upper extremity trauma

By…By…

Dr. Muhammad Salman KhanDr. Muhammad Salman Khan

Upper Extremity Upper Extremity TraumaTrauma

TopicsTopics

ClavicleClavicle HumerusHumerus ForearmForearm Distal RadiusDistal Radius Shoulder DislocationShoulder Dislocation Elbow dislocationElbow dislocation

Clavicle FracturesClavicle Fractures


MechanismMechanism– Fall onto shoulder Fall onto shoulder

(87%)(87%)– Direct blow (7%)Direct blow (7%)– Fall onto outstretched Fall onto outstretched

hand (6%)hand (6%) Trimodal distributionTrimodal distribution

0

10

20

30

40

50

60

70

80

Group I(13yrs)

Group 2(47yrs)

Group 3(59yrs)

Percent

The clavicle is the last ossification

center to complete (sternal end) at about 22-25yo.


Clinical EvaluationClinical Evaluation– Inspect and palpate for deformity/abnormal Inspect and palpate for deformity/abnormal

motionmotion– Thorough distal neurovascular examThorough distal neurovascular exam– Auscultate the chest for the possibility of lung Auscultate the chest for the possibility of lung

injury or pneumothoraxinjury or pneumothorax Radiographic ExamRadiographic Exam

– AP chest radiographs.AP chest radiographs.– Clavicular 45deg A/P oblique X-raysClavicular 45deg A/P oblique X-rays

Clavicle FracturesClavicle Fractures Allman Classification of Clavicle FracturesAllman Classification of Clavicle Fractures

– Type IType I Middle Third (80%)Middle Third (80%)– Type IIType II Distal Third (15%)Distal Third (15%)

Differentiate whether ligaments Differentiate whether ligaments attached to lateral or medial fragmentattached to lateral or medial fragment

– Type IIIType III Medial Third (5%)Medial Third (5%)

Clavicle FractureClavicle Fracture

Closed TreatmentClosed Treatment– Sling immobilization for usually 3-4 weeks with Sling immobilization for usually 3-4 weeks with

early ROM encouragedearly ROM encouraged Operative interventionOperative intervention

– Fractures with neurovascular injuryFractures with neurovascular injury– Fractures with severe associated chest injuriesFractures with severe associated chest injuries– Open fracturesOpen fractures– Group II, type II fracturesGroup II, type II fractures– Cosmetic reasons, uncontrolled deformityCosmetic reasons, uncontrolled deformity– NonunionNonunion

Associated InjuriesAssociated Injuries– Brachial Plexus InjuriesBrachial Plexus Injuries

Contusions most common, penetrating Contusions most common, penetrating (rare)(rare)

– Vascular InjuryVascular Injury– Rib Fractures Rib Fractures – Scapula FracturesScapula Fractures– PneumothoraxPneumothorax


Proximal Humerus FracturesProximal Humerus Fractures


EpidemiologyEpidemiology– Most common fracture of the humerusMost common fracture of the humerus– Higher incidence in the elderly, thought to be Higher incidence in the elderly, thought to be

related to osteoporosisrelated to osteoporosis– Females 2:1 greater incidence than malesFemales 2:1 greater incidence than males

Mechanism of InjuryMechanism of Injury– Most commonly a fall onto an outstretched arm Most commonly a fall onto an outstretched arm

from standing heightfrom standing height– Younger patient typically present after high Younger patient typically present after high

energy trauma such as Motor Vehicle Accidentenergy trauma such as Motor Vehicle Accident


Clinical EvaluationClinical Evaluation– Patients typically present with Patients typically present with

arm held close to chest by arm held close to chest by contralateral hand. Pain and contralateral hand. Pain and crepitus detected on palpationcrepitus detected on palpation

– Careful NV exam is essential, Careful NV exam is essential, particularly with regards to the particularly with regards to the axillary nerve. Test sensation axillary nerve. Test sensation over the deltoid. Deltoid atony over the deltoid. Deltoid atony does not necessarily confirm does not necessarily confirm an axillary nerve injuryan axillary nerve injury


