UPPER EXTREMITY FRACTURES

AND DISLOCATIONS

Orthopaedic & Traumatology Department

Soetomo General Hospital
Surabaya
2015
 Topics
• Clavicle
• Shoulder Dislocation
• Humerus
• Elbow
• Forearm
• Distal Radius
FRACTURE of the CLAVICLE
 Anatomy

strut Suspension
• Neurovascular structure around the clavicle
 EPIDEMIOLOGI
• Clavicle fractures account for 2.6% - 12% of all
fractures and for 44% - 66% of fractures
around the shoulder
• Mechanism
– Fall onto shoulder (87%)
– Direct blow (7%)
– Fall onto outstretched hand (6%)
• Deforming muscle
 Diagnosis
• Clinical Evaluation
– Inspect and palpate for deformity/abnormal
motion
– Thorough distal neurovascular exam
– Auscultate the chest for the possibility of lung
injury or pneumothorax
• Radiographic Exam
– AP chest radiographs.
– Clavicular 45° AP oblique X-rays
Clavicle Fractures
• Classification of Clavicle Fractures:
Allman:
– Type I Middle Third (80%)
– Type II Distal Third (15%)
– Type III Medial Third (5%)
 TREATMENT
• Non operative
– Most clavicle fractures can be successfully
treated nonoperatively with some form of
immobilization
– Comfort and pain relief are the main goals
– Sling immobilization or figure of 8 bandage
for 3-4 weeks with early ROM encouraged
• Operative indication:
– Absolute
Shortening of >20 mm
Open fracture
Impending skin disruption
Vascular compromise and/or progressive neurologic loss
Pathologic fracture with associated trapezial paralysis
Scapulothoracic dissociation
– Relative
Displacement of >20 mm
Neurologic disorder: Parkinson's, Seizure
Multitrauma
Floating shoulder
Intolerance to immobilization
Bilateral fractures
Ipsilateral upper extremity fracture
Cosmesis
Open Reduction and Internal Fixation
 COMPLICATION
• Neurovascular compromise
• Malunion: This may cause an unsightly
prominence, but operative management may
result in an unacceptable scar
• Nonunion: The incidence of nonunion following
clavicle fractures ranges from 0.1% to 13.0%,
with 85% of all nonunions occurring in the
middle third
• Posttraumatic arthritis
SHOULDER DISLOCATION
ANATOMY
• Glenoid: size of the humeral head is
significantly greater than the glenoid. A large
portion of the humeral head does not contact
the glenoid
 Shoulder Dislocations
Epidemiology
• The shoulder is the most commonly dislocated
major joint of the body, accounting for up to
45% of dislocations.
• This is due to a number of factors:
- the shallowness of the glenoid socket
- extraordinary range of movement
- ligamentous laxity or glenoid dysplasia
• Displacement
– Anterior: Most common, 90%
– Posterior: Uncommon, 10%,
– Inferior (Luxatio Erecta): Rare,
hyperabduction injury
Mechanism of Injury
• Direct or indirect forces.
• Indirect trauma to the upper extremity with the
shoulder in abduction, extension, and external
rotation is the most common mechanism.
• Direct, anteriorly directed impact to the posterior
shoulder may produce an anterior dislocation
• Convulsive mechanisms and electrical shock
typically produce posterior shoulder dislocations,
 DIAGNOSIS
• Clinical Evaluation
– The patient typically presents with the
injured shoulder held in slight abduction
and external rotation
– Look: deformity, sulcus sign, open wound
– Feel: the head of humerus in
anterior/posterior/inferior part of shoulder.
(compare to the normal side)
– Examine axillary nerve (deltoid function,
sensation over lateral shoulder)
– Examine M/C nerve (biceps function and
anterolateral
forearm sensation)
• Radiographic Evaluation
– True AP shoulder
– Scapular Y-view
 TREATMENT
• EMERGENCY!!!
• Nonoperative treatment
- Closed reduction should be performed after
adequate clinical evaluation and appropriate
sedation
- Reduction Techniques:
• Traction/countertraction- Generally used
with a sheet wrapped around the patient
and one wrapped around the reducer.
• Hippocrates technique - Effective for one
person
• Stimson technique- Patient placed prone with
the affected extremity allowed to hang free.
Gentle traction may be used
• Postreduction
– Post reduction x-rays are a must to confirm
the position of the humeral head
– Pain control
– Immobilization for 2 to 5 weeks. A shorter
period of immobilization may be used for
patients older than 40 years
• Operative Indications
– Fracture dislocation
– Recurrent dislocation at a young age
– Irreducible dislocation
– Open dislocation
– Unstable reduction
– Young patients with high-demand activities
 COMPLICATION
• Anterior Dislocation Recurrence Rate
– Age 20: 80-92%
– Age 30: 60%
– > Age 40: 10-15%
• Vascular: Axillary artery injury
• Nerve: Axillary nerve neuropraxia
• Rotator cuff tear
• Stiffness
HUMERAL SHAFT FRACTURE
 ANATOMY
• Proximally the humerus is roughly cylindrical
in cross section, tapering to a triangular shape
distally
• The humerus is well enveloped in muscle and
soft tissue, hence its good prognosis for
healing
• The brachial artery, median nerve, and
musculocutaneous nerve all remain in the
anterior compartment
 EPIDEMIOLOGY
• Common injury, representing 3% to 5% of all
fractures
• Mechanism of Injury
– Direct trauma is the most common
especially MVA
– Indirect trauma such as fall on an
outstretched hand
• Bimodal distribution:
- high energy trauma was responsible for the
majority of injuries in young patients
- simple falls in older women
 DIAGNOSIS
• Clinical evaluation
– Thorough history: mode of injury, a history
of minimal trauma in the older patient may
be the first point to alert the surgeon that
