Fractures and Dislocations of the Upper Limb
Transcript of Fractures and Dislocations of the Upper Limb
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Fractures & DislocationsFractures & Dislocationsof the Upper Limbof the Upper Limb
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Upper Limb includeUpper Limb include
ClavicleScapula
Shoulder JointHumerusElbow JointForearm BonesWrist JointScaphoid Bone
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MechanismMechanism of Injuries of theof Injuries of theUpper LimbUpper Limb
Mostly Indirect
Commonly described as a fall onoutstretched hand
Type of injury depends on position of theupper limb at the time of impact : Flexed,Extended, adducted, abducted, pronatedor supinated
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Fracture of the clavicle in AdultsFracture of the clavicle in Adults
Common especially in children and elderlyCommonest site is the middle one third
Mainly due to indirect injuryDirect injury leads to comminuted fracture
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T reatmentT reatment
Conservative by an arm sling or figure of eight bandage
Operative fixation is indicated if there is anopen fracture, neurovascular injury or nonunion
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Figure of eight BandageFigure of eight Bandage
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Dislocation of the Shoulder Dislocation of the Shoulder
Mostly A nterior > 95 % of dislocations
Posterior Dislocation occurs < 5 %
T rue Inferior dislocation (luxatio erecta ) occurs < 1%
Habitual Non traumatic dislocation may presentas Multi directional dislocation due togeneralized ligamentous laxity and is Painless
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Mechanism of anterior shoulder Mechanism of anterior shoulder dislocationdislocation
Usually Indirect fall on Abducted andextended shoulder
May be direct when there is a blow on the
shoulder from behind
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Anterior Shoulder dislocation Anterior Shoulder dislocation
Usually also inferior
B ankarts Lesion
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Clinical PictureClinical Picture
Patient is in painHolds the injured limbwith other hand close tothe trunkT he shoulder isabducted and the elbow
is kept flexedT here is loss of thenormal contour of theshoulder
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Clinical PictureClinical PictureLoss of the contour of the shoulder mayappear as a step
Anterior bulge of headof humerus may bevisible or palpable
A gap can be palpatedabove the dislocated
head of the humerus
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X Ray anterior Dislocation of X Ray anterior Dislocation of Shoulder Shoulder
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Associated injuries of anterior Associated injuries of anterior Shoulder DislocationShoulder Dislocation
Injury to the neuro vascular bundle in axilla( rare )
Injury of the Ax illary or Circumfle x Nerve( Usually stretching leading to temporaryneuropraxia )
Associated fracture
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Axillary Axillary Nerve InjuryNerve Injury
Also called circumflexnerveIt is a branch from
posterior cord of BrachialplexusIt hooks close round neckof humerus from posterior
to anterior It pierces the deep surfaceof deltoid and supply itand the part of skin over it
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Axillary Axillary nerve injurynerve injury
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Management of Anterior Shoulder Management of Anterior Shoulder DislocationDislocation
Is an E mergencyIt should be reduced in less than 24 hours
or there may be Avascular Necrosis of head of humerusFollowing reduction the shoulder shouldbe immobilised strapped to the trunk for 3-4 weeks and rested in a collar and cuff
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Methods of Reduction of Methods of Reduction of
anterior shoulder Dislocationanterior shoulder DislocationHippocrates Method ( A form of anesthesia or pain abolishing is required )
Stimpsons technique ( some sedationand analgesia are used but No anesthesiais required )
Kochers technique is the method usedin hospitals under general anesthesia andmuscle relaxation
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Hippocrates MethodHippocrates Method
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Stimpsons techniqueStimpsons technique
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K ochers T echniqueK ochers T echnique
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Complications of anterior Shoulder Complications of anterior Shoulder Dislocation : EarlyDislocation : Early
Neuro vascular injury ( rare )
Axillary nerve injury
Associated Fracture of neck of humerus or
greater or lesser tuberosities
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Complications of anterior shoulder Complications of anterior shoulder Dislocation : LateDislocation : Late
A vascular necrosis of the head of theHumerus (high risk with delayedreduction)Heterotopic calcification ( used to becalled Myositis Ossificans )
