Fractures & Dislocations of the Upper Limb

1. Fractures & Dislocations of the Upper Limb Dr Munir Saadeddin, FRCSE

2. Upper Limb include • Clavicle • Scapula • Shoulder Joint • Humerus • Elbow Joint • Forearm Bones • Wrist Joint • Scaphoid Bone

3. 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

4. Mechanism of Injury

5. Splintage & Elevation in Upper Limb • The Hand has to be Higher than the Elbow • Simplest splint is the tri-angular splint which can be made of any piece of cloth • Commonest splint used is the Collar & cuff splint • Strapping the upper limb to the trunk is one method of Immobilisation of shoulder and humerus

6. Fractures of the Clavicle • A common injury in all ages • Most fractures are in the Middle third • Usually it is the result of Indirect injury • Direct injuries are more serious ( possible injury to neuro vascular structures ) • In children it may be a Green stick fracture • Fracture site can be identified easily because clavicle is a subcutaneous bone

7. ? Fracture of the Clavicle

8. ? Fracture of the clavicle • A child with sudden painful swelling over left clavicle • History of a fall injury few days ago • The swelling is over mid clavicle and is tender • Initial x rays do not show a fracture • The Answer is to repeat the X ray two weeks later

9. Fracture of the clavicle 2 weeks later

10. Fracture of the clavicle in Adults

11. Fracture of the clavicle in Adults • Usually displaced with deformity • May be comminuted • mostly heal with a degree of Mal-Union • Delayed union or Non union are less common • Usually is treated conservatively • Open reduction gives satisfactory alignment but results in unsightly scar

12. Figure of eight Bandage

13. Figure of Eight bandage • It is the common way for treating fractures of clavicle conservatively • Simple to apply in Emergency room • It helps to reduce overlap of fracture ends • It should not be applied very tight or it may compress the neuro vascular structures at axilla

14. Union of Fracture of the clavicle • Early union occurs in 1-2 weeks in children • In adults early union occurs in 3 weeks , union in 6 weeks and consolidation in 12 weeks • Callus formation can be visible and palpable • Mal united overlap of fracture can be treated by trimming some bone after union of fracture • Non Union is treated by compression Plating and bone grafting

15. Dislocation of the Shoulder • Mostly Anterior> 95 % of dislocations • Posterior Dislocation occurs < 5 % • True Inferior dislocation ( Luxato Inferno ) occurs < 1% • Habitual Non traumatic dislocation may present as Posterior dislocation or Multi directional dislocation due to ligament laxity and is Painless

16. 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

17. Anterior Shoulder dislocation • Usually also inferior • There is damage ( Overstretching ) to the shoulder capsule and subscapularis muscle • Commonly there is avulsion to the antero inferior part of the Glenoid labrum with adjacent periosteom on the neck of scapula = Bankart’s Lesion

18. 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

19. 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

20. X Ray anterior Dislocation of Shoulder

21. Associated injuries of anterior Shoulder Dislocation • Injury to the neuro vascular bundle in axilla ( rare ) • Injury ofthe Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) • Associated fracture

22. Axillary or Circumflex 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

23. Axillary or circumflex nerve injury

24. Management Of Anterior Shoulder dislocation • Is an Emergency • It should be reduced in less than 24hours 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

25. Methods of Reduction of anterior shoulder Dislocation • Hippocrates Method ( A form of anesthesia or pain abolishing is required ) • Stimpson’s technique ( some sedation and analgesia are used but No anesthesia is required ) • Kocher’s technique is the method used in hospitals under general anesthesia and muscle relaxation

26. Hippocrates Method

27. Stimpson’s technique

28. Kocher’s Technique

29. Complications of anterior Shoulder Dislocation : Early • Neuro vascular injury ( rare ) • Axillary or Circumflex nerve injury • Associated Fracture of neck of humerus or greater or lesser tuberosities

30. Complications of anterior shoulder Dislocation : Late • Avascular necrosis of the head of the Humerus ( may be delayed up to 2 years and only following delayed reduction ) • Heterotopic calcification ( used to be called Myositis Ossificans ) • Recurrent dislocation

31. Associated fractures

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

33. Fracture Proximal Humerus

34. Fracture Proximal Humerus : Plating or Rush Nail insertion

35. Fracture Proximal Humerus : Intra-medullary K wire fixation

36. Intra-medullary K wire fixation

37. Fractures Shaft of the Humerus • Commonly Indirect injury • Indirect injury results in Spiral or Oblique fractures • Direct injuries results in transverse or comminuted ( Butterfly ) fracture • May be associated with Radial Nerve injury

38. Fracture shaft of the Humerus

39. Radial Nerve Injury • Results in Drop Wrist • Associated with fracturehumerus in up to 12% of fractures • 2/3 ( 8%) of Radial injury are Neuropraxia • 1/3 ( 4%) are nerve lacerations or transection

40. 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

41. 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

42. Exploration Radial Nerve

43. Management of Fracture Shaft of the Humerus • Preferably Conservative • Closed Reduction in upright position followed by application of U shaped Slap of POP or Cylinder cast • Few weeks later or initially in stable fractures Functional Brace may be used

44. U Shaped slap of POP

45. Functional brace Fracture Shaft of Humerus

46. 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

47. Plating fracture Shaft of humerus

48. Intra- medullary K Wire Fixation

49. Supra- condylar Fracture of Humerus

50. Supra-Condylar fracture of t Humerus