the fracture may involve pathologic bone
– Patients typically present with pain,
swelling, and deformity of the upper arm
• Look for open wound, other associated injury
• Careful NV exam important as the radial nerve
is in close proximity to the humerus and can
be injured
• Radial nerve injury: DROP HAND
 Special type fracture
• Holstein-Lewis Fractures
– Distal 1/3 fractures
– May entrap or lacerate radial nerve as the
fracture passes through the intermuscular septum
• Radiographic evaluation
– AP and lateral views of the humerus
– Traction radiographs: for severe displacement or a
lot of comminution
 TREATMENT
• Conservative Treatment
– Goal of treatment is to establish
union with acceptable alignment
– >90% of humeral shaft fractures heal
with nonsurgical management
• 20 degrees of anterior angulation,
30 degrees of varus angulation
and up to 3 cm of shortening are
acceptable
• Most treatment begins with
application of a coaptation spint
or a hanging arm cast followed by
placement of a fracture brace
• Operative Treatment
• Indications for operative
treatment include inadequate
reduction, nonunion, associated
injuries, open fractures,
segmental fractures, associated
vascular or nerve injuries
• Most commonly treated with
plates and screws but also IM
nails
 COMPLICATION
• Radial nerve injury occurs in up to 18% of
cases. Most injuries are neurapraxias or
axonotmesis; function will return within 3 to 4
months
• Vascular injury
• Non union: because of fracture distraction, soft
tissue interposition, and inadequate
immobilization
• Malunion
ELBOW DISLOCATION
 ANATOMY
• 3 joints:
– Ulnohumeral (hinge).
– Radiohumeral (rotation).
– Proximal radioulnar (rotation).
• Ligaments and capsules
 EPIDEMIOLOGY
• Accounts for 11-28% of injuries to the elbow
– Posterior dislocations most common
– Highest incidence in the young 10-20 years
and usually sports injuries
• Mechanism of injury
– Most commonly due to fall on outstretched
hand or elbow resulting in force to unlock
the olecranon from the trochlea
– Anterior dislocation ensuing from direct
force to the posterior forearm with elbow
flexed
 DIAGNOSIS
• Clinical Evaluation
– Patients typically present guarding the
injured extremity
– Usually has gross deformity and swelling
– Careful NV exam in important and should be
done prior to radiographs or manipulation
– Repeat after reduction
• Radiographic Evaluation
– AP and lateral elbow films should be
obtained both pre and post reduction
– Careful examination for associated fractures
X-rays
 TREATMENT
• EMERGENCY!!!
• Closed reduction
– Posterior Dislocation
• Under sedation and adequate analgesia
• Reduction should be performed with the
elbow flexed while providing distal
traction
• Post reduction management includes a
posterior splint or Long Arm Cast with the
elbow at > 90 degrees flexion
• Operative management indication:
- failed closed reduction
- unstable reduction
- associated fracture
- open dislocation
- neurovascular injury
 Elbow Dislocations
• Associated injuries
– Radial head fx (5-11%)
– Medial or lateral
epicondylar fx (12-34%)
– Coronoid process fractures
(5-10%)
Forearm Fractures
 Forearm Fractures
• Epidemiology
– Highest ratio of open to
closed than any other
fracture except the tibia
– More common in males than
females, most likely
secondary mva, contact
sports, altercations, and falls
• Mechanism of Injury
– Commonly associated with
mva, direct trauma missile
projectiles, and falls
 Forearm Fractures
• Clinical Evaluation
– Patients typically present
with gross deformity of the
forearm and with pain,
swelling, and loss of
function at the hand
– Careful exam is essential,
with specific assessment of
radial, ulnar, and median
nerves and radial and ulnar
pulses
– Tense compartments,
unremitting pain, and pain
with passive motion should
raise suspicion for
compartment syndrome
 Forearm Fractures
• Radiographic
Evaluation
– AP and lateral
radiographs of
the forearm
– Don’t forget to
examine and x-
ray the elbow
and wrist
 Forearm Fractures
• Ulna Fractures
– These include nightstick and Monteggia fractures
– Monteggia denotes a fracture of the proximal ulna with an
associated radial head dislocation
– Monteggia fractures classification: Bado
• Type I: Anterior Dislocation of the radial head with fracture of
ulna at any level- produced by forced pronation
• Type II: Posterior/posterolateral dislocation of the radial head-
produced by axial loading with the forearm flexed
 Forearm Fractures
Type III: Lateral/anterolateral
dislocation of the radial head
with fracture of the ulnar
metaphysis- forced abduction of
the elbow
Type IV: anterior dislocation of
the radial head with fracture of
radius and ulna at the same
level- forced pronation with
radial shaft failure
 Forearm Fractures
• Radial Diaphysis Fractures
– Fractures of the proximal
two-thirds can be considered
truly isolated
– Galeazzi or Piedmont
fractures refer to fracture of
the radius with disruption of
the distal radial ulnar joint
– A reverse Galeazzi denotes a
fracture of the distal ulna
with disruption of radioulnar
joint
 Forearm Fractures
Mechanism
• Usually caused by direct or
indirect trauma, such as fall
onto outstretched hand
• Galeazzi fractures may
result from direct trauma
to the wrist, typically on
the dorsolateral aspect, or
fall onto outstretched hand
with pronation
• Reverse Galeazzi results
from fall with hand in
supination
 Forearm Fractures
Complications

