Common upper limb fractures
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Common upper limb fracturesDr Tarif Alakhras Orthopedic surgeon KFMCClavicle FractureClavicle 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 FractureEtiology It may be caused by direct or indirect trauma. Or from fall onto an outstretched hand.
Clavicle FractureThe 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 indicationsSevere displacement causing tenting of the skin with the risk of punctureFractures with 2 cm of shorteningComminuted fractures with a displaced (or Z-shaped) fragmentNeurovascular compromise or mediastinal structures at riskOpen fractures(floating shoulder)
Humerus can be divided into Proximal end Mid shaft Distal end
the proximal end fracture
The upper end:The headSurgical neckGreater tuberosityLesser tuberosity
Theaxillary nervecan be damaged in this type of fractures.
Mid shaft fracture
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 fractureLateral condyle fractureFracture radial headPosition of the medial epicondyle.
Supracondylar fractureconsists of more than half of all pediatric elbow fracturesextension type most common (95-98%)Physical examnerve examAnterior Interosseus N neurapraxiaunable to make OK signRadial nerve neurapraxiainability to extend wrist or digitsvascular statusvascular insufficiency at presentation is present in 5 -17%defined as cold, pale, and pulseless handa warm, pink, pulseless hand does not qualify as vascular insufficiency
S/C frx: Management Nonoperativeposterior molded splint then long arm casting at at 90 or lessindicationsType I (non-displaced) fracturesType II fractures that meet the following criteriaanterior humeral line intersects capitellumminimal swelling presentno medial comminution
Operativeclosed reduction and percutanous pinningindications - in most supracondylar fractures -- open reduction with percutaneous pinning (If close reducion failed)
S/C complicationsCubitus valguscan lead totardy ulnar nerve palsyCubitus varus(gunstock deformity)usually acosmetic issuewith little functional limitationsRecurvatumcommon with non-operative treatement of Type II and Type III fracturesNerve palsyusually resolveVascular Injury and Volkmann ischemic contracturePostoperative Stiffness
Lateral Condyle Fracture - Pediatric
17% of all distal humerus fractures in the pediatric populationtypically occurs in patients aged 5-10 years omechanism 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: treatmentNonoperativelong arm castingindicationsonly indicated if< 2 mm of displacement, which indicates the cartilaginous hinge is most likely intactsub-acute presentation (>4 weeks)OperativeClose reduction & Percut fixationindicationssome authors suggest CRPP for all lateral condylar fractures with< 2 mm of displacement
open reduction and fixationindicationsif > 2mm of displacementany joint incongruityfracture non-unionComplications:of delayed or inadequate reductionnon union:AVN of capitellumcubitus 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 nervepalsy 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 neckare 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 manifestationsassociated injuries: distal radius fracture dislocation of thedistal RU joint (Essex Lopresti Fracture) valgus instability (MCL rupture) rupture of the triceps tendonElbow 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 fractureis a fracture of theradius with dislocation of thedistal radioulnar joint.Ricardo Galeazzi(18661952), an Italian surgeon It was first described in 1842, by Cooper, 92 years before Galeazzi reported his results.
Galeazzi fracture :TreatmentIt has been called the fracture of necessitybecause it necessitates open surgical treatment in the adult.in skeletally immature patients the fracture is typically treated with closed reduction.
Monteggia fracture:Giovanni Battista Monteggiais afracture of theproximalthird of theulnawith dislocation of thehead of the radius.(hyper-pronation injury)isolated ulnar shaft fractures (most commonly seen in defense against blunt trauma) is nota Monteggia fracture. It is called a 'nightstick fracture'.
Managementopen reduction and internal fixation of the ulnar shaft is considered the standard treatment in adults.Monteggia fractures may be managed conservatively inchildrenwith closed reduction but due to high risk of displacement causing malunion,open reduction internal fixationis typically performed.Distal radius fractureColles' fractureSmith's fracture Barton's fractureChauffeur's fractureThe Universal classificationType I: extra articular, undisplacedType II: extra articular, displacedType III intra articular, undisplacedType IV: intra articular, displaced
CollesfractureIs an extra-articularfractureof thedistal 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 withosteoporosis.most commonly caused by people falling onto a hard surface with outstretched arms
Smith's fracture reverseColles' fractureRobert William Smith(18071873)is an extra-articular fracture of the distalradius. 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 thewrist joint.
TreatmentColles & SmithTreatment depends on severity:Undisplaced fracture may be treated with a cast aloneFractures with angulation and displacement require closed reduction and above elbow castingPosition in cast:In colles frx the wrist immobilized in flexionIn smith frx the immobilization should be in extension
Is an intra articularfracture of thedistal radiuswith dislocation of theradiocarpal joint.Intra-articular component distinguishes this fracture from aSmith'sor aColles' fracture.caused by a fall on an extended andpronated wrist
Barton's fracture :treatmentis best treated by closed reduction, application ofexternal fixation, followed bypercutaneous pin insertion.tendency to redisplace may requireORIF by buttres plate
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 is the most frequently fractured carpal bone.It usually cause pain and te