Neer ClassificationNeer Classification– Four partsFour parts

Greater and lesser Greater and lesser tuberosities, tuberosities,

Humeral shaftHumeral shaft Humeral headHumeral head

– A part is displaced if A part is displaced if >1 cm displacement >1 cm displacement or >45 degrees of or >45 degrees of angulation is seenangulation is seen

Proximal Humerus FracturesProximal Humerus Fractures TreatmentTreatment

– Minimally displaced fractures- Sling immobilization, early Minimally displaced fractures- Sling immobilization, early motionmotion

– Two-part fractures- Two-part fractures- Anatomic neck fractures likely require ORIF. High incidence Anatomic neck fractures likely require ORIF. High incidence

of osteonecrosisof osteonecrosis Surgical neck fractures that are minimally displaced can be Surgical neck fractures that are minimally displaced can be

treated conservatively. Displacement usually requires ORIFtreated conservatively. Displacement usually requires ORIF– Three-part fracturesThree-part fractures

Due to disruption of opposing muscle forces, these are Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement unstable so closed treatment is difficult. Displacement requires ORIF. requires ORIF.

– Four-part fracturesFour-part fractures In general for displacement or unstable injuries ORIF in the In general for displacement or unstable injuries ORIF in the

young and hemiarthroplasty in the elderly and those with young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%)severe comminution. High rate of AVN (13-34%)

Humeral Shaft FracturesHumeral Shaft Fractures


Mechanism of InjuryMechanism of Injury– Direct trauma is the most common especially Direct trauma is the most common especially

MVAMVA– Indirect trauma such as fall on an outstretched Indirect trauma such as fall on an outstretched

handhand– Fracture pattern depends on stress appliedFracture pattern depends on stress applied

Compressive- proximal or distal humerusCompressive- proximal or distal humerus Bending- transverse fracture of the shaftBending- transverse fracture of the shaft Torsional- spiral fracture of the shaftTorsional- spiral fracture of the shaft Torsion and bending- oblique fracture usually Torsion and bending- oblique fracture usually

associated with a butterfly fragmentassociated with a butterfly fragment


Clinical evaluationClinical evaluation– Thorough history and Thorough history and

physicalphysical– Patients typically Patients typically

present with pain, present with pain, swelling, and deformity swelling, and deformity of the upper armof the upper arm

– Careful NV exam Careful NV exam important as the radial important as the radial nerve is in close nerve is in close proximity to the proximity to the humerus and can be humerus and can be injuredinjured


Radiographic evaluationRadiographic evaluation– AP and lateral views of the humerus AP and lateral views of the humerus – Traction radiographs may be indicated Traction radiographs may be indicated

for hard to classify secondary to severe for hard to classify secondary to severe displacement or a lot of comminutiondisplacement or a lot of comminution

Humeral Shaft FracturesHumeral Shaft Fractures Conservative TreatmentConservative Treatment

– Goal of treatment is to Goal of treatment is to establish union with establish union with acceptable alignmentacceptable alignment

– >90% of humeral shaft >90% of humeral shaft fractures heal with fractures heal with nonsurgical managementnonsurgical management 20 degrees of anterior 20 degrees of anterior

angulation, 30 degrees of varus angulation, 30 degrees of varus angulation and up to 3 cm of angulation and up to 3 cm of shortening are acceptableshortening are acceptable

Most treatment begins with Most treatment begins with application of a coaptation spint application of a coaptation spint or a hanging arm cast followed or a hanging arm cast followed by placement of a fracture brace by placement of a fracture brace


TreatmentTreatment– Operative TreatmentOperative Treatment

Indications for operative Indications for operative treatment include treatment include inadequate reduction, inadequate reduction, nonunion, associated nonunion, associated injuries, open fractures, injuries, open fractures, segmental fractures, segmental fractures, associated vascular or associated vascular or nerve injuriesnerve injuries

Most commonly treated Most commonly treated with plates and screws with plates and screws but also IM nailsbut also IM nails


