Fractures & Dislocations of the Upper Limb Dr Munir Saadeddin, FRCSE

Upper Limb include Clavicle Clavicle Scapula Scapula Shoulder Joint Shoulder Joint Humerus Humerus Elbow Joint Elbow Joint Forearm Bones Forearm Bones Wrist Joint Wrist Joint Scaphoid Bone Scaphoid Bone

Mechanism of Injuries of the Upper Limb Mostly Indirect Mostly Indirect Commonly described as “ a fall on outstretched hand “ 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 Type of injury depends on position of the upper limb at the time of impact : Flexed, Extended, adducted, abducted, pronated or supinated

Mechanism of Injury

Splintage & Elevation in Upper Limb The Hand has to be Higher than the Elbow The Hand has to be Higher than the Elbow Simplest splint is the tri- angular splint which can be made of any piece of cloth Simplest splint is the tri- angular splint which can be made of any piece of cloth Commonest splint used is the Collar & cuff splint Commonest splint used is the Collar & cuff splint Strapping the upper limb to the trunk is one method of Immobilisation of shoulder and humerus Strapping the upper limb to the trunk is one method of Immobilisation of shoulder and humerus

Fractures of the Clavicle A common injury in all ages A common injury in all ages Most fractures are in the Middle third Most fractures are in the Middle third Usually it is the result of Indirect injury Usually it is the result of Indirect injury Direct injuries are more serious ( possible injury to neuro vascular structures ) Direct injuries are more serious ( possible injury to neuro vascular structures ) In children it may be a Green stick fracture In children it may be a Green stick fracture Fracture site can be identified easily because clavicle is a subcutaneous bone Fracture site can be identified easily because clavicle is a subcutaneous bone

? Fracture of the Clavicle

? Fracture of the clavicle A child with sudden painful swelling over left clavicle A child with sudden painful swelling over left clavicle History of a fall injury few days ago History of a fall injury few days ago The swelling is over mid clavicle and is tender The swelling is over mid clavicle and is tender Initial x rays do not show a fracture Initial x rays do not show a fracture The Answer is to repeat the X ray two weeks later The Answer is to repeat the X ray two weeks later

Fracture of the clavicle 2 weeks later

Fracture of the clavicle in Adults

Usually displaced with deformity Usually displaced with deformity May be comminuted May be comminuted mostly heal with a degree of Mal-Union mostly heal with a degree of Mal-Union Delayed union or Non union are less common Delayed union or Non union are less common Usually is treated conservatively Usually is treated conservatively Open reduction gives satisfactory alignment but results in unsightly scar Open reduction gives satisfactory alignment but results in unsightly scar

Figure of eight Bandage

Figure of Eight bandage It is the common way for treating fractures of clavicle conservatively It is the common way for treating fractures of clavicle conservatively Simple to apply in Emergency room Simple to apply in Emergency room It helps to reduce overlap of fracture ends It helps to reduce overlap of fracture ends It should not be applied very tight or it may compress the neuro vascular structures at axilla It should not be applied very tight or it may compress the neuro vascular structures at axilla

Union of Fracture of the clavicle Early union occurs in 1-2 weeks in children Early union occurs in 1-2 weeks in children In adults early union occurs in 3 weeks, union in 6 weeks and consolidation in 12 weeks In adults early union occurs in 3 weeks, union in 6 weeks and consolidation in 12 weeks Callus formation can be visible and palpable Callus formation can be visible and palpable Mal united overlap of fracture can be treated by trimming some bone after union of fracture Mal united overlap of fracture can be treated by trimming some bone after union of fracture Non Union is treated by compression Plating and bone grafting Non Union is treated by compression Plating and bone grafting

Dislocation of the Shoulder Mostly Anterior > 95 % of dislocations Mostly Anterior > 95 % of dislocations Posterior Dislocation occurs < 5 % Posterior Dislocation occurs < 5 % True Inferior dislocation ( Luxato Inferno ) occurs < 1% True Inferior dislocation ( Luxato Inferno ) occurs < 1% Habitual Non traumatic dislocation may present as Posterior dislocation or Multi directional dislocation due to ligament laxity and is Painless Habitual Non traumatic dislocation may present as Posterior dislocation or Multi directional dislocation due to ligament laxity and is Painless

Mechanism of anterior shoulder dislocation Usually Indirect fall on Abducted and extended shoulder Usually Indirect fall on Abducted and extended shoulder May be direct when there is a blow on the shoulder from behind May be direct when there is a blow on the shoulder from behind

Anterior Shoulder dislocation Usually also inferior Usually also inferior There is damage ( Overstretching ) to the shoulder capsule and subscapularis muscle There is damage ( Overstretching ) to the shoulder capsule and subscapularis muscle Commonly there is avulsion to the antero inferior part of the Glenoid labrum with adjacent periosteom on the neck of scapula = Bankart’s Lesion Commonly there is avulsion to the antero inferior part of the Glenoid labrum with adjacent periosteom on the neck of scapula = Bankart’s Lesion

