Upper Limb Fractures Part 2

Dr. Apoorv JainD’Ortho, DNB Ortho

drapoorvjain23@gmail.com+91-9845669975

• The elbow joint is a modified hinge joint formed by 3 separate articulations,– Ulnotrochlear(hinge)– Radocapitellar(rotation)– Proximal radioulnar(rotation)

Ligaments1- Radial collateral lig.2- Anular lig. Of radius3- Ulnar collateral lig.4- Transverse lig.

Ulnar ligament is also known as the medial collateral ligament. It

prevent abduction of elbow joint. It cosists of 3 bands: Anterior,

posterior, Transverse.

Radial ligament is also called as the lateral collateral ligament.it

prevent adduction of elbow

• The soft tissue restriants can be divided intoStatic stabilizersDynamic stabilizers

• Static stabilizers include:oJoint capsuleoLCL & MCL

• Dynamic stabilizers include Biceps, Brachialis & Triceps

Stability is contributed by:• Antero-posterior:

– Trochlea-olecranon fossa– Coronoid fossa– Radiocapitellar joint– Biceps-triceps-brachialis

• Valgus: – Medial collateral ligament complex – Anterior capsule– Radiocapitellar joint

• Varus:– Lateral collateral ligament is static– Anconeus muscle is dynamic stabilisaer

Two set of movements occur at the elbow:

A)Flexion and extension at the Ulnotrochlear joint

B)Pronation and supination at Superior radio-ulnar joint

Normal range of motion:0 to 150°flexion85° supination & 80° pronation

Functional range of motion:a 100° arc (30 to 130 degrees flexion)50° supination & 50° pronation

Movement of elbow

Dislocation of the elbowDislocation of UlnoHumeral joint

Mechanism of injury:Most commonly injury is caused by fall onto an

outstretched hand or elbow• Posterior dislocation: a combination of elbow

hyperextention, valgus stress, arm abduction and forearm supination

• Anterior dislocation: a direct force strikes the posterior forearm with elbow in flexed position

• Most elow dislocations & fracture dislocations result in injury to all capsulo-ligamentous stabilizers of elbow joint

• The capsuloligamentous injury progresses from lateral to medial (HORI CIRCLE)

Signs and SymptomsPain, Swelling and EcchymosisInstability, Crepitus and Deformity(With the elbow flexed at 90 degrees,the medial &

lateral epicondyles & olecranon process should from isosceles triangle)

A complete peripheral neurological examination for both motor & sensory functions should be done

Radial & ulnar pulses should be compared on both sides

ClassificatonAccording to direction of displacement of ulna relative to the humerus • Posterior• Posterolateral• Posteromedial• Lateral • Medial• Anterior

Treatment principlesRestoration of the inherent bony

stability is goal

Ulnotrochlear and Radiocapitellar contact.The LCL is more important than MCL in setting

of most cases of traumatic elbow instabilityMCL will usually heal properly without any

repair

• Parvin’s method Of Closed reductionPatient lies prone Physician applies gentle downward traction of the wrist for few min, as the olecranon begin to slip distally, the physician lift up gently on the arm

• Meyn and Quigley’s method of reduction:

Only the forearm hangs from the side of the stretcher as gentle downward traction is applied on the wrist, the physican gudies the reduction of olecranon with the opposite hand

Surgical repair (if elbow clinically is unstable post reduction)

Direct repair of the ligaments,capsule and muscles

Static or Hinged external fixator applicationCross pining of the jointTemporary bridge plating of the elbow

• If the elbow remains unstable inspite of repair to lateral structures the medial side of the elbow is approached with care taken to protect the ulnar nerve

• If the elbow is still unstable then an External fixator should be placed

ComplicationsVascular injury of brachial artery may occurNerve injury the medial ulnar nerve may be affected Myositis ossificans which is more common if passive

exercise is inflicted on the patient.Late complications

Stiffness Heterotopic ossification Unreduced dislocation Recurrent dislocation Osteoarthritis after severe fracture dislocation.