Holstein-Lewis FracturesHolstein-Lewis Fractures– Distal 1/3 fracturesDistal 1/3 fractures– May entrap or lacerate radial nerve as the May entrap or lacerate radial nerve as the

fracture passes through the intermuscular fracture passes through the intermuscular septumseptum

Forearm FracturesForearm Fractures

Forearm FracturesForearm Fractures

EpidemiologyEpidemiology– Highest ratio of open to closed than any Highest ratio of open to closed than any

other fracture except the tibiaother fracture except the tibia– More common in males than females, More common in males than females,

most likely secondary mva, contact most likely secondary mva, contact sports, altercations, and fallssports, altercations, and falls

Mechanism of InjuryMechanism of Injury– Commonly associated with mva, direct Commonly associated with mva, direct

trauma missile projectiles, and fallstrauma missile projectiles, and falls

Forearm FracturesForearm Fractures Clinical EvaluationClinical Evaluation

– Patients typically present with gross deformity of Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of the forearm and with pain, swelling, and loss of function at the handfunction at the hand

– Careful exam is essential, with specific Careful exam is essential, with specific assessment of radial, ulnar, and median nerves assessment of radial, ulnar, and median nerves and radial and ulnar pulsesand radial and ulnar pulses

– Tense compartments, unremitting pain, and pain Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for with passive motion should raise suspicion for compartment syndromecompartment syndrome

Radiographic EvaluationRadiographic Evaluation– AP and lateral radiographs of the forearmAP and lateral radiographs of the forearm– Don’t forget to examine and x-ray the elbow and Don’t forget to examine and x-ray the elbow and

wristwrist

Forearm FracturesForearm Fractures Ulna FracturesUlna Fractures

– These include nightstick and Monteggia fracturesThese include nightstick and Monteggia fractures– Monteggia denotes a fracture of the proximal Monteggia denotes a fracture of the proximal

ulna with an associated radial head dislocationulna with an associated radial head dislocation Monteggia fractures classification- BadoMonteggia fractures classification- Bado Type I- Anterior Dislocation of the radial head with Type I- Anterior Dislocation of the radial head with

fracture of ulna at any level- produced by forced fracture of ulna at any level- produced by forced pronationpronation

Type II- Posterior/posterolateral dislocation of the radial Type II- Posterior/posterolateral dislocation of the radial head- produced by axial loading with the forearm flexedhead- produced by axial loading with the forearm flexed

Type III- Lateral/anterolateral dislocation of the radial Type III- Lateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysis- forced head with fracture of the ulnar metaphysis- forced abduction of the elbowabduction of the elbow

Type IV- anterior dislocation of the radial head with Type IV- anterior dislocation of the radial head with fracture of radius and ulna at the same level- forced fracture of radius and ulna at the same level- forced pronation with radial shaft failurepronation with radial shaft failure

Forearm FracturesForearm Fractures Radial Diaphysis FracturesRadial Diaphysis Fractures

– Fractures of the proximal two-thirds can be considered Fractures of the proximal two-thirds can be considered truly isolatedtruly isolated

– Galeazzi or Piedmont fractures refer to fracture of the Galeazzi or Piedmont fractures refer to fracture of the radius with disruption of the distal radial ulnar jointradius with disruption of the distal radial ulnar joint

– A reverse Galeazzi denotes a fracture of the distal ulna A reverse Galeazzi denotes a fracture of the distal ulna with disruption of radioulnar jointwith disruption of radioulnar joint

MechanismMechanism– Usually caused by direct or indirect trauma, such as fall Usually caused by direct or indirect trauma, such as fall

onto outstretched handonto outstretched hand– Galeazzi fractures may result from direct trauma to the Galeazzi fractures may result from direct trauma to the

wrist, typically on the dorsolateral aspect, or fall onto wrist, typically on the dorsolateral aspect, or fall onto outstretched hand with pronationoutstretched hand with pronation

– Reverse Galeazzi results from fall with hand in supinationReverse Galeazzi results from fall with hand in supination