Clinical Picture Patient is in pain Patient is in pain Holds the injured limb with other hand close to the trunk Holds the injured limb with other hand close to the trunk The shoulder is abducted and the elbow is kept flexed The shoulder is abducted and the elbow is kept flexed There is loss of the normal contour of the shoulder There is loss of the normal contour of the shoulder

Clinical Picture Loss of the contour of the shoulder may appear as a step Loss of the contour of the shoulder may appear as a step Anterior bulge of head of humerus may be visible or palpable Anterior bulge of head of humerus may be visible or palpable A gap can be palpated above the dislocated head of the humerus 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 to the neuro vascular bundle in axilla ( rare ) Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) Associated fracture Associated fracture

Axillary or Circumflex Nerve Injury It is a branch from posterior cord of Brachial plexus It is a branch from posterior cord of Brachial plexus It hooks close round neck of humerus from posterior to anterior 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 It pierces the deep surface of deltoid and supply it and the part of skin over it

Axillary or circumflex nerve injury

Management Of Anterior Shoulder dislocation Is an Emergency Is an Emergency It should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerus 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 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 ) 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 ) 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 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 ) Neuro vascular injury ( rare ) Axillary or Circumflex nerve injury Axillary or Circumflex nerve injury Associated Fracture of neck of humerus or greater or lesser tuberosities 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 ( may be delayed up to 2 years and only following delayed reduction ) Avascular necrosis of the head of the Humerus ( may be delayed up to 2 years and only following delayed reduction ) Heterotopic calcification ( used to be called Myositis Ossificans ) Heterotopic calcification ( used to be called Myositis Ossificans ) Recurrent dislocation Recurrent dislocation

Associated fractures

Fractures of The Humerus Proximal Humerus (includes surgical and anatomical neck ) Proximal Humerus (includes surgical and anatomical neck ) Shaft of Humerus Shaft of Humerus Distal humerus ( includes Supra Condylar fracture in children ) Distal humerus ( includes Supra Condylar fracture in children )

Fracture Proximal Humerus

Fracture Proximal Humerus : Plating or Rush Nail insertion

Fracture Proximal Humerus : Intra-medullary K wire fixation

Intra-medullary K wire fixation

Fractures Shaft of the Humerus Commonly Indirect injury Commonly Indirect injury Indirect injury results in Spiral or Oblique fractures Indirect injury results in Spiral or Oblique fractures Direct injuries results in transverse or comminuted ( Butterfly ) fracture Direct injuries results in transverse or comminuted ( Butterfly ) fracture May be associated with Radial Nerve injury May be associated with Radial Nerve injury

Fracture shaft of the Humerus

Radial Nerve Injury Results in Drop Wrist Results in Drop Wrist Associated with fracture humerus in up to 12% of fractures Associated with fracture humerus in up to 12% of fractures 2/3 ( 8%) of Radial injury are Neuropraxia 2/3 ( 8%) of Radial injury are Neuropraxia 1/3 ( 4%) are nerve lacerations or transection 1/3 ( 4%) are nerve lacerations or transection

Management of Radial Nerve Injury When present in open fractures ; immediate exploration and ± repair 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 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 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 If No spontaneous recovery occurs in 12 weeks confirmed by NCS and EMG ;then exploration of the nerve should be carried out

Exploration Radial Nerve

Management of Fracture Shaft of the Humerus Preferably Conservative Preferably Conservative Closed Reduction in upright position followed by application of U shaped Slap of POP or Cylinder cast Closed Reduction in upright position followed by application of U shaped Slap of POP or Cylinder cast Few weeks later or initially in stable fractures Functional Brace may be used Few weeks later or initially in stable fractures Functional Brace may be used

U Shaped slap of POP

Functional brace Fracture Shaft of Humerus

Indications for ORIF Fracture Shaft of Humerus Failure to reduce fracture conservatively Failure to reduce fracture conservatively Bilateral humeral fractures Bilateral humeral fractures Open fracture with radial nerve Injury Open fracture with radial nerve Injury Unconscious patient Unconscious patient Delayed-Union, Non-Union and Mal-Union Delayed-Union, Non-Union and Mal-Union

Plating fracture Shaft of humerus

Intra- medullary K Wire Fixation

Supra- condylar Fracture of Humerus

Supra-Condylar fracture of t Humerus

Supra-condylar fracture of Humerus

Acute Volkmann's Ischemia

Reduction of supra-condylar Fracture Absolute Emergency Absolute Emergency Should de done under G A by experienced doctor as soon as possible 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 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 At present time Percutaneous K wire fixation is ALWAYS carried out after reduction

Reduction Supra-Condylar Fracture

Complications Supra-Condylar Fractures A. Early= Brachial Artery injury ( Acute Volkmann's Ischemia ) Volkmann's Ischemia ) Nerve Injury : Median, Ulnar or Nerve Injury : Median, Ulnar or Radial Radial B. Late= Stiffness Volkmann's Ischemic contracture Volkmann's Ischemic contracture Heterotopic Calcification Heterotopic Calcification Mal-Union ( Cubitus Valgus ) Mal-Union ( Cubitus Valgus )

