4.

4 FRACTURES OF THE UPPER EXTREMITY 1

DR. TAN \\ DATE:
1.01

FRACTURES OF THE UPPER EXTREMITY DEFORMING FORCES ON THE CLAVICLE

CLAVICULAR FRACTURES
THE CLAVICLE Medial End Pulled Upwards by
 An S-shaped bone Sterno-clavicular Sternocleidomastoid
 acts as a strut which provides the only bony connection ligaments
between upper limb and the thorax
 It protects major underlying vessels, lung, and brachial
plexus. Displaced clavicle fractures can injure these
structures because of their proximity and sharp edges.

CLAVICULAR FRACTURES
 Most common fx in both adults and children Lateral end pulled downwards
Weight of arm
 The fx usually occurs in the junction between the middle third by coracoclavicular ligament
& the outer third of the shaft
 Can present in the newborn period, especially following a
difficult delivery SIGNS & SYMPTOMS
 Nearly half of all clavicle fractures occur in children younger  Tenderness
than 7 years.  Crepitus
MECHANISMS OF INJURY  Deformity & tenting of skin
 Fall onto shoulder or outstretched Fall onto shoulder or  Ecchymosis, especially when severe displacement causes
outstretched upper extremity  Bleeding from open fracture (rare)
 Direct blow to clavicle seizures  Nonuse of arm on affected side in neonates

CLASSIFICATION OF CLAVICULAR FRACTURES  Decreased breath sounds on auscultation, indicating

 Medial Third (Group III) - 5%
 Middle Third (Group I) – 85%
 Lateral Third (Group II) – 10%
possible pneumothorax
 Decreased pulses or evidence of decreased perfusion on
vascular exam, suggesting vascular compromise
 Diminished sensation or weakness on distal neurovascular
exam, suggesting neurologic compromise
DIAGNOSIS: IMAGING STUDIES
 Best visualized w/ AP view & view w/ beam angled 30 deg.
angled 30 deg. angled 30 deg. angle cephalad (angulated);

ORTHO GUSTILO 1 of 5
 CLOSED TREATMENT  Capsular structures (anterior and posterior)
 It is difficult to reduce and maintain the reduction of clavicle  Glenoid labrum
fractures  Osseous (acromion, coracoid process)
 Despite deformity, healing usually proceeds rapidly  Active stabilizing structures
 Union usually occurs rapidly & produces prominent callus  Rotator cuff muscles
FIGURE-8 BANDAGE  Long head of biceps tendon

TYPES OF SHOUDER DISCLOCATION

SHOULDER
DISLOCATION

ANTERIOR POSTERIOR
DISLOCATION DISLOCATION

Subclavicular
Subglenoid

Subglenoid
Subspinous

OPEN TREATMENT Subcoracoid

 INDICATIONS FOR SURGERY:
 Open fractures
ANTERIOR SHOULDER DISLOCATION
 Gross displacement of fracture w/ tenting of skin  the most frequent type of shoulder dislocation (85-90%
 Presence of neurovascular injuries of shoulder dislocations)
COMPLICATIONS  Anterior dislocations are usually the result of direct or indirect
 Brachial plexus compression resulting from hypertrophic trauma, with the arm forced into abduction and external
callus formation rotation
 Delayed union or nonunion (especially with distal third  40% become recurrent as a result of associated damage of
fractures) the surrounding ligamentous and capsular structures that
 Poor cosmetic appearance stabilize the joint
 Posttraumatic arthritis
 Intrathoracic injury
 Pneumothorax
 Subclavian artery and vein injury
 Internal jugular vein injury
 Axillary artery injury

SHOULDER DISLOCATION
 The shoulder is the most commonly dislocated joint in the
body, 96% of these dislocations due to trauma
 Shoulder dislocations account for 45-50% of all dislocations.
Approximately 85% are anterior dislocations

POSTERIOR SHOULDER DISLOCATION

 Posterior dislocations are rare (approximately 2-4%).
 They may result from a fall on the outstretched hand, direct
trauma to the shoulder, or violent muscle contractions from
electric shocks or seizures.