Distal Radius FracturesDistal Radius Fractures


EpidemiologyEpidemiology– Most common fractures of the upper extremityMost common fractures of the upper extremity– Common in younger and older patients. Usually Common in younger and older patients. Usually

a result of direct trauma such as fall on out a result of direct trauma such as fall on out stretched handstretched hand

– Increasing incidence due to aging populationIncreasing incidence due to aging population Mechanism of InjuryMechanism of Injury

– Most commonly a fall on an outstretched Most commonly a fall on an outstretched extremity with the wrist in dorsiflexionextremity with the wrist in dorsiflexion

– High energy injuries may result in significantly High energy injuries may result in significantly displaced, highly unstable fracturesdisplaced, highly unstable fractures


Clinical EvaluationClinical Evaluation– Patients typically present with gross Patients typically present with gross

deformity of the wrist with variable deformity of the wrist with variable displacement of the hand in relation to the displacement of the hand in relation to the wrist. Typically swollen with painful ROMwrist. Typically swollen with painful ROM

– Ipsilateral shoulder and elbow must be Ipsilateral shoulder and elbow must be examinedexamined

– NV exam including specifically median NV exam including specifically median nerve for acute carpal tunnel compression nerve for acute carpal tunnel compression syndromesyndrome

Radiographic EvaluationRadiographic Evaluation

3 view of the wrist including AP, Lat, 3 view of the wrist including AP, Lat, and Obliqueand Oblique– Normal RelationshipsNormal Relationships

23 Deg

11 mm

11 Deg

Distal Radius FracturesDistal Radius Fractures EponymsEponyms

– Colles FractureColles Fracture Combination of intra and extra articular fractures of the distal Combination of intra and extra articular fractures of the distal

radius with dorsal angulation (apex volar), dorsal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortentingdisplacement, radial shift, and radial shortenting

Most common distal radius fracture caused by fall on Most common distal radius fracture caused by fall on outstretched handoutstretched hand

– Smith Fracture (Reverse Colles)Smith Fracture (Reverse Colles) Fracture with volar angulation (apex dorsal) from a fall on a Fracture with volar angulation (apex dorsal) from a fall on a

flexed wristflexed wrist– Barton FractureBarton Fracture

Fracture with dorsal or volar rim displaced with the hand and Fracture with dorsal or volar rim displaced with the hand and carpuscarpus

– Radial Styloid Fracture (Chauffeur Fracture)Radial Styloid Fracture (Chauffeur Fracture) Avulsion fracture with extrinsic ligaments attached to the Avulsion fracture with extrinsic ligaments attached to the

fragmentfragment Mechanism of injury is compression of the scaphoid against Mechanism of injury is compression of the scaphoid against

the styloidthe styloid


TreatmentTreatment– Displaced fractures require and attempt at Displaced fractures require and attempt at

reduction.reduction. Hematoma block-10ccs of lidocaine or a mix of lidocaine Hematoma block-10ccs of lidocaine or a mix of lidocaine

and marcaine in the fracture siteand marcaine in the fracture site Hang the wrist in fingertraps with a traction weightHang the wrist in fingertraps with a traction weight Reproduce the fracture mechanism and reduce the Reproduce the fracture mechanism and reduce the

fracturefracture Place in sugar tong splintPlace in sugar tong splint

– Operative ManagementOperative Management For the treatment of intraarticular, unstable, malreduced For the treatment of intraarticular, unstable, malreduced

fractures.fractures. As always, open fractures must go to the OR.As always, open fractures must go to the OR.

