FRACTURE UPPER LIMB pdf - د.هشام القطان

Fifth stage

Surgery

Lec-4

هشام القطان

18/10/2015

Upper Limb Fracture

Fracture clavicle

Mechanism of injury



A fall on the shoulder or outstretched hand may break the clavicle in common mid shaft,
fracture outer end.

Clinical features



The arm is clasped to the chest to prevent movement.



Subcutaneous lump obvious.



Occasionally sharp fragment threatens the skin.



Vascular complication rare.

X-ray



We can see the site of the fractures.



Middle, outer third

Treatment



Accurate reduction is neither possible nor essential.



All that is needed is to support the arm in a sling (2-3 weeks).



Or figure of eight bandage.



Internal fixation rarely done.( in outer third fracture).



Then physiotherapy.

Complications

Early :



Pneumothorax,



damage to subclavian artery,



brachial plexus injures.

Late:



Non union,



Malunion



stiffness of the shoulder

Dislocation of the shoulder



Of the large joints the shoulder is the one that most commonly dislocate it is due to the
following .

Predisposing factors:
1.  shallowness of the glenoid.
2.  extraordinary range of movement.
3.  ligament laxity, or glenoid dysplasia.

Anterior dislocation

Pathology and mechanism



Caused by a fall on the hand



Humerus is driven forewards,tearing the capsule or avulsing the glenoid labrum.



Occasionally posteriolateral part of the head is crushed.

Clinical features



Pain sever.



Patient support the arm with the opposite hand and prevent any kind of examination.



Flattened lateral outline of shoulder



Bulge below the clavicle.

Examination for axillary nerve and nearby vessel is important

Radiological examination



Ap will show overlapping shadows of the humeral head and glenoid.



Head usually lying below and medial to the glenoid.

Treatment



Stimsons’ technique.



Hippocratic method.



Kochers’ method.



Spaso technique

Stimsons’ technique:



Patient is left prone with the arm hanging over the side of the bed. after 15-20 min the
shoulder may reduce.

Hippocratic method:



Gently increasing traction is applied to the arm with the shoulder is slight abduction



Counter traction either by assistant with towel slung or the foot of the examiner.

Kochers’ method:



Under G/A. with assistant



Elbow is bent 90 degree and held close to the body.



No traction.



The arm slowly rotated 75 degree externally.



The elbow is lifted forwards.



Finally the arm is rotated medially.



The arm rest in sling for 3 weeks



Then movement started with avoidance abduction and lateral rotation.

Complications

Early:

–  Rotator cuff tear.
–  Nerve injury.
–  Vascular injury.
–  Fracture dislocation.

Late:

–  Shoulder stiffness.
–  Unreduced dislocation.
–  Recurrent dislocation

Fractures of the humerus



Fracture proximal humerus.



Fracture shaft of the humerus.

Fractured shaft of humerus

Mechanism of injury:



A fall on the hand may twist the humerus.



A fall on the elbow.



A direct blow to the arm.



In elderly may be metastasis.

Clinical features



The arm is painful.



Bruised and swollen.



It is important to test the radial nerve (before and after treatment).

X - ray



Site of the fracture.



Type of the fracture



Degree of displacement.



Any evidence of pathological fracture.

Treatment



Fracture of the humerus heal readily.



External cast 2-3 weeks.



Replaced with polypropylene brace worn for 6 weeks more.



physiotherapy.



If failed surgery. internal fixation, external.

Complications
Early :



Vascular injure

(brachial artery).



nerve injure ( radial nerve)

wrist drop.

Late



Delayed union.



joint stiffness.



non union.

fractures around elbow in children
Supracondylar fractures

1.Anterior displacement(Rare)
Mechanism of injury



2. posterior displacement or angulation(95%) of all cases.



Fall on outstretched hand.



Humerus break just above the condyles.



Distal segment pushed backwards and twisted inwards.



Some time injury to brachial artery or median nerve.

Clinical features



History of fall.



Sever pain



Swollen elbow.



( s shape deformity ).



Abnormal bony land mark.



It is important to feel distal pulse and capillary return.



Dorsiflexion wrist should pain free.



Distal nerve should be examined.

Radiological examination



AP AND LATERAL



We can see the degree of displacement.

Treatment



Depend on the degree of displacement.

Undisplaced :



In cast for at least 3 weeks.

Displaced



Under anesthesia.