THE SHOULDER JOINT

 Passive stabilizing structures
 Size, shape, and tilt of the glenoid fossa
 Vacuum effect SIGNS & SYMPTOMS
 Ligamentous structures  Pain& tenderness at shoulder; Muscle spasm/splinting may
 superior glenohumeral ligament be present
 middle glenohumeral ligament  Limited motion of shoulder joint due to extreme pain
 inferior glenohumeral ligament  Deformity of shoulder joint
 coracohumeral ligament  Shoulder may be locked in flexion or extension

ORTHO FRACTURES OF THE UE 2 of 5

 DIAGNOSIS: Imaging Studies ACROMIOCLAVICULAR & STERNOCLAVICULAR JOINT
 X-Rays: DISLOCATIONS
 Shoulder AP-Y views, Axillary view MECHANISM OF INJURY
 CT scan  Falling on the point of the shoulder (sports-related or due to
 MRI vehicular accidents, falls)
 Arthrography AC Joint Dislocation
GRADE 1 GRADE 2 GRADE 3
TREATMENT
 Closed reduction of dislocation
 Sling/Shoulder immobilizer for 2 weeks
 Rehabilitation (mobilization, strengthening)

1. Stimson
Technique

TREATMENT AC JOINT DISLOCATION

 Grades 1 & 2 can be treated conservatively with sling
support. Grade 3 injuries are usually treated with surgical
repair
STERNOCLAVICULAR JOINT DISLOCATION

2. Milch
Maneuver

 Anterior dislocations are more common & can be reduced by

3. Hippocratic closed means
Maneuver  Posterior dislocations are rare but are potentially more
serious because the clavicle can impinge on vital structures
in the neck (esp. the trachea)
FRACTURES OF THE PROXIMAL HUMERUS
 2-3% of all upper extremity fractures occur in the proximal
humerus
 75% of proximal humerus fractures occur in the elderly (60
years up), mostly women
 Most fractures occur through osteoporotic bone in elderly,
although high-energy trauma may also be a cause
BASIC ANATOMY, FOUR PARTS:
 articulating surface
4. Traction – Counter traction  greater tuberosity
Technique  lesser tuberosity
 humeral shaft
Rotator cuff
DISPLACING FORCES:

Subscapularis
Deltoid

COMPLICATIONS
 High recurrence rate (re-dislocations, joint instability)
 High incidence of rotator cuff tear in ages >40 years old Pectoralis
 Axillary nerve / artery damage
 Glenoid fossa fx’s, labrum tears

ORTHO FRACTURES OF THE UE 3 of 5

 NEER CLASSIFICATION OF PROXIMAL HUMERAL FRACTURES CLOSED TREATMENT OF HUMERAL SHAFT FRACTURES
 Although most fractures of the humeral shaft are inherently
1 – Part 2 – Part 3 - Part unstable, nonoperative treatment remains the standard
OPEN TREATMENT OF HUMERAL SHAFT FRACTURES
 ORIF - IM nailing
 ORIF plate & screws
COMPLICATIONS
 Radial nerve injury occurs in up to 16-18% of humeral shaft
fractures
 Brachial artery injury
 Nonunion, Malunion, Delayed union

SUPRACONDYLAR FRACTURES
 Supracondylar fractures occur in the distal humeral
metaphysis, above the joint capsule, & are completely extra
4 - Part articular
 Usually occur from an extension injury (Fall on an
outstretched hand)
 Peak age of occurrence is 5-7 years, usually boys
MECHANISM OF INJURY
 Trauma: Fall from a height (70%)
 Fall onto an outstretched hand with the elbow extended