RADIAL HEAD FRACTURE

EPIDEMIOLOGY 4% of all fractures and 30% of all elbow

fractures 1/3 patients associated injury to shoulder,

humerus, forearm,wrist or hand.

Rare in children due to cartilagenous nature of radial head

Radial neck fracture more common in children

Anatomy of proximal radius

RadioCapitellar joint transmit 50-60% load across elbow

Radius Head Surgical Anatomy

Important for: Valgus Stability Posterolateral Rotatory

Stability Longitudinal Forearm

Stability (Along With Interossi

Membrane & Druj)

Elbow Stability

MCL & Ulnohumeral Joint: Primary Stabilizer

Radial Head & Capsule: Secondary Stabilizer

Mechanism Of Injury (1) Fall On Outstreched Hand (most Common) Distal Radius

Interossi Membrane(forearm)

Radial Head Impaction Against Capitellum

(2) Valgus Injury To Elbow/Direct Injury

Mcl Rupture/Olecranon Fracture Unstable Elbow

Signs and Symptoms Swelling Ecchmosis Anconeus Triangle Fullness Range Of Motion Restriction Stability Active Finger Extension

Forearm/Interossi Membrane Tenderness Wrist Tenderness

ESSEX LOPRESTI Lesion

Essex Lopresti Lesion

This is defined as longitudinal disruption of forearm

interosseous ligament,usually combined with radial head

fracture and/or dislocationplus distal radioulnar joint injury

Muscle Attachment Around Proximal Radius:

SUPINATOR ATTACHMENT AT PROXIMAL RADIUS. BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.

Posterior Interossei Nerve At Risk:

Posterior Interosseous Nerve Traverses From Anterior To Posterior Through Supinator Muscle.

Always Check Pre Operative Active Finger Extension

Radiographic Findings STANDARD AP AND LATERAL X RAY of elbow OBLIQUE(GREEN SPAN)VIEW FOREARM AND WRIST X RAY IF REQUIRED

X RAY FINDINGS

Classification Of Radial Head FracturesMason classification

Type IMinimally displaced, no

mechanical block to rotation,intraarticular displacement <2mm

Type II Displaced fx >2mm or angulated, possible mechanical block to

forearm rotation

Type III Comminuted and displaced fx, mechanical block to motion

Type IV Radial head fracture with elbow dislocation

MORREY MODIFIED MASON CLASSIFICATION BY QUANTIFYING DISPLACEMENT AREA >30% AND DISPLACEMENT OF >2 MM

TreatmentGoal

Correction Of Any Block To Forearm Rotation

Early Mobilisation Of Elbow And Forearm

Stability Of Elbow And Forearm

Prevention Of Secondary Osteoarthrosis Of Elbow

Non Operative Treatment

Indication: Isolated Radial Head Fracture With Mason Type 1

(Undisplaced <2mm) Plaster Slab For 3 Weeks Early Active Mobilization Of Elbow Persistant Pain.Inflammation,contracture

Suspect Capitellar Fracture

Operative Management(Open Reduction & Internal Fixation)

INDICATION FOR ORIF: Mason type II with mechanical block(displaced) Large fragment >2 mm Mason type III where ORIF feasible(>3 FRAGMENT POOR

OUTCOME) Mechanical block to motion (lignocaine inj in elbow joint) Presence of other complex ipsilateral elbow

injuries(without metaphyseal bone loss)

FRAGMENT EXCISION LEADS TO INSTABILITY

TRY TO PRESERVE SMALLEST FRAGMENT

PRONATE FOREARM WHILE FIXATION

Which implant to use? Mini fragment screw(2.4 or 2.7 mm)

