Fractures

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Fractures Dislocations of the Upper Limb

• Abdulaziz Al-Ahaideb MD, FRCS(C)

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Upper Limb include

• Clavicle
• Shoulder Joint
• Humerus
• Elbow Joint
• Forearm Bones
• Wrist Joint
• Scaphoid Bone

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Mechanism of Injuries of the Upper Limb

• Mostly Indirect
• Commonly described as a fall on outstretched
  hand
• Type of injury depends on
• position of the upper limb at the time of impact
  
• force of injury
• age

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Fracture of the clavicle

• Common fracture
• Commonest site is the middle one third
• Mainly due to indirect injury
• Direct injury leads to comminuted fracture

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Treatment

• Conservative by an arm sling or figure of eight
  bandage
• Operative fixation is indicated if there is
• tenting of the skin
• open fracture
• neurovascular injury
• nonunion

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Figure of eight Bandage
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Dislocation of the Shoulder

• Mostly Anterior gt 95 of dislocations
• Posterior Dislocation occurs lt 5
• True Inferior dislocation (luxatio erecta) occurs
  lt 1
• Habitual Non traumatic dislocation may present as
  Multi directional dislocation due to generalized
  ligamentous laxity and is Painless

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Mechanism of anterior shoulder dislocation

• Usually Indirect fall on Abducted and extended
  shoulder
• May be direct when there is a blow on the
  shoulder from behind

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Anterior Shoulder dislocation

• Usually also inferior
• Bankarts Lesion

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Clinical Picture

• Patient is in pain
• Holds the injured limb with other hand close to
  the trunk
• The shoulder is abducted and the elbow is kept
  flexed
• There is loss of the normal contour of the
  shoulder

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Clinical Picture

• Loss of the contour of the shoulder may appear as
  a step
• Anterior bulge of head of humerus may be visible
  or palpable
• A gap can be palpated above the dislocated head
  of the humerus

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X Ray anterior Dislocation of Shoulder
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Associated injuries of anterior Shoulder
Dislocation

• Injury to the neuro vascular bundle in axilla
• Injury of the Axillary Nerve ( Usually stretching
  leading to temporary neuropraxia )
• Associated fracture

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Axillary Nerve Injury

• It is a branch from posterior cord of Brachial
  plexus
• It hooks close round neck of humerus from
  posterior to anterior
• It pierces the deep surface of deltoid and supply
  it and the part of skin over it

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Axillary nerve injury
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Management of Anterior Shoulder Dislocation

• Is an Emergency
• It should be reduced in less than 24 hours or
  there may be Avascular Necrosis of head of
  humerus
• Following reduction the shoulder should be
  immobilised strapped to the trunk for 3-4 weeks
  and rested in a collar and cuff

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Methods of Reduction of anterior shoulder
Dislocation

• Hippocrates Method ( A form of anesthesia or pain
  abolishing is required )
• Stimpsons technique ( some sedation and
  analgesia are used but No anesthesia is required
  )
• Kochers technique is the method used in
  hospitals under general anesthesia and muscle
  relaxation

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Hippocrates Method
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Stimpsons technique
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Kochers Technique
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Complications of anterior Shoulder Dislocation
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 Dislocation
Late

• Avascular necrosis of the head of the Humerus
  (high risk with delayed reduction)
• Heterotopic ossification ( used to be called
  Myositis Ossificans )
• Recurrent shoulder dislocations

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Fractures of The Humerus

• Proximal Humerus (includes surgical and
  anatomical neck )
• Shaft of Humerus
• Distal humerus ( includes Supra Condylar
  fracture in children )

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Fractures of the Proximal Humerus
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Fracture Proximal Humerus
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Intra-medullary K wire fixation
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Fractures Shaft of the Humerus

• Commonly Indirect injury
• Indirect injury results in Spiral or Oblique
  fractures
• Direct injuries results in transverse or
  comminuted fracture
• May be associated with Radial Nerve injury

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Fracture shaft of the Humerus
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Management of Fracture Shaft of the Humerus

• Most of the time is Conservative
• Closed Reduction in upright position followed by
  application of U shaped Slab of POP or Cylinder
  cast
• Few weeks later or initially in stable fractures
  Functional Brace may be used

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U Shaped slab of POP
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Functional brace Fracture Shaft of Humerus
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Indications for surgical fixation of Shaft of
Humerus Fractures

• Failure to reduce fracture conservatively
• Ipsilateral elbow or forearm fractures
• Bilateral humeral fractures
• Open fracture with radial nerve Injury
• Unconscious patient
• Delayed-Union, Non-Union and Mal-Union

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Plating fracture Shaft of humerus
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Intra- medullary K Wire Fixation
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External fixator
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Radial Nerve Injury

• Results in Wrist drop
• Associated with fracture humerus in up to 12 of
  fractures
• 2/3 ( 8) of Radial injury are Neuropraxia
• 1/3 ( 4) are nerve lacerations or transection

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Management of Radial Nerve Injury

• When present in open fractures immediate
  exploration and repair
• In closed injuries treated conservatively
  initial management is doing Nerve Conduction
  Studies ( NCS ) and Electromyography ( EMG ) and
  awaiting for spontaneous recovery

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Management of Radial Nerve injury

• Recovery usually starts after few days but may
  take up to 9 months for full recovery
• If No spontaneous recovery occurs in 12 weeks
  confirmed by NCS and EMG then exploration of the
  nerve should be carried out

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Supra- condylar Fracture of Humerus
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Pediatric Supra-Condylar Humeral fracture
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Pediatric Supra-condylar fracture
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Reduction of supra-condylar Fracture

• Absolute Emergency
• Should de done under G A by experienced doctor as
  soon as possible
• In the past the arm was held in flexed elbow
  position in back-slab POP after reduction
• At present time Percutaneous K wire fixation is
  ALWAYS carried out after reduction

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Complications Supra-Condylar Fractures

• Early Compartment syndrome
• Brachial Artery injury
• Nerve Injury Median,
  Ulnar or Radial
• Late Stiffness
• Volkmann's Ischemic
  contracture
• Heterotopic Ossification
• Mal-Union ( Cubitus valgus
  or varus)

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Volkmann's Ischemic Contracture
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Supracondylar fracture in Adults
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Fracture dislocation
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MONTEGGIA FRACTURE-DISLOCATION
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MONTEGGIA FRACTURE-DISLOCATION
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GALEAZZI FRACTURE-DISLOCATION
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Distal radius fracture.
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Distal radius fracture.
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Types of treatment
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Types of treatment
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SCAPHOID
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