Shoulder DislocationsShoulder Dislocations


EpidemiologyEpidemiology– Anterior: Most commonAnterior: Most common– Posterior: Uncommon, 10%, Think Posterior: Uncommon, 10%, Think

Electrocutions & SeizuresElectrocutions & Seizures– Inferior: Rare, hyper-abduction injuryInferior: Rare, hyper-abduction injury


Clinical EvaluationClinical Evaluation– Examine axillary nerve (deltoid function, not Examine axillary nerve (deltoid function, not

sensation over lateral shoulder)sensation over lateral shoulder)– Examine M/C nerve (biceps function and Examine M/C nerve (biceps function and

anterolateral forearm sensation)anterolateral forearm sensation) Radiographic EvaluationRadiographic Evaluation

– True AP shoulderTrue AP shoulder– Axillary LateralAxillary Lateral– Scapular YScapular Y– Stryker Notch View (Bony Bankart)Stryker Notch View (Bony Bankart)


Anterior Dislocation Recurrence RateAnterior Dislocation Recurrence Rate– Age 20: 80-92%Age 20: 80-92%– Age 30: 60%Age 30: 60%– > Age 40: 10-15%> Age 40: 10-15%

Look for Concomitant InjuriesLook for Concomitant Injuries– Bony:Bony: Glenoid Fracture, Greater Tuberosity Glenoid Fracture, Greater Tuberosity

FractureFracture– Soft Tissue: Soft Tissue: Subscapularis TearSubscapularis Tear– Vascular:Vascular: Axillary artery injury (older pts with Axillary artery injury (older pts with

atherosclerosis)atherosclerosis)– Nerve:Nerve: Axillary nerve neuropraxia Axillary nerve neuropraxia

Anterior DislocationAnterior Dislocation– TraumaticTraumatic– Atraumatic Atraumatic

(Congenital Laxity)(Congenital Laxity)– Acquired Acquired

(Repeated (Repeated Microtrauma)Microtrauma)


Posterior DislocationPosterior Dislocation– Adduction/Flexion/IR at time of Adduction/Flexion/IR at time of

injuryinjury– Electrocution and Seizures Electrocution and Seizures

cause overpull of subscapularis cause overpull of subscapularis and latissimus dorsiand latissimus dorsi

– Look for “lightbulb sign” and Look for “lightbulb sign” and “vacant glenoid” sign“vacant glenoid” sign

– Reduce with traction and gentle Reduce with traction and gentle anterior translationanterior translation


Inferior DislocationsInferior DislocationsLuxatio ErectaLuxatio Erecta– Hyperabduction injuryHyperabduction injury– Arm presents in a flexed Arm presents in a flexed

“asking a question” posture“asking a question” posture– High rate of nerve and High rate of nerve and

vascular injuryvascular injury– Reduce with in-line traction Reduce with in-line traction

and gentle adductionand gentle adduction


Shoulder DislocationShoulder Dislocation TreatmentTreatment

– Nonoperative treatmentNonoperative treatment Closed reduction should be performed after adequate Closed reduction should be performed after adequate

clinical evaluation and appropriate sedationclinical evaluation and appropriate sedation

– Reduction Techniques:Reduction Techniques: Traction/countertraction- Generally used with a sheet Traction/countertraction- Generally used with a sheet

wrapped around the patient and one wrapped around the wrapped around the patient and one wrapped around the reducer.reducer.

Hippocratic technique- Effective for one person. One foot Hippocratic technique- Effective for one person. One foot placed across the axillary folds and onto the chest wall placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial then using gentle internal and external rotation with axial tractiontraction

Stimson technique- Patient placed prone with the affected Stimson technique- Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be extremity allowed to hang free. Gentle traction may be usedused

Milch Technique- Arm is abducted and externally rotated Milch Technique- Arm is abducted and externally rotated with thumb pressure applied to the humeral headwith thumb pressure applied to the humeral head

Scapular manipulationScapular manipulation


PostreductionPostreduction– Post reduction films are a must to confirm the Post reduction films are a must to confirm the

position of the humeral headposition of the humeral head– Pain controlPain control– Immobilization for 7-10 days then begin Immobilization for 7-10 days then begin

progressive ROMprogressive ROM Operative IndicationsOperative Indications

– Irreducible shoulder (soft tissue interposition)Irreducible shoulder (soft tissue interposition)– Displaced greater tuberosity fracturesDisplaced greater tuberosity fractures– Glenoid rim fractures bigger than 5 mmGlenoid rim fractures bigger than 5 mm– Elective repair for younger patientsElective repair for younger patients