CLASSIFICATION
 TYPE I –undisplaced fracture
 TYPE II –Displaced, but with intact posterior cortex
 TYPE III –Displaced, with no cortical contact
SIGNS & SYMPTOMS
MECHANISMS OF INJURY  Pain & swelling at elbow area
 Fall on the arm  Ecchymosis & edema
 Strong muscular contractions (electric shock, seizures)  S-shaped deformity
 Direct blow to the shoulder  Puckering of cubital fossa
 Limitation of motion / splinting of the affected elbow
DIAGNOSIS: IMAGING STUDIES CLOSED TREATMENT OF SUPRACONDYLAR FRACTURES
 Anteroposterior and lateral views of the humerus, as well as  Immobilization by traction
transthoracic and axillary views of the shoulder, should be OPEN TREATMENT OF SUPRACONDYLAR FRACTURES
adequate to visualize a fracture  Percutaneous pinning
SIGNS & SYMPTOMS  ORIF using plates & screws
 Pain, swelling, tenderness COMPLICATIONS
 Ecchymosis & edema  Vascular injury (brachial artery involvement)
 Decreased range of motion (ROM)  Nerve injury (radial, medial nerves; rarely ulnar nn.)
CLOSED TREATMENT OF PROXIMAL HUMERAL FRACTURES  Malunion (resulting in cubitus varus)
 Most fractures are displaced minimally and treated  Volkmann’s ischemic contracture
conservatively  Myositis ossificans (very rare)
OPEN TREATMENT OF PROXIMAL HUMERAL FRACTURES
 Operative treatment decisions are based primarily on the CONDYLAR FRACTURES OF THE DISTAL HUMERUS
number of segments involved and degree of displacement.
Three-and 4-part fractures often need operative repair MEDIAL EPICONDYLE/EPICONDYLE
COMPLICATIONS MECHANISMS OF INJURY
 Axillary nerve injury  Fall on outstretched arm
 Avascular necrosis of the humeral head  Avulsion fx’s due to muscle pull
 Stiff shoulder/Frozen shoulder
TREATMENT
FRACTURES OF THE HUMERAL SHAFT  Cast Immobilization for undisplaced fractures
 Fractures of the humeral shaft account for approximately 3%  ORIF
of all fractures
 the humerus is also a common site for metastases and LATERAL EPICONDYLE / CONDYLE
pathologic fractures MECHANISM OF INJURY
DIAGNOSIS: Imaging Studies  Avulsion due to pull of wrist extensors
 AP & lateral x-ray views of the arm  Falling on outstretched hand
 CT & MRI are rarely indicated TREATMENT
MECHANISM OF INJURY  Cast Immobilization for undisplaced or minimally displaced
 Bending force produces transverse fx of the shaft; fractures
 Torsion force will result in a spiral fracture;  ORIF
 Combination of bending and torsion produce oblique fx w/ or
w/o a butterfly fragment INTERCONDYLAR FRACTURES
 Compression forces will fracture either proximal or distal  Fractures involving both condyles & epicondyles
ends of humerus MECHANISM OF INJURY
SIGNS & SYMPTOMS  High energy vehicular accidents
 Arm pain, tenderness, swelling  Fall from significant height
 Deformity, shortening of arm  Gunshot
 Motion and crepitus present on manipulation

ORTHO FRACTURES OF THE UE 4 of 5

TREATMENT
 ORIF using combination of implants
 Objectives: restoration of the structural integrity of the distal
humerus (including articular surface), & achieving rigid
stabilization of the fracture
COMPLICATIONS
 Elbow stiffness
 Posttraumatic arthritis of the elbow
 Tardy ulnar nerve palsy
 Cubito valgus/varus deformity of the elbow

DISLOCATIONSOF THE ELBOW JOINT

 Elbow dislocation is the second most common major joint
dislocation
 The elbow is more stable than the shoulder, requiring a
considerable force to dislocate.
 30% of elbow dislocations are associated with fractures of
bony components of the elbow
 Dislocations occur more commonly in adults, since the same
force in children more often results in a supracondylar
fracture

TYPES OF DISLOCATION
1. ANTERIOR
 Due to a strong blow to the posterior aspect of a flexed
elbow
 Drives the olecranon forward in relation to the humerus
 Less common
2. POSTERIOR
 Due to a fall on an extended abducted arm
 Drives the olecranon backward in relation to the
humerus
 Much more common
SIGNS & SYMPTOMS
 Pain
 Ecchymosis
 Swelling around elbow joint; effusion
 Extremely limited range of motion
 Joint deformity

DIAGNOSIS: Imaging Studies

 AP & Lateral views of the elbow are usually sufficient to
diagnose a dislocation
CLOSED TREATMENT OF ELBOW DISLOCATIONS
 Closed reduction of dislocation, with subsequent
immobilization
OPEN TREATMENT OF ELBOW DISLOCATIONS
SURGICAL MANAGEMENT IS REQUIRED IF…
 There is malalignment of the fragments.
 There is joint incongruity.
 The elbow is unstable after reduction
 Associated fractures requiring surgery

COMPLICATIONS
 Brachial artery injury
 Medial nerve injury
 Ulnar nerve injury
 Concomitant fractures
 Avulsion of the triceps mechanism insertion (anterior
dislocation only)
 Entrapment of bone fragments within the joint space
 Joint stiffness with decreased range of motion (particularly in
extension)
 Myositis ossificans

REFERENCES
1. Previous batch trans

ORTHO FRACTURES OF THE UE 5 of 5