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Fifth stage
Surgery
Lec-2
د
.
مثنى الحموشي
13/12/2016
Injuries of the upper limbs
Fracture clavicle
it is occur due to fall on out stretched hands.
The common sites of the fracture in the clavicle is mid shaft .the outer segment displaced
down ward and the medial one displaced upward due to the effect of the sternomastoid
muscle .
Complication :
early :injuries to subclavian artery , brachial plexus , pnemothrax all are rare
late : malunion , nonunion .
Treatment :by splinting the arm by sling or by use figure of 8 for one month .
accurate reduction is neither possible nor essential .. If there is complication then open
reduction and fixation (rarely required)
Figure of 8 in treatment of fracture clavicle
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Shoulder dislocation
Shoulder joint is the commonest large joint which suffer from dislocation ; due to many
factors like shallow glenoid and its wide range of movements .
Types of shoulder dislocation :
1- anterior dislocation (the commonest) .
2-posterior dislocation (rare) .
3- inferior dislocation (rare) .
Anterior dislocation of the shoulder
It caused by fall on out stretched hand , the head of the humerus driven foreword tearing
the capsule or avulsing the glenoid labrum, and settled under the clavicle in the
infraclavicular fossa .
Clinically : history of trauma , sever pain , the patient support his arm with the opposite
hand and resist any kind of examination .
On examination : there is loss of normal contour of the affected shoulder , visible or
palpable boney mass below the clavicle .
Neurovascular examination for axillary nerve and distal pulsation is very important before
any attempt of reduction for medicoleagal purpose.
X –ray :
1- antero-posterior view show the head of the humerus out of the glenoid and located
usually below of the clavicle or the coracoid process .
2- axillary view is very helpful also .
Treatment : 3 methods of reduction :
1- Kocher’s maneuver : most commonly used under general anesthesia , with the assistant
do counter traction, flexion of the elbow 90` and held close to the body , no traction , slow
lateral rotation of the arm then adduction and medial rotation .
2-Hippocratic’s method . Traction on the line of the limb with counter traction .
3-stimson’s technique (gravity) .patient prone the arm hanged beside the bed for 15 – 20
minutes
Anterior shoulder dislocation
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Complications :
Early :
1- nerves injuries : axillary nerve is the most commonly injured ; the patient is unable to do
contraction of the deltoid muscle and there will be small patch of anesthesia over the tip of
the shoulder . The lesion is usually neuropraxia and recovery will occur after few weeks
2-vascular injuries : mainly the axillary vessels .
3- rotator cuff tear : there will be difficulty in abduction of the shoulder .
4- associated fractures : fracture proximal humerus , fracture greater tuberosity of hum.
Late :
1- stiffness of the shoulder .
2- recurrent dislocation . It occur due to avulsion of the labrum or sever tear of
the capsule . It should be treated by surgery.
3- unreduced dislocation .(missed)
Posterior shoulder dislocation
It is rare less than 2% it occur due to marked internal rotation with adduction ; it occur in
Convulsion or with electrical shock .
Clinically : the arm is held in medial rotation and it locked in that position .
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Fracture proximal humerus
This type of fracture occur in old and middle age osteoporotic people .
In the majority of the cases displacement is not marked , only 20% of cases has
considerable displacement .
The fracture occur due to fall on out stretched arm
Proximal humerus include 4 major components these are :
1-head of humerus . 2-greater tuberosity .
3-lesser tuberosity . 4-surgical neck of the
humerus .
classification .
neer
of this fracture called
Classification
kin , sign of
s
function , swelling , bruises on the
story of trauma , pain ,loss of
hi
:
Clinically
axillary nerve or brachial plexus injury may be detected .
taken to exclude associated dislocation .
should be
p , lat.view or axillary view
-
:a
ray
-
X
Proximal humerus fracture
:
Treatment
Minimally displaced fracture (majority) need only sling of the arm for 3 weeks until the pain
subside and then gentle passive movement is advised ; active movements is encouraged
after 6 weeks .
If there is considerable displacement of one or more of the 4 components , then
manipulation is advised , if fail then open reduction and fixation .
If the fracture is 4 peaces and displaced and the patient is old then do prosthetic
replacement of the proximal humerus .
:
Complication
Early : neurovascular injuries (axillary n. , a.)
Late :
1- stiffness of the shoulder ; this can minimized by early mobilization .
2- avascular necrosis of the head of the humerus .
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Fracture shaft of humerus
this fracture caused by fall on out stretched Hands or by direct blow on the arm .
Fracture above the deltoid insertion (deltoid tuberosity), the proximal segment is adducted
by pectoralis major muscle , and if the fracture below the deltoid insertion then the
proximal segment is abducted by the effect of the deltoid muscle .
Injury to the radial nerve is common with this fracture mainly at the junction of the upper
two third and the lower one third of the shaft due to close contact of the nerve to the bone
at that site so it is very important to test for the radial nerve function with this fracture
before and after treatment and this is done by assessing active extension of fingers and
wrist .
:
Treatment
: this include hanging cast which is p.o.p cast made from the arm to
Conservative treatment
the wrist with elbow flexed 90`, the limb is slinged from the wrist so the weight of the cast
will pull the fragments into alignment this can be left for 2-3 weeks and then replaced by
shoulder to elbow cast (u-shape slab) for further 4-6 weeks .
Exercise of the wrist and the fingers should be started from the beginning to avoid stiffness.
Exercise of the shoulder should be started as early as possible to avoid stiffness( mainly in
elderly).
:
Operative treatment
:
Types of fixation
1-compresion plate and screws .
2-inter locking intra medullary nail .
3-external fixators .
:
Indications of fixation
1-sever multiple injuries .2-open fracture .
3-segmental fracture . 4- pathological fracture .
5-radial nerve palsy after manipulation .
6- non-union .
:
Complications
:
Early
1-vascular injury (brachial artery) .
2- nerve injury ; radial nerve palsy will cause
wrist drop .
:
Late complication
1- delayed union and non union .
2- joint stiffness (minimized by early activity).