Traction 2-3 min in the length with the length of the arm.



Counter traction.



Correction of deformity.



Gradual flexion of the elbow with pronation of the forearm.



Then feel the pulse and capillary return.



If distal circulation suspicious immediate relaxing the elbow till improvement.



Back slab splint.



X-ray to confirm

Sever displaced



Open and internal fixation with k-wire

Complications
Early :



Vascular injury.



Compartment syndrome.



Nerve injury (median nerve, ulnar nerve).

Late:



Malunion is common .(gunstock deformity).



Elbow stiffness and Myositis ossificans

Fractures of the lateral condyle (capitellar)

Mechanism of injury:



Falls on the hand with the elbow extended and forced into Varus



A large fragment which includes the lateral condyle,breaks off and is pulled upon by the
attached wrist extensor.



The fracture line usually runs along the physis and in to the trochlea.

Clinical features



Swollen elbow.



Deformed.



Tenderness over the lateral condyle



Passive flexion of the wrist may be painful.

X -ray



Must include oblique view or the fracture may be missed.



Ap and lateral.



We can see the fracture.

Treatment



If no displacement



Splint applied and exercise after 2 weeks



Displaced > 2mm



Open and k-wire applied.



With cast immobilization to be removed with the wire after 4 weeks.

Separation of the medial epicondylar apophysis
Mechanism of injury



Fall on the outstretched hand with the wrist and elbow extended.



Avulsion occurred.



Sometimes the apophysis is draged within the joint.

Clinical features



Swelling and bruising on the medial side of the elbow.



If elbow dislocated the deformity is obvious.



Sensation for the ulnar should be checked.

X ray



Ap and lateral to confirm



The epicondyle may sometime appeared within the joint.



Normal limb should be x-rayed for comparison.

Treatment



Minor displaced only slab.



If the epicondyle within the joint surgery advised.



If displaced fracture and the fracture not trapped within the joint. joint manipulation can
improve the position

Fractured neck of the radius

Mechanism of injury:



A fall on outstretched hand forces the elbow into valgus and pushes the radial head
against the capitellum.

Clinical features



Pain in the elbow.



Pain in rotating forearm.



Localized tenderness over the radial head.

X-ray



The fracture line transverse.

Treatment



Up to 30 degree radial head tilt and up to 3 mm displacement are acceptable.



So put arm in collar and cuff and exercise after a week.



More than 30 reduction by



manipulation \ anesthesia.



If fail open and internal fixation



Then put in pop .for 2 weeks.

Pulled elbow



In young children the elbow may be injured by pulling on the arm. usually with the
forearm pronated.



It is due to slipping of the orbicular ligament over the head to the joint

Clinically



A child age with 2-3 years brought with a painful dangling arm.



History of jerky movement of the arm .



The forearm held with pronation and extension.



No x-ray changes.

Treatment



Dramatic cure obtained by forcefully supinating and then flexing the elbow

Fractures around elbow
in adult

Fractured head of the radius

Mechanism



A fall on outstretched hand with the elbow extended and forearm pronated causes
impaction of the radial head against the capitulum.

Clinical features



This fracture some time missed.



Pain on pronation and supination should suggest the diagnosis.



Tenderness over the head by direct pressure over the head.

X ray



Three types



Type 1 (vertical split)



Type 2 (single fragment laterally displaced).



Type 3 (comminuted head.)

Treatment



Type 1 analgesia with collar and cuff. then exercise.



Type 2 :segment should reduced and fixed.



Type 3:excision radial head.

Complications



Joint stiffness.



Myositis ossificans.



Recurrent instability.

Fractures of the olecranon



Comminuted due to direct blow.



A clean transverse break (indirect force).



due to traction when the patient falls onto the hand while the triceps is contracted.

Clinical features



Painful swelling around elbow.



Localized tenderness.



Bruise over the elbow.



May be palpable gap and the patient unable to extend the elbow against resistance.

X-ray



Either comminuted or transverse.



The position of the radial head should be checked.

Treatment



Comminuted :



By holding and exercise after clinical improvement.



Undisplaced transverse:



Cast immobilization then exercise.



Displaced:



Operative fixation.

Complications



Stiffness.



Non union



Osteoarthritis.

Dislocation of the elbow

Mechanism of injury



In 90% posterior or posteriolateral .