(counter sink must) Headless compression compression

screw/Herbert screw Low profile plate/mini t plate(in safe

zone/postero lateral) K WIRE

COMPLICATION OF ORIF

PIN INJURY

HARDWARE FAILURE

HARDWARE IMPINGEMENT

STIFFNESS OF ELBOW

RESTRICTION OF SUPINATIONPRONATION

Radial Head Replacement To prevent proximal migration of the radius Silicon implant poor outcome : SILICON

SYNOVITIS Titanium/vitallium metallic implant of choice

RADIAL HEAD EXCISION

INDICATION: Low demand, sedentary patients In a delayed setting for continued pain of an isolated

radial head fracture

CONTRAINDICATION: In children Presence of destabilizing injuries (Essex-lopresti

lesion,fracture dislocation elbow(mason type 4),monteggia)

Terrible triad of elbow(coronoid fracture,MCL deficiency)

Distal Radius Fractures

Common injury

Potential for functional impairment and frequent complications

HISTORY First surgeon to recognize these injuries

was Pouteau 1783. His work was not widely publicized.

Later Abraham Colles 1814 gave the classic description of “Colles fracture”

Advent of X rays at the end of nineteenth century contributed much to the understanding of different patterns of injury.

Incidence

One sixth of all fractures treated in the Emergency Room (16%)

Bimodal distribution less than 30 years (70% men) over 50 years (85% women) Males age 35 or older - 90 per 100,000

population

Introduction Occurs through the distal metaphysis of

the radius May involve articular surface. Mechanism of injury

forced extension of the carpus, impact loading of the distal radius.

Diagnosis: History and Physical Findings

History Wrist is typically swolen with ecchymosis and

tender Visible deformity of the wrist, with the hand

most commonly displaced in the dorsal direction less comonly in volar direction

Movement of the hand and wrist are painful. Adequate and accurate assessment of the

neurovascular status of the hand is performed, before any treatment is carried out.

Diagnosis: Diagnostic Tests and Examination

General physical exam of the patient, including an evaluation of the injured joint, and a joint above and below

Radiographs of the injured wrist-pa and lat view , oblique view

CT scan of the distal radius to know extent of intrarticular involvement

Osseous Anatomy

Distal radius – 80% of axial load Scaphoid fossa Lunate fossa Sigmoid notch – DRUJ

Distal ulna

Anatomy Scaphoid and lunate

fossa Ridge normally exists

between these two

Sigmoid notch: second important articular surface

Triangular fibrocartilage complex(TFCC): distal edge of radius to base of ulnar styloid

Anatomy Articular Surface

Scaphoid facet

Lunate facet

Sigmoid notch

Normal range of movement

RADIOLOGY

Ulnar inclination (avg 23°)

Volar tilt (avg 11 to 12°)

Radial Height (avg 11 mm)

Ulnar variance (+/- 1 mm)

Measurement of Radial Length and Inclination

Inclination = 23 degrees

Computed TomographyIndications:

Intra-articular fxs with multiple fragments

centrally impacted fragments

DRUJ incongruity

Common Classifications

Column theory

Gartland/Werley Frykman Weber (AO/ASIF) Melone Fernandez (mechanism)

Frykman ClassificationExtra-articular

Radio-carpal joint

Radio-ulnar joint

Both joints

{Same pattern as odd numbers, except ulnar styloid also fractured

AO/ OTA Classification

Group A: Extra-articular

Group B: Partial Intra-articular

Group C: Complete Intra-articular

COONEY (1990) UNIVERSAL CLASSIFICATION

Type I Extraarticular, undisplaced Type 2 Extraarticular, displaced Type 3 Intraarticular, undisplaced Type 4 Intraarticular, displaced

MODIFIED AO

Type A Extraarticular Type B Partial articular B1–radial styloid fracture B2–dorsal rim fracture B3–volar rim fracture B4–die-punch fracture Type C Complete articular

