Fracture in Upper Extremity2558

Fracture in Upper Extremity
For 4th year medical students
S. Wattanakamolchai, M.D.
Department of Orthopaedics , KKU
Overviews
Clavicle
Proximal humerus
Humeral shaft
Distal humerus
Olecranon
Radial head
Radius and ulna shaft
Clavicle
Epidemiology
Anatomy
▪ 2.6-12% of all fractures
▪ first bone to ossify (fifth week of
▪ 44-66% of fractures about the
gestation)
▪ S shape
▪ medial 1/3 protects the brachial
plexus, subclavian and axillary vessels,
and superior lung
▪ strongest in axial load
shoulder
Clavicle
Mechanism of injury
Clinical evaluation
▪ Fall on affected shoulder (87%)
▪ arm adducted across the chest and
▪ Direct impact (7%)
supported by the contralateral hand
▪ distal neurovascular exam
▪ auscultate the chest for the possibility of
lung injury or pneumothorax
▪ Fall on outstretched hand (6%)
proximal fracture end is usually prominent
and may tent the skin**
Clavicle
Associated injury
Radiographic evaluation
▪ rib fractures
▪ standard clavicle AP view**
▪ BPI (contusion>penetration)
▪ CT scan (proximal third, distal third)
▪ vascular injury
▪ pneumothorax
Clavicle
Allman classification
▪ Group I: middle third fractures
▪ Group II: lateral third fractures
▪ Group III: medial third fractures
Subclassified by Neer
Type I: coracoclavicular ligaments intact
Type II: coracoclavicular ligaments detached from the
medial segment but trapezoid intact to distal segment
Type III: intra-articular extension into the acromioclavicular
joint
Clavicle
Treatment
▪ Non operative treatment
▪ Arm sling
▪ Figure of eight brace or cast
▪ Operative treatment
▪ Plate and screws
▪ Intramedullary pin
▪ External fixation
Clavicle AP
Proximal humerus
Epidemiology
▪ 4-5% of all fractures
▪ Most common humerus fracture
(45%)
▪ 2:1 female to male
▪ The four osseous segments (Neer)
1. humeral head
2. greater tuberosity
3. lesser tuberosity
4. humeral shaft
Proximal humerus
Clinical evaluation
Radiographic evaluation
▪ Held closely to the chest by the contralateral
▪ Shoulder AP, transcapular view
hand
▪ Pain, swelling, tenderness and painful range of
motion
▪ Attention to axillary nerve function
(sensation on the lateral aspect of the
proximal arm overlying the deltoid)
▪ Axillary view (best for evaluation of
glenoid articular fractures and
dislocations) ! difficult because of
pain and displacement
▪ Velpeau axillary view
▪ CT scan
Shoulder AP
transcapular
transaxillary
Proximal humerus
Neer classification
A part is defined as
▪ displaced >1 cm
▪ Angulation >45 degrees
Fracture types include:
▪ One-part fractures ! no displaced
▪
▪
▪
▪
fragments regardless of number of fracture
lines
Two-part fractures
Three-part fractures
Four-part fractures,Valgus impacted
Articular surface fractures
Proximal humerus
Treatment
▪ 1-part ! Sling immobilization or
swathe
▪ 2,3,4-part ! ORIF (young),
prosthesis (osteonecrosis)
▪ 2 part fracture dislocations ! may tx
by closed after shoulder reduction
unless remain displaced
Humeral shaft
Epidemiology
Anatomy
▪ 3-5% of all fractures
▪ Extend from pectoralis major
insertion to supracondylar ridge
Humeral shaft
Mechanism of injury
Clinical evaluation
▪ Direct trauma
▪ pain, swelling, deformity, and
▪ Indirect ! fall on outstretched arm
shortening of the affected arm
▪ attention to radial nerve function !
Holstein-Lewis Fractures
(elderly)
Humeral shaft
Radiographic evaluation
▪ AP and lateral view of humerus,
including the shoulder and elbow
joints on each view
▪ CT and MRI (rarely)
Humeral shaft
Treatment
▪ Non operative treatment (>90%)
▪
▪
▪
▪
U slab or Sugar tong slab
Hanging cast
Coaptation splint
Shoulder spica cast
▪ Operative treatment
▪ Plate and screws
▪ Intramedullary nail
▪ External fixator
Goal
1. Establish union with an acceptable
humeral alignment
2. Restore the patient to preinjury level of
function
Acceptable alignment
Anterior angulation 20 degrees
Varus angulation 30 degrees
Up to 3 cm of bayonet apposition
Distal huemerus
Epidemiology
▪ 2 % of all fractures
▪ 1/3 of all humerus fractures
Anatomy
Distal huemerus
Mechanical of injury
Clinical evaluation
▪ Fall on outstretch hand (low energy
▪ Signs and symptoms vary with degree
trauma) ! middle age to elderly
women
▪ Motor vehicle and sporting accidents
are more common in younger
of swelling and displacement
▪ Crepitus, neurovascular exam
▪ Heuter triangle
Distal huemerus
Radiographic evaluation
▪ Elbow AP and lateral view
▪ CT
Elbow
AP
lateral
Distal huemerus
Goal of treatment
: Painless, stable, and mobile elbow joint
Non-operative treatment
Operative treatment :
▪ High risk of functional impairment
▪ Favorable outcome for most
(stiffness , flail/useless)
displaced intra-articularfracture
▪ Complex and labor-intensive , high
risk of complication
Distal huemerus
Operative treatment
▪ Recommend ORIF with double plates
Gold standard ! Anatomical reduction
with rigid internal fixation
and screws (bicolumn, orthogonal or
parallel plating techniques)
▪ Total Elbow Arthroplasty
Timing of Surgery :
▪ Best ! within 48 to 72 hours
▪ Decreases complications such as HO
& stiffness
Orthogonal
Parallel
Total elbow arthroplasty
Olecranon
Epidemiology
Ulnohumeral joint is a primary stabilizer for elbow stability**
Anatomy
▪ Bimodal distribution
▪ Younger individuals as a result of high-
energy trauma
▪ Older individuals as a result of a
simple fall
▪ Avulsion fracture from triceps
mechanism
▪ Displacement represents a functional
disruption of the triceps mechanism,
resulting in loss of active extension
Olecranon
Mechanism of injury
Clinical evaluation
▪ Fall on the point of the elbow or
▪ upper extremity supported by the
direct trauma to the olecranon !