The cause of posterior dislocation is usually a fall on the outstretched hand with elbow in
extension.



There might be associated fracture to the near by structure, and near by soft tissue
disruption.

Clinical features:



His or her forearm with the elbow in slight flexion.



Sever swelling



Obvious deformity



The bony landmark around elbow abnormally displaced (olecranon and epicondyle)

x ray:



is essential to confirm dx



to identify any associated fractures.

Treatment
Uncomplicated dislocation.



Under anesthesia, elbow is slightly flexed olecranon process is pushed forward with the
thumb.



Distal neurovascular reexamination should be done.



and x-ray to confirm diagnosis.



Arm hold in a collar with flexed elbow in 90 degree



Then 1 week after start physiotherapy.



Dislocation with associated fractures:



Might need open and correction accordingly.

Complications
Early:



Vascular (brachial artery may be damaged.



Nerve injury median or ulnar

Late



Stiffness



Heterotopic ossification



Unreduced dislocation.



Recurrent dislocation.



Osteoarthritis.

Injuries of the forearm and wrist



Fractures of the radius and ulna:

Mechanism :



Fractures of the shafts of both forearm bones occur quite commonly in road accident.



Twisting force (usually a fall on the hand) produce spiral fractures.



Direct blow produce transverse fracture.



Additional rotation deformity may produced by muscle pull (biceps and supinator )to the
upper third.



Pronator teres to the middle



Pronator quadratus to the lower third



Bleeding and swelling of the muscle compartment of the forearm may cause circulatory
impairment

Clinical features



Pain



obvious deformity.



Swelling



Distal neural and vascular examination is essential



Repeated examination is necessary to detect an impeding compartment syndrome

x-ray



different type of fracture appeared.

Treatment:



In children



Closed reduction is usually successful because the periostum tends to guide and then
control reduction.



Immobilization with pop cast.(6-8 weeks).



Proximal to Pronator teres limb held in supination



Distal to it in pronation.



If failed surgery done.

Adults:



Unless the fragments are held in close apposition reduction is difficult



and open and internal fixation done.

Complications:

Early .



Nerve injury



Vascular injury



Compartment syndrome
Late:



Delayed union.



non union.



Malunion

teggia fracture – dislocation of the ulna:

Fracture of the ul

a upper third associated with dislocation of the proximal radioulnar

joint,radiocapitellar subluxation.
Mechanism of injury:



A fall on the hand with the body twisting.

Clinical features:



Pain



Obvious deformity



Tenderness on the lateral side of the elbow.



Distal neurovascular examinations should be done.

X ray:



AP and lateral view.



Either there were forward bowing, backward or lateral bowing of the ulna.



Posterior or lateral displacement of the radial head may appear.

Treatment:



The clue to successful treatment is to restore the length of the fractured ulna.



This mean operation.

Complications:



Nerve injury.



Malunion



Non union

leazzi

fracture – dislocation of the r

dius

Mechanism



A fall on the hand with superimposed rotation, the radius fractures in its lower third and
the inferior radioulnar joint subluxates or dislocation.

Clinical features



Much more common than Monteggia.



Prominence or tenderness over the lower end of the ulna is the striking feature.



Balloting the distal end of the ulna (piano – key sign)



Distal ulnar nerve examination is important.

X ray



A transverse or short oblique fracture is seen in the lower third of the radius, with
angulations or overlap.



The inferior radioulnar joint is subluxated or dislocated.

Treatment



In children closed is often successful



In adult open and internal fixation.

Smith's fracture



The distal fragment is displaced anteriorly (reverse colles')

Clinical features



Fall on the back of the hand.



Pain



No dinner fork deformity.

X ray



Fracture through distal radial metaphysis



The distal fragment is displaced and tilted anteriorly opposite colles'

Treatment



Under anesthesia



Traction



And extension of the wrist



The forearm is immobilized in a cast for 6 weeks.

Colles' fracture



Is a transverse fracture of the radius just above the wrist ,with dorsal displacement of
the distal fragment.

Mechanism



Force is applied in the length of the forearm with the wrist in extension.



The bone fracture at the corticocancellous junction and the distal fragment collapses into
extension, dorsal displacement, radial tilt and shortening.

Clinical features



History fall on outstretched hand



Pain deformity in form of dinner - fork shape .



Local tenderness.

x-ray



there is transverse fracture, often ulnar styloid process fracture, there might be
impaction of the distal piece ,some time severely comminuted or crushed.

