Common upper limb fractures Dr Tarif Alakhras Orthopedic surgeon KFMC

Clavicle Fracture Clavicle injuries affect 1 in 1000 people per year. The most common of all pediatric fractures. 10-16% of all fractures in this age group. can present even in the newborn period, especially following a difficult delivery. A large peak incidence occurs in males younger than 30 years due to sports injuries.

Clavicle Fracture Etiology It may be caused by direct or indirect trauma. Or from fall onto an outstretched hand.  Clinically

Clavicle Fracture The most common injury is a type 1 fracture , which affects the middle third of the clavicle.

Clavicle Fracture :Management typically included the use of either a shoulder sling or a figure-of-eight brace. Surgical indications Severe displacement causing tenting of the skin with the risk of puncture Fractures with 2 cm of shortening Comminuted fractures with a displaced (or Z-shaped) fragment Neurovascular compromise or mediastinal structures at risk[5] Open fractures (floating shoulder)

Fracture Humerus Proximal end Mid shaft Distal end  Humerus can be divided into Proximal end Mid shaft Distal end

the proximal end fracture The upper end: The head Surgical neck Greater tuberosity Lesser tuberosity

The axillary nerve can be damaged in this type of fractures.

Mid shaft fracture

Management

FRACTURE DISTAL HUMERUS Elbow fractures are the most common fractures in children. An understanding of the basic anatomy and x-ray landmarks of the elbow is essential in choosing appropriate treatment to avoid complications.

Four important questions Is there a sign of Joint effusion? Is there a Normal alignment between the bone ? Are the Ossification centers normal? Is there a Subtle fracture?

There are 6 ossification centres around the elbow joint. 1. Capitellum 2. Radial Head 3. Internal epicondyle 4. Trochlea 5. Olecranon 6. Lateral Epicondyle 1-3-5-7-9-11 years C-R-I-T-O- L

An elevated anterior lucency or a visible posterior lucency on a true lateral radiograph of an elbow flexed at 90° is described as a positive fat pad sign

Radiocapitellar line Anterior humeral line.

Supracondylar fracture Lateral condyle fracture Fracture radial head Position of the medial epicondyle.

Supracondylar fracture

Supracondylar fracture consists of more than half of all pediatric elbow fractures extension type most common (95-98%) Physical exam nerve exam Anterior Interosseus N neurapraxia  unable to make “OK sign” Radial nerve neurapraxia inability to extend wrist or digits vascular status vascular insufficiency at presentation is present in 5 -17% defined as cold, pale, and pulseless hand a warm, pink, pulseless hand does not qualify as vascular insufficiency

S/C frx: Management Type II fractures that meet the following criteria Nonoperative posterior molded splint then long arm casting at at 90° or less indications  Type I (non-displaced) fractures  Type II fractures that meet the following criteria anterior humeral line intersects capitellum minimal swelling present no medial comminution Operative closed reduction and percutanous pinning   indications  - in most supracondylar fractures -- open reduction with percutaneous pinning (If close reducion failed)

S/C complications Cubitus valgus Cubitus varus (gunstock deformity) can lead to tardy ulnar nerve palsy Cubitus varus (gunstock deformity)  usually a cosmetic issue with little functional limitations   Recurvatum common with non-operative treatement of Type II and Type III fractures Nerve palsy usually resolve Vascular Injury and Volkmann ischemic contracture Postoperative Stiffness

Lateral Condyle Fracture - Pediatric 17% of all distal humerus fractures in the pediatric population typically occurs in patients aged 5-10 years o mechanism of injury pull-off theory avulsion fracture that results from the pull of the common extensor push-off theory impaction of the radial head into the lateral condyle

Lateral Condyle Fracture: treatment Nonoperative long arm casting indications only indicated if < 2 mm of displacement, which indicates the cartilaginous hinge is most likely intact sub-acute presentation (>4 weeks) Operative Close reduction & Percut fixation some authors suggest CRPP for all lateral condylar fractures with < 2 mm of displacement open reduction and fixation if > 2mm of displacement any joint incongruity  fracture non-union

Complications: of delayed or inadequate reduction  non union:   AVN of capitellum  cubitus varus:    a more common complication than cubitus valgus;  may be due to over-stimulation of the lateral condylar physis. cubitus valgus:  premature growth arrest of lateral condyle. ulnar nerve palsy may appear as a late complication.

Fracture head and neck of radius frx of the radial head occurs primarily in adults, whereas fractures of the radial neck  are more common in children.  frx of the radial head and neck of the radius generally results from a hard fall on an outstretched hand.