• The ends of broken bones are

often sharp and can cut or tear
surrounding blood vessels or
nerves.
• Excessive bleeding and swelling -
> acute compartment syndrome,
a (occurs within 24 to 48 hours) :
severe pain when passive stretch
the fingers, loss of sensation and
function, and requires
emergency surgery once it is
diagnosed -> Fasciotomy
 Forearm Fractures
Treatment
1.Immediate Treatment
• Realign the bone (Reduction) : w/
Pain control
• Apply splint (allows swelling)
• Control the movement of the
broken bone
2. Nonsurgical Treatment
• Cast/ Brace
• Closely monitor the healing of the
fracture (X-Rays Frequently)
• If the fracture shifts in position ->
may require surgery
 Forearm Fractures
3. Surgical Treatment
• If the bones have punctured
the skin (open fracture),
surgery is usually required
Immediately
• Antibiotics by vein
(intravenous) in the
emergency room + Tetanus
shot
• Debridement
• Open reduction and internal
fixation with plates and
screws
• Open reduction and internal
fixation with rods
• External fixation
 Distal Radius Fractures
• Epidemiology
– Most common fractures of the upper
extremity
– Common in younger and older patients.
Usually a result of direct trauma such as
fall on out stretched hand
– Increasing incidence due to aging
population
• Mechanism of Injury
– Most commonly a fall on an outstretched
extremity with the wrist in dorsiflexion
– High energy injuries may result in
significantly displaced, highly unstable
fractures
 Distal Radius Fractures
• Clinical Evaluation
– Patients typically present with gross deformity of
the wrist with variable displacement of the hand
in relation to the wrist. Typically swollen with
painful ROM
– Ipsilateral shoulder and elbow must be examined
– NV exam including specifically median nerve for
acute carpal tunnel compression syndrome
 Radiographic Evaluation
• 3 view of the wrist including AP, Lat, and
Oblique
– Normal Relationships

23 Deg 11 Deg

11 mm
 Distal Radius Fractures
Eponyms

1. Colles Fracture: Combination of intra

and extra articular fractures of the
distal radius with dorsal angulation
(apex volar), dorsal displacement,
radial shift, and radial shortenting.
- Most common distal radius fracture
caused by fall on outstretched hand.

2. Smith Fracture (Reverse Colles):

Fracture with volar angulation (apex
dorsal) from a fall on a flexed wrist
 Distal Radius Fractures
3. Barton Fracture: Fracture with
dorsal or volar rim displaced with the
hand and carpus.

4. Radial Styloid Fracture (Chauffeur

Fracture):
- Avulsion fracture with extrinsic
ligaments attached to the fragment
- Mechanism of injury is compression
of the scaphoid against the styloid
 Distal Radius Fractures
Treatment
– Displaced fractures require
reduction.
– Hematoma block-10ccs of
lidocaine or a mix of lidocaine
and marcaine in the fracture
site/ Pain management.
– Hang the wrist in fingertraps
with a traction weight
– Reproduce the fracture
mechanism and reduce the
fracture
– Place in sugar tong splint/ Long
arm cast/ Below elbow cast
 Distal Radius Fractures
– Operative Management
• For the treatment of intraarticular, unstable, malreduced fractures.
• As always, open fractures must go to the OR.