coracoclavicular ligaments in an adult .

Floating shoulder: Fractures of both theclavicle and the surgical neck of the scapula

A patient that cannot endure the suffer of

figure-of-eight bandage fixation .

Redisplacement after reduction that cannotbe accepted by the patient.


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ComplicationComplication

1. Malunion is common (union is bad time

and position).

2. Non union is uncommon .

3. Injury of subclavian vessels and brachial

plexus.

4. Tear in muscle .5. Stiffness of shoulder joint .


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Fracture of the outer third (15%)Fracture of the outer third (15%)

Usually no displacement occurs because

both fragment are attached to the scapula

by ligament .

When the coraco clavicular ligament is

ruptured the outer segment displaces

forward and inward .

If no displacememt , no treatment is

required (but analgesics)


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ContCont

When there is displacement , the fracture

is treated by internal fixation.

Fracture of inner third are rare

(5%).


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Fracture of the scapulaFracture of the scapula

The commonest fracture of the

scapula involve is either the neck or the

body of bone .

Fracture of the neck of scapula:

the fracture result from direct violenceand the fracture line usually run from .


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ContCont

The suprascapular notch to below the

coracoids process .

Treatment : broad arm sling and early

active shoulder movement .


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Fracture of the body of the scapula:Fracture of the body of the scapula:

The fracture result from direct violence .

The fracture is stellate .

Treatment is board arm sling and activeshoulder movement .

Important to look for and exclude an

associated chest injury.


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Fractures of the scapula

1-Neck 2-body


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Dislocation of the ShoulderDislocation of the Shoulder

MostlyAnterior> 95 % of dislocations

PosteriorDislocation occurs < 5 %

True Inferiordislocation (luxatio erecta) occurs < 1%


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Anterior dislocationAnterior dislocation

The head of the humerus usually

dislocates forward to assume one of

the following position :

1. subcoracoid (commonest).

2.Subclavicular.

3.Subglenoid.


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1.subcoracoid(commonest).

2.Subclavicular.

3.Subglenoid.


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Mechanism of anterior shoulderMechanism of anterior shoulder

dislocationdislocation

1. UsuallyIndirectfall on Abducted and

extended and external rotation

shoulder.

2. May be direct when there is a blow on the

shoulder from behind


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Anterior Shoulder dislocationAnterior Shoulder dislocation


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Clinical PictureClinical Picture

1. Flatten of theshoulder: Loss of

the contour of the

shoulder may appear

as a step .

2. Swelling: Anterior

bulge of head ofhumerus may be

visible or palpable.


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4- A gap can be palpated above the dislocated

head of the humerus.

5-Deformit y: abduction + external rotation.

6-Change in the length of the arm .


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Diaganosis:

clinical picture+ x-ray (AP views).


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X Ray anterior Dislocation ofX Ray anterior Dislocation of

ShoulderShoulder


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1. Axillary nerve injuny.

2. Avulusion of the supraspinatus tendon is discovered by inability of the

pt to initiate abduction .

3. associated of greater tuberosity or humeral neck fracture .

4. Recurrent dislocation .

5. rupture of the inferior part of the capsule.

Avascular necrosis of the head of the Humerus (high risk with

delayed reduction)


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Axillary Nerve InjuryAxillary Nerve Injury

Also called circumflex nerve

It is a branch from posteriorcord 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

M t f A t i


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Management of AnteriorManagement of Anterior

Shoulder DislocationShoulder Dislocation

Is an Emergency.

It should be reduced in less than 24hours

or there may be Avascular Necrosis ofhead of humerus.

Following reduction the shoulder should

be immobilised strapped to the trunk for 3-4 weeks and rested in a collar and cuff.

M th d f R d ti fM th d f R d ti f


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Methods of Reduction ofMethods of Reduction of

anterior shoulder Dislocationanterior shoulder Dislocation

1. Hippocrates Method( A form of anesthesiaor pain abolishing is required).

2. Stimpsons technique ( some sedation andanalgesia are used but No anesthesia isrequired ).

3. Kochers technique : is the method usedin hospitals under general anesthesia andmuscle relaxation .


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Hippocrates MethodHippocrates Method


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Stimpsons techniqueStimpsons technique


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Kochers TechniqueKochers Technique

o under general anesthesia , the operator externally

rotates the arm to relax the subscapularis muscle while

pulling down on the am to disengage the head .

o The humerus is adducted and internally rotated

bringing the elbow across the chest .

o Fixation in a sling and bandage for 3 weeks .


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Kochers TechniqueKochers Technique

T t t f tTreatment of recurrent


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Treatment of recurrentTreatment of recurrent

dislocationdislocation

1. putti-platt operation . The idea is to limit

external rotation of the shoulder by

capsulorraphy and shorten of the

subscapsularis muscle by overlapping .

2. bankart operation . The glenoidal

labrum is displayed and is repaired by

reattaching the labrum by suturing it tothe bony rim of the glenoid .


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Posterior dislocationPosterior dislocation

Should always be suspected after an

epileptic fit or an electric shock.