comminuted
▪ A fall onto the outstretched upper
extremity accompanied by a strong,
sudden contraction of the triceps !
transverse or oblique fracture
contralateral hand with the elbow in
relative flexion
▪ inability to extend the elbow actively
against gravity
▪ associated ulnar nerve injury is
possible
Olecranon
Radiographic evaluation
▪ Standard AP and lateral of elbow
Olecranon
Goal of treatment
Non operative treatment
▪ Restoration of the articular surface
▪ Indicated for nondisplaced fracture in
▪ Restoration and preservation of the
poorly functioning older individuals
▪ Long arm cast in elbow flexion 45-90
degrees
▪ Remove cast in 3 weeks and allow
protected ROME
elbow extensor mechanism
▪ Restoration of elbow motion and
prevention of stiffness
Olecranon
Operative treatment
▪ Indicated in disruption of extensor
▪
▪
▪
▪
mechanism (any displaced fracture)
Intramedullary fixation
Tension band wiring (simple)
Plate and screws (comminuted)
Excision and triceps advancement
Radial head
Epidemiology
Anatomy
▪ 1/3 in elbow fractures
▪ radial head plays a role in valgus
stability of the elbow
Radial head
Mechanism of injury
Clinical evaluation
▪ Fall on outstretched hand (low to
▪ Limited elbow and forearm motion
high energy injury)
and pain on passive rotation
▪ Tenderness overlying radial head
▪ Should associated with medial
collateral ligament in valgus force
Radial head
Radiographic evaluation
▪ Standard AP and lateral view of
elbow
▪ Radiocapitellar view (Greenspan
view)
▪ CT scan
Fat pad sign :
Induded by intra-articular effusion
Greenspan view
Radial head
Mason classification
▪ Type I: Nondisplaced fractures
▪ Type II: Marginal fractures with
displacement (impaction, depression,
angulation)
▪ Type III: Comminuted fractures
involving the entire head
▪ Type IV: Associated with dislocation
of the elbow (Johnston)
Radial head
2 mm, 33%
Radius and Ulnar shaft
Epidemiology
Anatomy
▪ Men > women (10 times)
Ring form
Ulna is an axis
Radius and Ulnar shaft
Mechanism of injury
Clinical evaluation
▪ Motor vehicle injury (most common)
▪ Gross deformity of the involved
▪ Direct trauma
▪ Pathological fracture are uncommon
▪
▪
▪
▪
forearm
Pain, swelling, loss of hand and
forearm function
Radial and ulnar pulse
Median radial and ulnar nerve
Associated with Compartmental
syndrome**
Radius and Ulnar shaft
Radiographic evaluation
▪ Standard AP and lateral view of
forearm
▪ Should include the wrist and elbow
to rule out the presence of
associated fracture or dislocation
Radius and Ulnar shaft
Treatment
Non operative treatment
Operative treatment
▪ Rare
▪ Restore length, rotation, and radial
▪ Non displaced of both bone forearm
bow (rotational function)
▪ Fixation by plates and screws both
bone
▪ Well mold long arm cast in neutral
rotation with elbow flex in 90
degrees
▪ ORIF ! tx of choice
Ulnar shaft fracture
Nightstick fracture
Treatment
▪ Non displaced! conservative tx by
cast immobilization
▪ Displaced (>10 degree angulation in
any plane or >50% displacement of
the shaft) ! ORIF
direct trauma to the ulna
Ulnar shaft fracture
Monteggia fracture
▪ Fracture proximal ulna with radial head
dislocation
How do you know about dislocation
of radial head?
Radiocapitellar line
▪ Straight line in all position
Monteggia fracture
Bado classification
Closed tx was preserved for
pediatric only
Closed reduction of radial head
and ORIF of ulna is tx of choice
After fixation of the ulna, the radial
head is usually stable (>90%)
Radial shaft fracture
Isolated radial shaft fracture !
rare
Fracture of distal third of radius
with distal radioulnar joint
involvement
Galeazzi
fracture referred to “fracture of
necessity”
requires open reduction and internal fixation to
achieve a good result
Galeazzi fracture
Open reduction and internal
fixation by plate and screws is a
treatment of choice
Closed tx has high failure rate
Postoperative immobilized in
supination for 4-6 wks
References :
Books :
Review article papers : http://www.jaaos.org
Journals : JBJS, JHS