Column Theory

Rikli & Regazzoni, 1996

3 Columns: Radial, Intermediate, Medial

Three Column Theory

Radial ColumnLateral side of radius

Intermediate ColumnUlnar side of

radius Ulnar Column

distal ulna

Radial column

Intermediate column

Ulnar column

Classification – Fernandez (1997)

I. Bending-metaphysis bending with loss of palmar tilt and radial shortening ,DRUJ injury(Colles, Smith)

II. Shearing-fractures of joint surface (Barton, radial styloid)

Classification – Fernandez (1997)

III. Compression-intraarticular fracture with impaction of subchondral and metaphyseal bone (die-punch)

IV. Avulsion-fractures of ligament attachments (ulna, radial styloid)

V. Combined/complex - high velocity injuries

Assessment of X-rays Assess involvement of dorsal or volar

rim Is comminution mainly volar or dorsal? is one of four cortices intact?

Look for “die-punch” lesions of the scaphoid or lunate fossa.

Assess amount of shortening

Look for DRUJ involvement

EPONYMS COLLES #-extra articular or intra articular distal radius -

clinicaly described as dinner fork deformity-mechanism---fall on to an hyper

extended ,radialy deviated wrist with the forearm in pronation

SMITH #(REVERSE COLLES #) # distal radius with volar

angulation or volar displacement of the hand and distal radius

mechanism—fall on to a flexed wrist with the forearm fixed in supination

unstable pattern often requires ORIF because of difficulty in maintaining closed reduction

BARTON #

# disdlocation or subluxation of wrist in which the dorsal or volar rim of distal radius is displaced

mechanism-fall on to a dorsiflexed wrist with the forearm fixed in pronation

unstable # requires ORIF

RADIAL STYLOID #(CHAUFFEUR’S #, BACKFIRE #,HUTCHINSON #)

Avulsion # with extrinsic ligaments remaining attached to styloid fragment

Mechanism-compression of scaphoid against styloid with the wrist in dorsiflexion and ulnar deviation

Often associated with intercarpal ligament injury

Requires ORIF

ASSESSMENT OF STABILITYfive factors indicative of instability (1)initial dorsal angulation of more than 20

degrees (volar tilt),(2) dorsal metaphyseal comminution,(3) intraarticular involvement, (4) an associated ulnar fracture, and(5) patient age older than 60 years

Treatment Goals Preserve hand and wrist function

Realign normal osseous anatomy

Promote bone healing

Avoid complications

Allow early finger and elbow ROM

Options for Treatment Casting

Long arm vs short arm Sugar-tong splint

External Fixation Joint-spanning Non bridging

Percutaneous pinning Internal Fixation

Dorsal plating Volar plating Combined dorsal/volar plating focal (fracture specific) plating

Indications for Closed Treatment

Low-energy fracture

Medical co-morbidities

Minimal displacement- acceptable alignment

Closed Treatment of Distal Radial Fractures

Obtaining and then maintaining an acceptable reduction.

Immobilization: long arm short arm adequate for elderly patients

Frequent follow-up necessary in order to diagnose redisplacement.

Technique of Closed Reduction Anesthesia

Hematoma block Intravenous sedation Bier block

Traction: finger traps and weights Reduction Maneuver (dorsally angulated

fracture): hyperextension of the distal fragment, Maintain weighted traction and reduce the

distal to the proximal fragment with pressure applied to the distal radius.

Apply well-molded “sugar-tong” splint or cast, with wrist in neutral to slight flexion.

Avoid Extreme Positions!