Fracture head of radius pain, effusion in the elbow, & tenderness on palpation directly over radial head are typical manifestations associated injuries:    distal radius fracture  dislocation of the distal RU joint (Essex Lopresti Fracture)   valgus instability (MCL rupture)  rupture of the triceps tendon Elbow dislocation:   terrible triad: RHF + MCL + coronoid process frcture

Fracture head and neck of radius An x-ray of the elbow will confirm the diagnosis and help determine the severity of the fracture . CT scan may also be indicated in order to choose the best treatment option.

Fracture head and neck of radius Nonsurgical treatment of radial head fractures is indicated if minimal displacement, minimal angulation, and minimal head involvement. Early motion with a functional brace is encouraged to minimize elbow stiffness. Surgery is required if the fracture involves more than 33% of the articular surface, is angulated more than 30°, or is displaced more than 3 mm.  excision of radial head & radial head implants:  For

Four Pearls for frx Head of Radius A visible posterior fat pad on the lateral view of the elbow is a sign of occult intraarticular pathology. Early elbow ROM is needed to prevent stiffness. Examine the wrist when examining all elbow injuries; a radial head fracture may be accompanied by a tear of the interosseous membrane and disruption of the distal radioulnar joint. The posterior interosseous nerve can be damaged by a radial head injury or by the surgery performed to treat the fracture. Therefore, document functional status preoperatively.

Galeazzi fracture is a fracture of the radius with dislocation of the distal radioulnar joint. Ricardo Galeazzi (1866–1952), an Italian surgeon It was first described in 1842, by Cooper, 92 years before Galeazzi reported his results.

Galeazzi fracture :Treatment It has been called the “fracture of necessity“ because it necessitates open surgical treatment in the adult. in skeletally immature patients the fracture is typically treated with closed reduction.

Monteggia fracture : Giovanni Battista Monteggia is a fracture of the proximal third of the ulna with dislocation of the head of the radius. (hyper-pronation injury) isolated ulnar shaft fractures (most commonly seen in defense against blunt trauma) is not a Monteggia fracture. It is called a 'nightstick fracture'.

Management open reduction and internal fixation of the ulnar shaft is considered the standard treatment in adults. Monteggia fractures may be managed conservatively in children with closed reduction but due to high risk of displacement causing malunion, open reduction internal fixation is typically performed.

Distal radius fracture Colles' fracture  Smith's fracture Barton's fracture Chauffeur's fracture The Universal classification  Type I: extra articular, undisplaced Type II: extra articular, displaced Type III intra articular, undisplaced Type IV: intra articular, displaced

Colles’fracture  Is an extra-articular fracture of the distal radius  with dorsal and radial displacement of the wrist and hand. The fracture is sometimes referred to as a "dinner fork" or "bayonet" deformity. often seen in elderly people with osteoporosis. most commonly caused by people falling onto a hard surface with outstretched arms

Smith's fracture  reverse Colles' fracture Robert William Smith (1807–1873)  is an extra-articular fracture of the distal radius.  It is caused by falling onto flexed wrists, as opposed to a Colles' fracture. The distal fracture fragment is displaced volarly . There may be one or many fragments and it may or may not involve the articular surface of the wrist joint. 

Treatment Colles’ & Smith Treatment depends on severity: Undisplaced fracture may be treated with a cast alone Fractures with angulation and displacement require closed reduction and above elbow casting Position in cast: In colles’ frx the wrist immobilized in flexion In smith frx the immobilization should be in extension

Barton's fracture Is an intra articular fracture of the distal radius with dislocation of the radiocarpal joint. Intra-articular component distinguishes this fracture from a Smith's or a Colles' fracture. caused by a fall on an extended and pronated wrist

Barton's fracture :treatment is best treated by closed reduction, application of external fixation, followed by percutaneous pin insertion. tendency to redisplace may require ORIF by buttres plate

Chauffeur's fracture An isolated fracture of the radial styloid process. Displacement of the fragment is uncommon. There can be associated injury to the scapholunate ligament. In most cases a fracture of the radial styloid process is part of a comminuted intraarticular fracture

Scaphoid fracture Scaphoid is the most frequently fractured carpal bone. It usually cause pain and tenderness in the   snuffbox area at the base of the thumb

Scaphoid fracture Fractures of scaphoid can occur from fall on the palm on an outstretched hand.  Often diagnosed by X-rays However not all fractures are apparent initially .repeat x ray Complications Avascular necrosis (AVN): mainly proximal 1/3 Non union: occur from undiagnosed or undertreated scaphoid wrist osteoarthritis.

Scaphoid fracture Complications Avascular necrosis (AVN): mainly proximal 1/3 Non union: occur from undiagnosed or undertreated scaphoid fracture wrist osteoarthritis.

Scaphoid fracture Treatment Non displaced or minimally displaced waist and distal fractures have a high rate of union with closed cast management.  it is generally accepted to use a short arm thumb spica for non displaced fractures