Recurrent dislocation
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Fractures of T he HumerusFractures of T he HumerusPro x imal Humerus (includes surgical andanatomical neck )
Shaft of Humerus
Distal humerus ( includes SupraCondylar fracture in children )
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Fracture Proximal HumerusFracture Proximal Humerus
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FractureFracture Pro x imalPro x imal Humerus :Humerus :Plating or Rush Nail insertionPlating or Rush Nail insertion
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IntraIntra--medullary K wire fixationmedullary K wire fixation
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FracturesFractures ShaftShaft of the Humerusof the Humerus
Commonly Indirect injuryIndirect injury results in Spiral or Oblique
fracturesDirect injuries results in transverse or comminuted fracture
May be associated with Radial Nerveinjury
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Fracture shaft of the HumerusFracture shaft of the Humerus
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Management of Radial NerveManagement of Radial Nerve
InjuryInjuryWhen present in open fractures ;immediate exploration and repair
In closed injuries treated conservatively ;initial management is doing NerveConduction Studies ( NCS ) andElectromyography ( EMG ) and awaitingfor spontaneous recovery
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Management of Radial NerveManagement of Radial Nerve
injuryinjuryRecovery usually starts after few days butmay take up to 9 months for full recovery
If No spontaneous recovery occurs in 12
weeks confirmed by NCS and EMG ;thenexploration of the nerve should be carriedout
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Management of FractureManagement of Fracture
Shaft of the HumerusShaft of the HumerusMost of the time is Conservative
Closed Reduction in upright positionfollowed by application of U shaped Slabof POP or Cylinder cast
Few weeks later or initially in stablefractures Functional B race may be used
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U Shaped slab of POPU Shaped slab of POP
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Functional brace Fracture ShaftFunctional brace Fracture Shaftof Humerusof Humerus
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IndicationsIndications for for ORIFORIF FractureFractureShaft of HumerusShaft of Humerus
Failure to reduce fracture conservatively
B ilateral humeral fractures
Open fracture with radial nerve Injury
Unconscious patient
Delayed -Union, Non -Union and Mal -Union
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PlatingPlating fracture Shaft of fracture Shaft of
humerushumerus
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IntraIntra-- medullary K Wire Fixationmedullary K Wire Fixation
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SupraSupra- - condylar Fracture of condylar Fracture of HumerusHumerus
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Pediatric SupraPediatric Supra- -Condylar Condylar HumeralHumeralfracturefracture
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Pediatric SupraPediatric Supra- -condylar condylar fracturefracture
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Reduction of supraReduction of supra- -condylar condylar
FractureFractureA bsolute E mergencyShould de done under G A by experienceddoctor as soon as possibleIn the past the arm was held in flexedelbow position in back-slab POP after reduction
At present time Percutaneous K wirefix ation is ALWAYS carried out after reduction
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Complications SupraComplications Supra- -Condylar Condylar FracturesFractures
A. E arly = Compartment syndromeBrachial Artery injury ( AcuteVolkmann's Ischemia )Nerve Injury : Median, Ulnar or Radial
B. Late = Stiffness
Volkmann's Ischemic contractureHeterotopic CalcificationMal-Union ( Cubitus Valgus or varus)
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Volkmann's IschemicVolkmann's Ischemic
ContractureContracture
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Supracondylar fracture.Supracondylar fracture.
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Fracture dislocationFracture dislocation
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MON T EGGIA FRAC T UREMON T EGGIA FRAC T URE--
DISLOCAT
IONDISLOCAT
ION
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MON T EGGIA FRAC T UREMON T EGGIA FRAC T URE--
DISLOCAT
IONDISLOCAT
ION
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GALEAZZI FRAC T UREGALEAZZI FRAC T URE--
DISLOCAT
IONDISLOCAT
ION
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Distal radius fracture.Distal radius fracture.
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Distal radius fracture.Distal radius fracture.
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T ypes of treatmentT ypes of treatment
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T ypes of treatmentT ypes of treatment
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SCAPHOIDSCAPHOID
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