Acceptable Reduction Criteria Radial length: within 2-3 mm of the

contralateral wrist Palmar tilt: neutral tilt Intrarticular step-off or gap< 2mm Radial inclination <5° loss Carpal malalignment: absent Ulnar variance: no more than 2 mm of

shortening compare to ulnar head

Indications for Immediate Surgical Treatment

High-energy injury Open injury Secondary loss of reduction Articular comminution, step-off, or gap Metaphyseal comminution or bone loss Loss of volar buttress with

displacement DRUJ incongruity

Operative Management of Distal Radius Fractures

External fixation: The treatment of choice for distal radius fractures

in the 1980’s

Spanning ( Ligamentotaxis)

A spanning fixator is one which fixes distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals

Use for comminuted fracture

Complications

Mal-unionPin track infectionFinger stiffness Loss of reduction; early vs lateTendon rupture

Non-spanning External Fixator

External Fixation- Disadvantages -

Bulky

Poor screw hold in porosis and comminution

Screws do not buttress

Cutaneous radial nerve injury

Pin tract infection

Reflex sympathetic dystrophy

Percutaneous Pins

Percutaneous Pinning-Kapandji

intrafocal pinning through fracture site

buttress against displacement

Drawback-tendency to translate distal fragment in opposite direction

Internal Fixation of Distal Radius Fractures

Useful for elevation of depressed articular fragments and bone grafting of metaphyseal defects

required if articular fragments can not be adequately reduced with percutaneous methods

Selection of Approach Based on location of comminution. Dorsal approach for dorsally angulated

fractures. Volar approach for volar rim fractures Radial styloid approach for buttressing of

styloid Combined approaches needed for high-

energy fractures with significant axial impaction.

Classical Henry approach(chung)

Extended carpal tunnel approach

VOLAR

Volar –Henry Approach

Freer elevator is used to elevate pronator quadratus

from radius

Fracture line is exposed

Volar plate positioned, insertion of first screw

Reduction and placement of Kirschner wires for provisional fixation

Courtesy J. Orbay, MD

-

DORSAL APPROACH

3rd DC –EPL(extensile)1-2nd DC

Dorsal Plating, PCP and Ex Fix

Generally not prefere because of high rate of complication like

- tendon dysfunction and rupture - tenosynovitis of extensor tendons indicated for- dorsal die-punch fractures or

fractures with displaced dorsal lunate facet fragments

DISTRACTION PLATE FIXATION

-less tendon irritation than dorsal

Volar Plating for Dorsal Fractures

Fixed angle locked screws ,,variable angle

Fragment Specific System

Five potential fracture fragments

radial column, dorsal cortical

wall, dorsal ulnar split, volar rim, and the central

intraarticular fragment

Radial pin-plate For stabilization of radial column

Ulnar pin-plate for stabilization of dorsal ulnar split fragment

Dorsal cortical wall fragment stabilized by small fragment

clamp

simultaneously stabilization of dorsal wall fragment and intraarticular component

Volar approach, application buttress plate

Dorsal approach, application of 2 “L” buttress plates

EPL Tendon

Extensor retinaculum repaired beneath EPL to prevent erosion against plate- EPL left transposed

Advanced TechniquesArthroscopic-Assisted

reduce articular incongruities also diagnose associated soft tissue

lesions minimally invasive

Complications After Fracture of Distal Radius

Arthritis/arthrosis Loss of motion Hardware complications Nerve compression/neuritis Osteomyelitis Persistent pain/pain syndromes (CRPS) Tendon (rupture, lag, trigger, tenosynovitis) Delayed union/nonunion/malunion Radioulnar (synostosis, disturbance)

Conclusions External fixators still have a role in the

treatment of distal radius fractures

Spanning ex fix does not completely correct fracture deformity by itself

Should usually combined with percutaneous pins (augmented fixation)

Conclusions new plating techniques allow for

accurate and rigid fixation of fragments

Plating allows early wrist ROM

Volar, smaller and more anatomic plates are better tolerated

combination treatment is often needed

Olecranon Fracture Forearm Fractures (including Galleazi and

Monteggia)

Commonly asked questions: Volkmann’s Ischaemic Contracture Reflex Symathetic Dystrophy (Sudeck’s

Osteodystrophy)

Important topics (must read): Bennet’s and Rolando’s Fractures Scaphoid Fractures