Re-written by: Daniel Habashi Upper Extremity Fractures And Dislocations

Shoulder Girdle Clavicle Scapula Humerus

Clavicle- Mechanism of Injury There is no correlation between the fracture location and the mechanism of injury Falls onto the affected shoulder 87% Direct impact 7% Falls onto an outstretched hand 6%

Clavicle – clinical evaluation Arm adducted across the chest and supported by the contra lateral hand Neurovascular examination Tenting the skin Crepitus X-ray

Clavicle – non operative treatment Reduction if needed Closed treatment is successful in most cases Dessaulte cast Figure-of-eight cast 4-6 weeks

Clavicle – operative treatment Open fractures Fractures with associated neurovascular injury Fractures with severe associated injuries (flail chest with multiple rib fractures) Cosmetic reasons

Clavicle – fixation Plate Intramedullary devices (pins) Cerclage suturing or wiring External fixation

Acromioclavicular joint – mechanism of injury Most often in the Spring Fall onto the shoulder with the arm adducted Fall onto an outstretched hand with force transmission up the arm

AC joint – clinical evaluation Step-off deformity Possible tenting of the skin overlying the distal clavicle Limited range of motion Tenderness X-ray

AC joint – classification Type I – sprain of the AC ligament Type II – tear of the AC ligament and sprain of the caracoclavicular ligament Type III – AC and coracoclavicular ligaments torn with AV joint dislocation

AC joint – non-operative treatment Type I - Rest 10 days, ice packs and sling Type II – Sling for 2 weeks, gentle range of motion, refrain from heavy activity for 6 weeks Type III – Sling, early range of motion, acceptance of deformity

AC joint – operative treatment Controversial patients Heavy laborers, patients years of age Open reduction and suturing

Sternoclavicular joint – mechanism of injury Direct hit Indirect force applied from antero-lateral or postero-lateral aspects of the shoulder

SC joint – classification Anterior dislocation – more common Posterior dislocation

SC joint – clinical evaluation Patient supports the affected extremity across the trunk with the contra-lateral arm Swelling, tenderness, painful range of motion X-ray

SC joint – treatment Mild sprain – ice packs, sling for 7 days Moderate sprain or subluxation – ice packs and sling for 4-6 weeks

Scapula – mechanism of injury Relatively uncommon injury Result of high energy trauma Suspicion of associated injuries Fractured ribs Clavicle Sternum Pneumothorax Pulmonary contusion Spinal column fractures

Scapula – Clinical Evaluation Full trauma evaluation Upper extremity supported by the contra-lateral hand Swelling of the posterior thorax X-ray

Scapula – treatment Most scapula fractures are treated non-operatively Sling and early range of motion

Proximal humerus – mechanism of injury A fall onto an outstretched upper extremity from standing height (typically seen in an elderly osteoporotic woman) High energy trauma (motor vehicle accident) Direct trauma Pathologic processes

proximal humerus - clinical evaluation Upper extremity supported by the contralateral hand Pain, swelling, tenderness, painful range of motion Crepitus, instability, ecchymosis X-ray

Proximal humerus – clinical evaluation A careful neurovascular evaluation is required

Proximal humerus – treatment Open reduction and internal fixation (plates, screws, K- wires, pins, flexible nails with tension band) Prosthetic replacement

Humeral shaft – mechanism of injury Direct trauma (most common) Indirect: fall on an outstretched arm

Humeral shaft – radial nerve injury Radial nerve injury is something we must take care of Symptoms of a radial nerve injury is: dropped hand since it’s responsible for the innervations of all the extensors

Humeral shaft – clinical evaluation Pain, swelling, deformity, shortening of the affected arm Instability with crepitus A careful neurovascular exam with special attention to the radial nerve function X-ray

Humeral shaft – non operative treatment Most humeral shaft fractures will heal with nonsurgical treatment A hanging cast A co-aptation splint Thoracobrachial immobilization (Dessaulte, Velpau dressing)

Humeral shaft – operative treatment Open reduction and internal fixation (plates, screws, intramedullar nails) External fixation  quite quite quite rare

Humeral shaft – radial nerve injury Most common with middle third fractures Generally neuropraxia or axonotmesis (function returns within 3-4 months) Laceration most common in gunshot injuries etc

Distal humerus – classification Supracondylar Transcondylar Intercondylar (most common) Condylar Capitellum Etc

Distal humerus – mechanism of injury Fall on outstretched hand with or without an abduction or adduction force (supra and transcondylar fractures) Force directed against the posterior aspect of an elbox flexed more than 90 degrees

Distal humerus – clinical evaluation Swelling, painful range of motion, crepitus, instability Elbow held in the flexed position A careful neurovascular evaluation is essential because the sharp fractured end….

Distal humerus – treatment Open reduction and internal fixation (screws, plates) Total elbow arthroplasty

Glenohumeral dislocation The shoulder is the most commonly dislocated joint of the body (45% of dislocations)

Glenohumeral dislocation – classification Anterior (most common – 84%) Posterior ( the second most common - 10%) Inferior (rare) Superior (rare)

Glenohumeral dislocation – mechanism of injury

Glenohumeral dislocation – clinical evaluation Determine the nature of the trauma Position of the affected extremity Painful shoulder, muscular spasm Neurovascular examination X-ray