Download - Fractures and Dislocations of the Upper Limb

8/6/2019 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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