Faculty of Medicine

Naresuan University Hospital

COMMON FRACTURE
OF UPPER EXTERMITY

Kongpob Reosanguanwong, MD
9/6/20
 REFERENCE

9/6/20
 CLAVICLE FRACTURE 1

Incidence: 2.6% of all fracture

Location: Midshaft 80%

Distal shaft 15%
Medial shaft 5%

Mechanism of injury: Direct injury

9/6/20
 PHYSICAL EXAMINATION
Swelling and ecchymosis

Deformity

Skin tenting(impending skin necrosis)

Neurovascular examination

Associated injury
- Floating shoulder
- Chest wall injury
- Brachial plexus injury
- Vascular injury (subclavian a.)
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 RADIOGRAPH
Film clavicle AP view

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 ALLMAN CLASSIFICATION

Base on fracture site

Group I : Middle third

Group II : Lateral third
Group III : Medial third

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 NONOPERATIVE TREATMENT

Indication
- Shortening and displacement ≤ 2 cm
- No neurological deTcit

Arm sling or Tgure of eight

- Immobilization for 2-6 weeks
- Less pain gentle ROM exercise
- Light work with restrict overhead activity 2-4 weeks

9/6/20
 OPERATIVE TREATMENT

Relative indications
- Displacement >2 cm, shortening > 2 cm
- Segmental fractures
- Open fracture
- Impending open fracture with soft tissue
compromise d
- Neurovascular injury requiring repair
- Floating shoulder

9/6/20
 ACROMIOCLAVICULAR JOINT INJURY 2

Mechanism of injury

Direct force to lateral aspect of the shoulder

with arm in adducted position

Falling on outstretched arm with

elbow extension

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 PHYSICAL EXAMINATION

Examine in standing or sitting position

Abnormal contour of the shoulder: Step-off deformity

Tenderness at AC joint

Pain exacerbation with cross-arm adduction

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 RADIOGRAPH

AC joint AP view
- Superimpose with
spine of scapula

Zanca view
- 10o-15o cephalic tilt
- Useful in suspicion in
small fracture of loose body

9/6/20
 RADIOGRAPH

Stress view
- Suspending 10-15 lbs weight on both wrist
- ConTrmation of Rockwood type II injury

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 ROCKWOOD CLASSIFICATION

9/6/20
 TREATMENT

Nonoperative treatment
- Type 1-3
- Pain control, ice, immobilization(arm sling)
- Early shoulder range of motion
- Regain functional motion by 6 weeks
- Return to normal activity at 12 weeks

Operative treatment
- Type 4-6
- Overhead athletes
- Fail conservative treatment
9/6/20
 Friar
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SHOULDER DISLOCATION
-

-
ou
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IN noooo
:

Mechanism of injury
onion
Indirect trauma >> the shoulder in abduction and external rotation is the most
common mechanism >> anterior dislocation

nwmw.mn/ilYoi YuEnli9ameht enaonVn-

Direct blow >> posterior or anterior dislocation

Convulsion & electrical shock >> posterior shoulder dislocations

www.aiwnoex.thlersdqnlos#g--H9xity
tendonitis
Congenital or acquired laxity >> recurrent instability

9/6/20
 SHOULDER STABILITY

Static stabilizers Dynamic stabilizers

ooh
- Glenoid/humeral head geometric relationship - Rotator cuff

t
naw I
- Glenoid labrum - Deltoid
- Negative intraarticular pressure a. arise - Periscapular muscle
- Adhesion-cohesion - Long head of bicep
- Capsule & ligament
UP Noir
,
Bone Muscle
Mio injury oooo No URN

Ligament Stability
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 CLASSIFICATION
ioinaviniuanrirbuua.sn Man
Severity: Subluxation vs dislocation

Duration: Acute (24-36 hr) vs chronic

-

22 note
Occurrence: First time vs recurrent

Mechanism: Traumatic vs non-traumatic

Direction: Anterior(90%), posterior or multidirectional

9/6/20
 PHYSICAL EXAMINATION
Slightly abduction & external rotation position Wherefrom VOÑO V01 Aaron

