Fractures & Dislocations of the Upper Limb

Upper Limb include

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

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 : Flexed, Extended, adducted, abducted, pronated or supinated

Fracture of the clavicle in Adults

Common especially in children and elderly Commonest site is the middle one third Mainly due to indirect injury Direct injury leads to comminuted fracture

Treatment
Conservative by an arm sling or figure of eight bandage Operative fixation is indicated if there is an open fracture, neurovascular injury or nonunion

Figure of eight Bandage

Dislocation of the Shoulder

Mostly Anterior > 95 % of dislocations Posterior Dislocation occurs < 5 %
True Inferior dislocation (luxatio erecta) occurs < 1%

Habitual Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless

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

Anterior Shoulder dislocation

Usually also inferior Bankarts Lesion

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

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

X Ray anterior Dislocation of Shoulder

Associated injuries of anterior Shoulder Dislocation

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

Axillary Nerve Injury

Also called circumflex nerve 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

Axillary nerve injury

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 34 weeks and rested in a collar and cuff

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

Hippocrates Method

Stimpsons technique

Kochers Technique

Complications of anterior Shoulder Dislocation : Early

Neuro vascular injury ( rare ) Axillary nerve injury Associated Fracture of neck of humerus or greater or lesser tuberosities

Complications of anterior shoulder Dislocation : Late

Avascular necrosis of the head of the Humerus (high risk with delayed reduction) Heterotopic calcification ( used to be called Myositis Ossificans ) Recurrent dislocation

Fractures of The Humerus

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

Fracture Proximal Humerus

Fracture Proximal Humerus : Plating or Rush Nail insertion

IntraIntra-medullary K wire fixation

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

Fracture shaft of the Humerus

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

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

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

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

U Shaped slab of POP

Functional brace Fracture Shaft of Humerus

Indications for ORIF Fracture Shaft of Humerus

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

Plating fracture Shaft of humerus

IntraIntra- medullary K Wire Fixation

SupraSupra- condylar Fracture of Humerus

Pediatric Supra-Condylar Humeral Suprafracture

Pediatric Supra-condylar fracture Supra-

Reduction of supra-condylar supraFracture

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

Complications Supra-Condylar SupraFractures

A. Early= Compartment syndrome Brachial Artery injury ( Acute Volkmann's Ischemia ) Nerve Injury : Median, Ulnar or Radial B. Late= Stiffness Volkmann's Ischemic contracture Heterotopic Calcification Mal-Union ( Cubitus Valgus or varus)

Volkmann's Ischemic Contracture

Supracondylar fracture.

Fracture dislocation

MONTEGGIA FRACTUREFRACTUREDISLOCATION

MONTEGGIA FRACTUREFRACTUREDISLOCATION

GALEAZZI FRACTUREFRACTUREDISLOCATION

Distal radius fracture.

Distal radius fracture.

Types of treatment

Types of treatment

SCAPHOID