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