Acromion head prominent

Flat deltoid

Humeral head prominent

Limit range of motion

KEY abroad Now Nail reduction
*
-

Neurological exam >> Axillary nerve, BPI

motor -

deltoid contraction
Misato nai tone
Radial Ulnar artery sensory deltoid
Vascular exam
,
area
-

9/6/20
 SPECIAL TEST

Ruler test ④ = acromion -

lateral epicondyle Duga's test normal :ÑWññouñué

'
dislocate :ÑWÑñouñua maybe no .HU,
VnÑñÑ deltoid Wis nnuqcromianswjop

9/6/20
 BEIGHTON SCORE Nokrinthhyperlaxity

dorsi flexion Niwmlpioint > 900=1 pt .

otutorearm
IN :
Ipt .

Wivelbow > 70° Winther > 100

window "wis
7,419 __
hyperlaxity
Ño£qwon Ehler danlos
syndrome

9/6/20
 RADIOGRAPH
but www.vglenoid Scapular yview
ÑMÑÑÑb
v3 view Ant dislocate
.

Trauma series IN 'ypn Hannahs coracoid

- True AP view(Grashey view)

- Scapula Y view
- Axillary view(Velpeau view)
loihrrfaiia.io post dislocation
.

v2 -3Wh oiinoioiwiaiv
Special view h9UÑKdyctionwwwÑi
www.go.ie?nnohvelpeayview
- -

- West point view: Bony Bankart lesion

- Stryker notch view: Hill-sachs lesion
- -
Z

dislocation:
hobbits

CT scan: assess of bony defect axillary view

win -

9/6/20 mi
MRI: assess soft tissue and ligament
UP,nNñmuño
 RADIOGRAPH
Hill-Sachs lesion Bony Bankart lesion
- Cortical depression in - Fracture of anteroinferior
posterolateral humeral head glenoid rim
n' iraivww Abominate

>

9/6/20
 CLOSE REDUCTION TECHNIQUE
Nowlin'awV Traction
counter
of invasive
traction
Hippocratic
iniiaironwi
Traction-counter traction
Hippocratic longitudinal
traction

Stimson *
Slow and steady

Milch(Zero position) 96944-450

forward flex 120-1600

Stimson
Mitch

9/6/20
 TREATMENT
conscious sedation

Anesthesia: IV sedation morphine 2-3 MY IV

* monitor
visualisation
Valium 5- long IV

Closed reduction

Immobilization: Interlocking armsling

- Duration: no effect to stability (>1 wk no beneWt)
Now 6014 N' nine 1Wh

Restriction ✗Yung external rotation abduction ex N' need WW

,
.

- Anterior dislocation ER<30, abduct<60

- Posterior dislocation Flex<60, IR<30, avoid crossbody
of NVVV
- Decrease gradually in -
2 month, full ROM at 3 month
un m

- Avoid high-impact sport for 6 month

rm -

contraction deltoid , bicep

Strengthening exercise WH ñnn Iai
, -

9/6/20 .
arm sling prevent muscle atrophy
 PROGNOSIS

Rate of recurrent for 1st time dislocation = 26-48%

Factors:
Hill
- Age - SigniTcant bone defect T bankSachs
-

art

- Level of activity - Hyperlaxity Beighton score

-

- Male

Age < 20 incidence = 55-95%

9/6/20
 INDICATION FOR SURGERY

Failed appropriate nonoperative therapy

Recurrent dislocation at a young

Irreducible >> soft tissue interposition ex .

long head bicep now

Open dislocation

Unstable reduction

9/6/20
 PROXIMAL HUMERUS FRACTURE servo
=
-

aiming aqn
4

7% of all fractures ②

80% of all humeral fractures

Mechanism of injury
- Older: Fall from standing height >90%
- Younger: High-energy trauma