Elbow Fracture/DislocationsElbow Fracture/Dislocations

Elbow DislocationsElbow Dislocations EpidemiologyEpidemiology

– Accounts for 11-28% of injuries to the elbowAccounts for 11-28% of injuries to the elbow– Posterior dislocations most commonPosterior dislocations most common– Highest incidence in the young 10-20 years and Highest incidence in the young 10-20 years and

usually sports injuriesusually sports injuries Mechanism of injuryMechanism of injury

– Most commonly due to fall on outstretched hand Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the or elbow resulting in force to unlock the olecranon from the trochleaolecranon from the trochlea

– Posterior dislocation following hyperextension, Posterior dislocation following hyperextension, valgus stress, arm abduction, and forearm valgus stress, arm abduction, and forearm supinationsupination

– Anterior dislocation ensuing from direct force to Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexedthe posterior forearm with elbow flexed

Elbow DislocationsElbow Dislocations

Clinical EvaluationClinical Evaluation– Patients typically present guarding the injured Patients typically present guarding the injured

extremityextremity– Usually has gross deformity and swellingUsually has gross deformity and swelling– Careful NV exam in important and should be Careful NV exam in important and should be

done prior to radiographs or manipulationdone prior to radiographs or manipulation– Repeat after reductionRepeat after reduction

Radiographic EvaluationRadiographic Evaluation– AP and lateral elbow films should be obtained AP and lateral elbow films should be obtained

both pre and post reductionboth pre and post reduction– Careful examination for associated fracturesCareful examination for associated fractures

Elbow Fracture/DislocationsElbow Fracture/Dislocations TreatmentTreatment

– Posterior DislocationPosterior Dislocation Closed reduction under sedationClosed reduction under sedation Reduction should be performed with the elbow flexed Reduction should be performed with the elbow flexed

while providing distal tractionwhile providing distal traction Post reduction management includes a posterior Post reduction management includes a posterior

splint with the elbow at 90 degreessplint with the elbow at 90 degrees Open reduciton for severe soft tissue injuries or bony Open reduciton for severe soft tissue injuries or bony

entrapmententrapment– Anterior DislocationAnterior Dislocation

Closed reduction under sedationClosed reduction under sedation Distal traction to the flexed forearm followed by Distal traction to the flexed forearm followed by

dorsally direct pressure on the volar forearm with dorsally direct pressure on the volar forearm with anterior pressure on the humerusanterior pressure on the humerus


Associated injuriesAssociated injuries– Radial head fx (5-Radial head fx (5-

11%)11%)– TreatmentTreatment

Type I- ConservativeType I- Conservative Type II/III- Attempt Type II/III- Attempt

ORIF vs. radial head ORIF vs. radial head replacementreplacement

No role for solely No role for solely excision of radial head excision of radial head in 2006.in 2006.


Associated Associated injuriesinjuries– Coronoid process Coronoid process

fractures (5-10%)fractures (5-10%)


Associated injuriesAssociated injuries– Medial or lateral epicondylar fx (12-Medial or lateral epicondylar fx (12-

34%)34%)

Elbow DislocationsElbow Dislocations Instability ScaleInstability Scale

– Type IType I Posterolateral rotary Posterolateral rotary

instability, lateral ulnar instability, lateral ulnar collateral ligament disruptedcollateral ligament disrupted

– Type IIType II Perched condyles, varus Perched condyles, varus

instability, ant and post instability, ant and post capsule disruptedcapsule disrupted

– Type IIIType III A: posterior dislocation with A: posterior dislocation with

valgus instability, medial valgus instability, medial collateral ligament disruptioncollateral ligament disruption

B: posterior dislocation, B: posterior dislocation, grossly unstable, lateral, grossly unstable, lateral, medial, anterior, and medial, anterior, and posterior disruptionposterior disruption

Thank You…!!!Thank You…!!!

upper extremity trauma

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