Volkman’s Ischemic contracture

Volkmann's Ischemic Contracture

Mal-Union Supra- condylar fracture Most commonly results in Cubitus Varus Most commonly results in Cubitus Varus Less common is Cubitus Valgus or Cubitus Recurvatum Less common is Cubitus Valgus or Cubitus Recurvatum Management is by Corrective Supra- Condylar Osteotomy Management is by Corrective Supra- Condylar Osteotomy

Intra- Articular fractures of Elbow Are sometimes difficult to diagnose exactly Are sometimes difficult to diagnose exactly X ray of the other shoulder is helpful in diagnosis X ray of the other shoulder is helpful in diagnosis C T may be required in some cases C T may be required in some cases Non displaced intra- articular fractures can be managed by immobilisation in functional position till union Non displaced intra- articular fractures can be managed by immobilisation in functional position till union Displaced fractures require ORIF Displaced fractures require ORIF

Intra-articular Fracture of Elbow

Intra-Articular Fracture of Elbow This is displaced fracture of capitullum which required ORIF This is displaced fracture of capitullum which required ORIF If not reduced Anatomically it will lead to stiffness, deformity and early OA If not reduced Anatomically it will lead to stiffness, deformity and early OA

ORIF Fracture Cpitullum

Fractures Head of Radius

Displaced Fracture Head of Radius

Displaced fractures Head of Radius require ORIF if possible Displaced fractures Head of Radius require ORIF if possible When unable to reconstruct articular surface Anatomically we carry out excision of the Head When unable to reconstruct articular surface Anatomically we carry out excision of the Head

Excision Comminuted Fracture Head of radius

Montegia Fracture Dislocation It is a fracture of the proximal 1/3 rd of the Ulna with dislocation of head of radius anteriorly. Posterirly or laterally It is a fracture of the proximal 1/3 rd of the Ulna with dislocation of head of radius anteriorly. Posterirly or laterally Head of Radius dislocates same direction as fracture Head of Radius dislocates same direction as fracture It requires ORIF or it will redisplace It requires ORIF or it will redisplace

Montegia : Lateral displacement

Galliazi Fracture It is a fracture of distal Radius and dislocation of inferior Radio- Ulnar joint It is a fracture of distal Radius and dislocation of inferior Radio- Ulnar joint Like Montegia fracture if treated conservatively it will redisplace Like Montegia fracture if treated conservatively it will redisplace This fracture appeared in acceptable position after reduction and POP This fracture appeared in acceptable position after reduction and POP

Galliazi Fracture Fracture redisplaced in POP Fracture redisplaced in POP This required ORIF This required ORIF

Fracture Both Bones of Forearm

Fractures Around the Wrist A. Extra-Articular : Greenstick fracture distal radius in children A. Extra-Articular : Greenstick fracture distal radius in children Colle’s fracture Colle’s fracture Smith fracture B. Intra-Articular : Smith fracture B. Intra-Articular : Barton’s fracture= volar and dorsal Barton’s fracture= volar and dorsal Comminuted Intra-articular fracture Comminuted Intra-articular fracture

Colles’ Fracture Most common fracture in Osteoporotic bones Most common fracture in Osteoporotic bones Extra-Articular : 1 inch of distal Radius Extra-Articular : 1 inch of distal Radius Results from a fall on dorsi flexed wrist Results from a fall on dorsi flexed wrist Typical deformity : Dinner Fork Typical deformity : Dinner Fork Deformity is : Impaction, dorsal displacement and angulation, radial displacement and angulation and avulsion of ulnar styloid process Deformity is : Impaction, dorsal displacement and angulation, radial displacement and angulation and avulsion of ulnar styloid process Management is usually conservative : MUA and forearm POP Management is usually conservative : MUA and forearm POP

Colles’ Fracture

Smith Fracture

Almost the opposite of Colles’ fracture Almost the opposite of Colles’ fracture Much less common compared to colles’ Much less common compared to colles’ Results from a fall on palmer flexed wrist Results from a fall on palmer flexed wrist Typical deformity : Garden Spade Typical deformity : Garden Spade Management is conservative : MUA and Above Elbow POP Management is conservative : MUA and Above Elbow POP

Volar Barton’s Fracture Dislocation It is Intra-Articular with volar displacement which looks like smith fracture It is Intra-Articular with volar displacement which looks like smith fracture There is dorsal type which looks like Colles’ fracture There is dorsal type which looks like Colles’ fracture Management is by ORIF Management is by ORIF

ORIF Volar Barton’s

Comminuted Intra- Articular fractures

External Fixator for Comminuted Fractures

Scaphoid Bone Fractures

Scaphoid bone Fractures

Scaphoid Bone Fractures