Caused by direct blow on the front of the

shoulder

The head slide backward to the lie below

the acromion ( subacromial dis ) or

infraspinous fossa of thescapula(subspinous dis )


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Fractures of The HumerusFractures of The Humerus

1. ProximalHumerus (includes surgical

and anatomical neck ).

2. Shaftof Humerus.

3. Distalhumerus ( includes SupraCondylar fracture in children ).


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Fracture Proximal HumerusFracture Proximal Humerus

more common in the elderly and usually

Associated with osteoporosis.

classification : 1-Articular surface or itsanatomical neck .

2- Greater T .

3- lesser T .

4-surgical neck.


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ContCont

The above classification then identify each one

according to :

- one part # no displacement .

two part # one segment isdisplaced .

three part # two segment is

displaced.

Four part # three segmentare dis.


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Mechanism of injuryMechanism of injury

Surgical neck :- fall on out stretched hand

in abduction and external rotation.

Anatomical neck :- fall on the shoulder

directly against the glenoid cavity.


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Clinical pictureClinical picture

1. pain in the shoulder and inability to

move the joint.

2. in minor impacted fracture of surgical

neck , limited movement may be

possible.

3. the diagnosis is made radiologically .


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Fracture Proximal HumerusFracture Proximal Humerus

Fracture Proximal Humerus :Fracture Proximal Humerus :


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Fracture Proximal Humerus :Fracture Proximal Humerus :

Plating or Rush Nail insertionPlating or Rush Nail insertion


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TreatmentTreatment

one part ( 80% of fracture are un displaced ):-External immobilization into a sling until pain has subsided.

two part fracture :- open reduction + internal fixation by

screw and wire then arm to neck sling for 3 weeks.

surgical neck :- closed reduction + collar and cuff sling for

3 weeks.


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ContCont

Three part # :- open reduction + internal fixation

+repair of the rotator cuff.

four part # :- usually associated with avascular

necrosis of the humeral head ___ so replacedby prosthetic head + repair of rotator cuff.


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Intra-medullary K wire fixationIntra-medullary K wire fixation


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1. shoulder stiffness.

2. axillary nerve injury.

3. Avascular necrosis of the humeral head .

4. Dislocation of the shoulder .

5. Malunion .

6. nonunion .


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Fractures Shaft of the HumerusFractures Shaft of the Humerus

Mechanism of injury:-

CommonlyIndirectinjury

Indirect injury results twisting injury of the

arm and /or fall on outstretched hand .

Direct injuries like bit stick.


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As general principles + deformity

Displacement:- this depends on the level

P. Fragment Distal fragment

bove the insertion of

deltoid .

Adducted by pectoralis or

latisums dorsi.

Abduction by deltoid muscle.

Below the insertion of deltoid .Abduction by deltoid. Adducted and pulled up wardby the coracobrachialis .

Fracture shaft of the HumerusFracture shaft of the Humerus


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Fracture shaft of the HumerusFracture shaft of the Humerus

(diagnosis)(diagnosis)


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TreatmentTreatment

Closed reduction + external fixation :-

Reduction : with gentle traction on the elbow.

fixation : u-shaped plaster slab for 8 weeks +

collar and cuff sling . if it is not possible to reduction by method used

___open reduction + plate and screws fixation or

bone graft

If the # is transverse or near the mid shaft ,

intramedullary nail is used


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U Shaped slabU Shaped slab


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Plating fracture Shaft of humerusPlating fracture Shaft of humerus


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1. Radial nerve injury.

2. Delayed union.

3. Nonunion.

4. Joint stiffness.


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Radial Nerve InjuryRadial Nerve Injury

Results in Wrist drop

Associated with fracturehumerus in up to 12%

of fractures

2/3 ( 8%) of Radial injury are Neuropraxia

1/3 ( 4%) are nerve lacerations or transection


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Supra-condylar Fracture of HumerusSupra-condylar Fracture of Humerus

Mechanism of trauma:-caused bya fall onto the outstretched hands ( its a

frequent in children )

Types:-1-extension types 99%

2-flexion types 1%


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As general + deformity

Extension types 99% flexion types 1%

Distal fragment . Displaced backward and upward .

Displaced forward and upward .

Treatment of supra-condylarTreatment of supra-condylar


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Treatment of supra-condylarTreatment of supra condylar

FractureFracture

Absolute Emergency.

Should de done under G A by experienceddoctor as soon as possible.

In the past the arm was held in flexed elbowposition in back-slab pop after reduction.

At present time Percutaneous K wire fixationis ALWAYScarried out after reduction.

C


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ContCont

After care : hospitalization and monitoring

of radial pulse for 48 hours.

Open reduction + internal fixation by wires

, when closed methods failed to reduction

S d l f tS d l f t


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Supra-condylar fracture.Supra-condylar fracture.

Complications Supra-CondylarComplications Supra-Condylar


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Complications Supra CondylarComplications Supra Condylar

FracturesFractures

Early= Compartment syndrome

Brachial Artery injury ( Acute

Volkmann's Ischemia )

Nerve Injury : Median, Ulnar or Radial

Late= Stiffness

Volkmann's Ischemic contracture

Heterotopic CalcificationMal-Union ( Cubitus Valgus or varus)

C


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Volkmann's Ischemic ContractureVolkmann's Ischemic Contracture

Massive infarction of the

muscles of forearm in the

case of s-p humerus

especially flexion type frominjury of brachia l artery.

