1. Common upper limb fractures
Dr Tarif Alakhras
Orthopedic surgeon
KFMC

2. Clavicle Fracture
Clavicle injuries affect 1 in 1000 people per year. The most common of all pediatric fractures % 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.

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

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

5. 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)

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

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

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

10. Mid shaft fracture

11. Management

12. 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.

13. 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?

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

15. 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

16. Radiocapitellar line
Anterior humeral line.

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

18. Supracondylar fracture

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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.

25. 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.

26. 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

27. 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.

28. 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

29. 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.

30. 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.

31. 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.

32. 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'.

33. 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.

34. 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

35. 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

36. 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. 

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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.

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

44. 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