Dr Abhishek Agarwal Lecturer Deptt orthopedics Upper limb injuries Dr Abhishek Agarwal Lecturer Deptt orthopedics

Upper Limb include Clavicle Scapula Shoulder Joint Humerus Elbow Joint Forearm Bones Wrist and Hand

Mechanism of Injuries of the Upper Limb Mostly Indirect 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 Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Fracture of the clavicle in Adults Common especially in children and elderly Commonest site is the middle one third Mainly due to indirect injury Direct injury leads to comminuted fracture Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Gutierrez G. Office management of upper limb fractures Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Treatment Conservative by an arm sling or figure of eight bandage Operative fixation is indicated if there is an open fracture, neurovascular injury or nonunion Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Figure of eight Bandage Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Dislocation of the Shoulder Mostly Anterior > 95 % of dislocations Posterior Dislocation occurs < 5 % True Inferior dislocation (luxatio erecta) occurs < 1% Habitual Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Mechanism of anterior shoulder dislocation Usually Indirect fall on Abducted and extended shoulder May be direct when there is a blow on the shoulder from behind Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Anterior Shoulder dislocation Usually also inferior Bankart’s Lesion Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Clinical Picture Patient is in pain Holds the injured limb with other hand close to the trunk The shoulder is abducted and the elbow is kept flexed There is loss of the normal contour of the shoulder Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Clinical Picture Loss of the contour of the shoulder may appear as a step Anterior bulge of head of humerus may be visible or palpable A gap can be palpated above the dislocated head of the humerus Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Gutierrez G. Office management of upper limb fractures Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

X Ray anterior Dislocation of Shoulder Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Associated injuries of anterior Shoulder Dislocation Injury to the neuro vascular bundle in axilla ( rare ) Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) Associated fracture Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

Axillary Nerve Injury Also called circumflex nerve It is a branch from posterior cord of Brachial plexus 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 http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Axillary nerve injury http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Management of Anterior Shoulder Dislocation Is an Emergency 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 http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Methods of Reduction of anterior shoulder Dislocation 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 ) Kocher’s technique is the method used in hospitals under general anesthesia and muscle relaxation http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Hippocrates Method http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Stimpson’s technique http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Kocher’s Technique http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Complications of anterior Shoulder Dislocation : Early Neuro vascular injury ( rare ) Axillary nerve injury Associated Fracture of neck of humerus or greater or lesser tuberosities http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Complications of anterior shoulder Dislocation : Late Avascular necrosis of the head of the Humerus (high risk with delayed reduction) Heterotopic calcification ( used to be called Myositis Ossificans ) Recurrent dislocation http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Fractures of The Humerus Proximal Humerus (includes surgical and anatomical neck ) Shaft of Humerus Distal humerus ( includes Supra Condylar fracture in children ) http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Fracture Proximal Humerus http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Fracture Proximal Humerus : Plating or Rush Nail insertion http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Intra-medullary K wire fixation http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Fractures Shaft of the Humerus Commonly Indirect injury Indirect injury results in Spiral or Oblique fractures Direct injuries results in transverse or comminuted fracture May be associated with Radial Nerve injury http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Fracture shaft of the Humerus http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Radial Nerve Injury Results in Wrist drop Associated with fracture humerus in up to 12% of fractures 2/3 ( 8%) of Radial injury are Neuropraxia 1/3 ( 4%) are nerve lacerations or transection http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Management of Radial Nerve Injury 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 http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Management of Radial Nerve injury 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 http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Management of Fracture Shaft of the Humerus Most of the time is Conservative Closed Reduction in upright position followed by application of U shaped Slab of POP or Cylinder cast Few weeks later or initially in stable fractures Functional Brace may be used http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

U Shaped slab of POP http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Functional brace Fracture Shaft of Humerus http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Indications for ORIF Fracture Shaft of Humerus Failure to reduce fracture conservatively Bilateral humeral fractures Open fracture with radial nerve Injury Unconscious patient Delayed-Union, Non-Union and Mal-Union http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Plating fracture Shaft of humerus http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Intra- medullary K Wire Fixation http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Supra- condylar Fracture of Humerus http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Pediatric Supra-Condylar Humeral fracture http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Pediatric Supra-condylar fracture http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Reduction of supra-condylar Fracture Absolute Emergency 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 At present time Percutaneous K wire fixation is ALWAYS carried out after reduction http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Complications Supra-Condylar Fractures Early= Compartment syndrome Brachial Artery injury ( Acute Volkmann's Ischemia ) Nerve Injury : Median, Ulnar or Radial Late= Stiffness Volkmann's Ischemic contracture Heterotopic Calcification Mal-Union ( Cubitus Valgus or varus) http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Volkmann's Ischemic Contracture http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Supracondylar fracture. http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

Fracture dislocation http://ptjournal.apta.org/cgi/collection/injuries_and_conditions_upper_extremity

MONTEGGIA FRACTURE-DISLOCATION Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

MONTEGGIA FRACTURE-DISLOCATION Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

GALEAZZI FRACTURE-DISLOCATION Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

Distal radius fracture. Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

Distal radius fracture. Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

contd Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

Types of treatment Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

Wrist & Hand Injuries Carpal tunnel (CTS) result from repetitive stress to tissue 64% of work injuries Compressive neuropathy Wrist flexion/ext and finger movements Risk factors exertion repetitive stress posture localized contact cold Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

Wrist & Hand Injuries Carpal fractures compressive loads to hyperextended wrist hyper flexion rotation loading against a fixed wrist Scaphoid 60-70% Lunate Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

Wrist & Hand Injuries Thumb: essential to prehension Sprain: skiers thumb fall with thumb in abducted position tensile loads on MCL Hyperextension Bennets fracture (fighting) Bowler’s thumb: ulnar digital nerve trauma tingling, sensitivity Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

Wrist & Hand Injuries Metacarpal & phalangeal injuries Fractures Boxers Dislocations Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.