Di l ti f th lb j i tDi l ti f th lb j i t


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Dislocation of the elbow jointDislocation of the elbow joint

It more common in adults.

Mechanism of trauma:

1-P-dislocation : fall on the outstretch hand

while the limb is extended .

2-A-dislocation : fall on the tip of the elbow .

Cli i l i tCli i l i t


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As general + 1-pain and tenderness

2-SWELLING

3-no movement at the elbow

T t tT t t


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TreatmentTreatment

P-DISLOCATION : Reduction bydownward traction and forward push on

the upper end of the ulna, fixation is done

90 flexion for 3 weeks .

A-DISLOCATION: reduction by posterior

push on the ulna and fixation in extenionposition in posterior slap


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FRACTURES OFFRACTURES OF

SHAFT OF RADIUSSHAFT OF RADIUSAND ULNAAND ULNA

A tAnatomy


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AnatomyAnatomy

radius & ulna lie parallel to eachother when forearm is supinated

interosseous membrane:joinradius and ulna, which is directedobliquely downward from radius

to ulna and is relaxant at theneutral position of forearm
http://www.ortho-u.net/orthoo/131.htmhttp://www.ortho-u.net/orthoo/131.htm


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special typespecial type

Monteggia fracture-dislocation

fractures of proximal third of ulna with

dislocation of radial head

Galeazzi fracture-dislocation

fracture of distal third of radius withdislocation of distal radioulnar joint

MONTEGGIA FRACTURE DISLOCATIONMONTEGGIA FRACTURE DISLOCATION


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MONTEGGIA FRACTURE-DISLOCATIONMONTEGGIA FRACTURE-DISLOCATION


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Monteggia fracture-dislocationMonteggia fracture-dislocation

M t i f t di l tiMonteggia fract re dislocation


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Monteggia fracture dislocationMonteggia fracture dislocation

Def: fracture of the upper 1/3 ulna anddislocation of the head of the radius from

superior radio-ulnar joint.

Types :

a. Extension type 85% ; the ulna is broken

and angulated anteriorly, and the head of

radiaus is displaced foreword.

t t ttreatment


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treatmenttreatment 1. close reduction and external fixation for 3

months.

2. open reduction and internal fixation by plate and

screws.

b. Flextion type; 15% the ulna is angulated and brokenbackward and the radius is dislocated backward.

Treatment: close reduction and external fixation 2-3

months.

G l i f t di l tiGaleazzi fracture dislocation


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Galeazzi fracture-dislocationGaleazzi fracture-dislocation

Glia i fract re dislocationGliazi fracture dislocation


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Gliazi fracture dislocationGliazi fracture dislocation

Fracture lower1/3 of the radius+ dislocation 1/3 of the ulna

Treatment ; open reduction and internal

fixation as it is unstable fracture by platesand screws.

DiagnosisDiagnosis


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DiagnosisDiagnosis

history of injury

clinical features: swelling, pain ,

subcutaneous ecchymosis, limitation ofupper extremity motion, deformity,tenderness, bony crepitus ,

normal postelbow triangle x-ray

T t tT t t


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TreatmentTreatment

Fractures of the forearm bones may resultin severe loss of function unless

adequately treated

Open reduction and internal fixation fordisplaced diaphyseal fractures in the adult

are generally accepted as the best methodof treatment.

I l fi i


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Internal fixationInternal fixation

A satisfactory device for internal fixation

must hold the fracture rigidly, eliminating

as completely as possible angular as well asrotary motions

method: intramedullary nail or the AO

compression plate


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FRACTURES OFFRACTURES OF

DISTAL RADIUSDISTAL RADIUS


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ClassificationClassification extension type Colles fracture flexion type

Smith fracture

colles fracturecolles fracture
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colles fracturecolle s fracture

Def :fracture of distal inch of radius which iscommonly comminuted and impacted.

Trauma:fall on the outstrech hand.

Common associated injury:1.Styloid fracture of the ulna and radius or both.

2.Tear in the triangular fibro-cartilage between

the lower end of radius and ulna with loss ospronation and supination.

Diagnosis of CollesDiagnosis of Colles


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g fg f

fracturefracture history of injury:fall on outstretched hand

clinical features: swelling,subcutaneous ecchymosis,pain ,limitation of wrist joint,tenderness,fork deformity

x-ray


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TreatmentTreatmentMost distal radial fractures can

be successfully treated

nonoperativelyManualreduction

ComplicationsComplications


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Malunion

Sundecks' atrophy

Tear of the extensor pollicis loungustendon

Stuffiness of finger & shoulder

Loss of movement

C ll f tColles fracture


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Colles fractureColles fracture

Smith fractureSmith fracture


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Due to fall on the dorsum of the

hand

The distal fragment of radius isdisplaced forward

S i h fS ith f t


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fractures and dislocations of the upper limb33333

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