Treatment



Undisplaced fracture.



Dorsal cast applied for 4 weeks then physiotherapy.

Displaced fracture



Must reduced under anesthesia



The hand is grasped and traction is applied in the length of the bone some time with
wrist extension for disimpaction



The distal segment is then pushed into place by pressing on the dorsum while
manipulating the wrist into flexion



Ulnar deviation



And pronation.



Dorsal slab applied from just below the elbow to the metacarpal necks.



Elevation of the arm2-3 days



Shoulder and finger exercise are started as soon as possible.



Check up after 10 days by x ray



If any redisplacement to be corrected.



Treatment completed for about 6 weeks.

Comminuted fracture:



Plaster in addition with k-wire



Or external fixation with bone graft.

Complications
Early



The circulation of the finger.



Nerve injury median nerve compression is fairly common



Reflex sympathetic dystrophy.

Late



Malunion is common.



Delayed union and non-union are rare



Stiffness of the shoulder, elbow and finger.



Tendon rupture (of extensor pollicis longus). occur after weeks

Fractured scaphoid:



It is account for 75% of all carpal fractures.

Mechanism



Combination of forced carpal movement and compression as a fall on dorsiflexed hand,
exerts severe stress on the bone and is liable to fracture.



The blood supply is diminished proximally and is result into non union or a vascular
necrosis.

Clinical features



History of fallen on the ground.



Pain around wrist



The appearance may be normal.



Tenderness at snuffbox



Some time observer can detect fullness in the anatomical snuffbox



Proximal pressure along the axis of the thumb may be painful.



Ap, lat, oblique, all essential.



A recent fracture show only in oblique view as transverse line (through the waist)



But may be proximally.



or tubercle of the scaphoid.



A few weeks after the injury evidence of non union



or a vascular necrosis appear of the proximal segment.

Treatment
Undisplaced fracture:



Need no reduction



Treated in plaster. the cast is applied from the upper forearm to just short of the mp
joints of the fingers but incorporating the proximal phalanx of the thumb



The wrist hold dorsiflexion and the thumb forward (glass-holding) position.



After 6 weeks the plaster opened



If no pain and tenderness so finished



If pain and tenderness re applying of the pop for another 6 weeks.

Displaced fracture:



Can be treated by pop



If failed open and fixation with compression screw

Complications:



Avascular necrosis (the proximal segment die).



Non union appeared by 3 months.



Osteoarthritis

Metacarpal fractures

Fracture of the metacarpal shaft:



Direct blow may fracture one or several bones transversely.



Twisting force may cause spiral fracture.

Clinically:



Pain



swelling



some time local hump.

Treatment:



Oblique or transverse fracture with slight displacement only crepe bandage

Transverse



fracture with displacement may need slight manipulation if failed may need k-wire

Spiral



may need k- wire or plate.

Fracture metacarpal neck



A direct blow usually the fifth finger (boxer's fracture )and occasionally one of the others

Clinically



Pain



local swelling,



flattening of the knuckle.



x- ray show an impacted transverse fracture with volar Angulation of the distal fragment.

Treatment



Flexion deformity about 40 deg is accepted, and a good outcome can be accepted



Hand is splinted with gutter splint.

BENNETT'S
Fracture –Dislocation



This fracture occurs at the base of the first metacarpal bone and is commonly due to
punching



Fracture is oblique and extends into the carpometacarpal joint and is unstable.



The thumb looks short and carpo metacarpal region swollen.



x-rays show the fracture at the base of the metacarpal bone

Treatment



Perfect reduction is essential



by pulling the thumb then abducting and extending it



then reduction held by pop or internal fixation.

MALLET FINGER INJURY



There are three types of mallet finger:

1.A tendinous avulsion
2.A small flake of bone
3.A large dorsal bone fragment.



After as sudden flexion injury the terminal phalanx droops and cannot be straight

Treatment



Immobilizing the terminal joint in slight hyperextension by special mallet splint



Occasionally k-wire used.

Fractures of the phalanges



Direct blow



This will lead to considerable swelling .

Treatment



Undisplaced by functional splint (finger is strapped to its neighbour and movement is
encouraged.



Displaced fracture must reduced and immobilized. with either splint or (k-wire).



Treatment may result to stiff finger which in some time can be worse than no finger.

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