Common Upper Limb Fractures By Chris Pullen

Common Fractures Clavicle Proximal Humerus Distal radius Scaphoid

Clavicle 4% to 15% of all fractures 35% of fractures about the shoulder middle third++ Mechanism Direct trauma indirect - fall onto the outstretched hand

Clavicle – Middle 1/3 Most are treated non-surgically with a sling for 3 - 4 weeks Thereafter ROM exercises

Clavicle – Middle 1/3 ORIF Indications open fractures neurovascular injury/compromise displaced fractures with impending skin compromise widely displaced midclavicular fractures shortening (20 mm) or gross displacement are risk factors for the development of nonunion

Clavicle – Middle 1/3

Clavicle – Lateral 1/3 Displaced ORIF (30% nonunion) Sling 6 weeks secondary to a fracture medial to the coracoclavicular ligaments ORIF (30% nonunion) Sling 6 weeks

Proximal Humerus 4% to 5% of all fractures ↑ age ↑ incidence Elderly - fall osteoporotic bone Young – significant trauma ~ 85% are minimally displaced

Proximal Humerus - Imaging Plain XR scapular anteroposterior (AP) lateral axillary radiographs +/- CT scan

Proximal Humerus - Classification 4 parts (anatomic fragments) humeral head greater tuberosity lesser tuberosity humeral shaft Determination of displacement >1 cm angulation > 45°

Proximal Humerus - Nonsurgical Minimally or non-displaced fractures Sling or collar & cuff Rpt XR 1 & 2 weeks Early passive motion within 14 days Active range of motion is started at 4 to 6 weeks A recent report indicated that functional outcome was inferior to previously reported results

Proximal Humerus - Surgical Two-part fractures of the surgical neck most common displaced proximal humeral fracture closed reduction - if stable ORIF - if cannot be reduced closed

Proximal Humerus - Surgical Two-part fractures of the greater tuberosity commonly occur with a shoulder dislocation After reduction the tuberosity may return to its anatomic position ORIF if displaced (=/- repair of the rotator cuff tear)

Proximal Humerus - Surgical Three-part fractures ORIF functional results better

Proximal Humerus - Surgical Four-part fractures ORIF young patients good bone quality Humeral head replacement preferred method in the elderly better functional scores

Distal Radius common incidence ~ 1 in 500 people bimodal age distribution adolescents and young adults high-energy injuries postmenopausal elderly women

Distal Radius - Imaging Plain XR posteroanterior (PA) Lateral oblique radiographs +/- CT scan

Distal radius - Nonsurgical Minimally or non-displaced fractures Elderly Below elbow POP 6 weeks Young adult Above elbow POP 6 weeks Rpt XR 1 & 2 weeks ROM exercises

Distal Radius - Surgical Indications Radial shortening of < 5mm at DRUJ Dorsal tilt >/= 15° or Volar tilt >/= 20° Intra-articular incongruity of >/= 2mm anatomic reduction is critical

Distal Radius - Surgical

Distal Radius - Surgical Options closed reduction +/- K wire fixation external fixation ORIF arthroscopically-assisted reduction bone defect filling

Distal Radius - Surgical

Distal Radius - Surgical

Scaphoid most common fractures of the carpus 75% of all carpal injuries Rare elderly or children

Scaphoid - Imaging Plain XR Some are XR apparent at presentation many a fracture line is not visible until bony resorption at the fracture advances Rpt XR at 10 days +/- bone scan used for diagnosis of occult scaphoid fractures

Scaphoid - Nonsurgical Tubercle +/- splintage for analgesia Early ROM exercises Nondisplaced immobilization until clinical or radiographic healing occurs ‘Glass-holding’ POP 8 to 26 weeks

Scaphoid - Surgical Indications ORIF (compression screw) > 10° of angular deviation 1 mm of displacement Proximal pole fractures ORIF (compression screw)

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