upper limb injuries dr abhishek agarwal lecturer deptt orthopedics

UPPER LIMB INJURIESDr 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


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


Figure of eight Bandage


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


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

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 shoulderGutierrez 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


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 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


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 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 (high risk with delayed reduction)

Heterotopic calcification ( used to be called Myositis Ossificans )

Recurrent dislocation


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


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 fracture May be associated with Radial Nerve

injury


Fracture shaft of the Humerus


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


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


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


U Shaped slab 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


Pediatric Supra-Condylar Humeral fracture


Pediatric Supra-condylar fracture


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


Complications Supra-Condylar Fractures

A. Early= Compartment syndrome 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 or varus)


Volkmann's Ischemic Contracture


Supracondylar fracture.


Fracture dislocation


MONTEGGIA 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.

GALEAZZI FRACTURE-DISLOCATION


Distal radius fracture.


contd


Types of treatment


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



Carpal fractures compressive loads

to hyperextended wrist

hyper flexion rotation loading

against a fixed wrist Scaphoid

60-70% Lunate



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



Metacarpal & phalangeal injuries

Fractures Boxers

Dislocations


upper limb injuries dr abhishek agarwal lecturer deptt orthopedics

Documents

injured limb

trunkthe shoulder

traumatic dislocation

shouldermostly anterior

multi directional dislocation

neurovascular injury

step anterior bulge

indirect injurydirect