9/6/20
 RADIOGRAPH

9/6/20
 PARTS OF PROXIMAL HUMERUS

4 parts
1. Humeral head
2. Lesser tuberosity
3. Greater tuberosity
4. Humeral shaft

9/6/20
 NEER'S CLASSIFICATION

Criteria of displacement
- Displacement > 10mm brink 182
or
- Angulation > 45o ypdrt.ws
No }Ñw
'

:D rotgtorcyffoqu, ohuhiibeservettrotgturcyff '

z

Greater tuberosity accept small displaced

Z
"

z
, z

- Displacement > 5mm 3

- Angulation >20o

9/6/20
 CONSERVATIVE TREATMENT

Indication
- Stable nondisplace or minimally displaced fracture
- Elderly patients with low functional demand

Immobilization www.wuwn synchronize

astronaut crepitations
- Duration: Single unit 1 wk / not single unit 2-4 wks
- Options: Arm sling, shoulder abduction cushion

!
nanny → aioiivriroivniiñraw
2h't -

- Pendulum I exercise
- Passive ROM

¥
himemsnhenii

9/6/20 [ forearm mask

exercise prevent nude
atrophy
 OPERATIVE TREATMENT
4- part

Indication
- Displaced two-part surgical neck fracture
- Displaced three-part fracture in young patient

=
- Displaced four-part fracture in young patient
- Displaced greater tuberosity fracture (>5mm)
- Humeral head splitting fracture in young patient
Waurn
:ÑwrÑn
-

now greater tuberosity E- wire

Options: Suture Txation, pinning, intramedullary nail
-
plate Jfsoew

nhiavainwuairn.vn
plate & screws Txation and arthroplasty
Quits www.rbhfixqtionnbw
9/6/20
 HUMERAL SHAFT FRACTURE 5

1-2% of all fractures

doom proximal humerus fx
14% of all humeral fractures

Mechanism of injury
- Older: low-energy trauma
- Younger: high-energy trauma

Associated injury
*
- Radial nerve injury
by Spiral 1 long oblique
auto nerve
9/6/20
 ASSOCIATED INJURY
qntstdorsalwebspqceseqsi
mints
hveainn.nwmwwovan.vn
www.wrwwvisheyrapraxia
oieiairnrr
.

Most common nerve injury = radial nerve

Most common in displaced spiral fracture

at mid or mid-distal shaft
Mild tormainrwnerveinjum
Neurapraxia >> good prognosis to recovery
a✗OhVoÑovj Lose } months
myelin sheath bÑWÑh recovery ravin]
Recommend to investigate after 3-4mo if non-recovery
EMG NCV

9/6/20
 NONOPERATIVE TREATMENT
velpeau
0-5190
Bandage
Most humeral shaft fractures (>90%) conservative
wind
Acceptable alignment axilla

- 20 degrees of sagittal angulation

- 30 degrees of coronal angulation(varus/valgus)
30mm
- 3 cm of shortening Hctngig functional
cast brace

Options: Velpeau bandage, u-slab Marino

.IN/illa80ldA9hd9rd
hanging cast, functional brace
don't
vivid

9/6/20 MWNVWVUMWirvwcompusswvelbomwnststiffness
jahtin.hn
 OPERATIVE TREATMENT

Indication
- Unacceptable alignment (angulation >20o, rotation >30o, shortening >3 cm)
- Segmental fracture
- Pathologic fracture
- Open fracture
- Vascular injury
- Brachial plexus injury

Options: Plating, intramedullary nail, external Txation

'

A owner; plate of screw

9/6/20
 OLECRANON FRACTURE 6

Mechanism of injury
- Direct blow>> comminuted fracture
- Indirect: Fall on partially kexed elbow IN WWW flex elbow
>> transverse or oblique fracture ticep 6Mt Ñd
olecranon

d
avulsion
Tricep inserted at posterior site

Inability to extend elbow indicated

loss of extensor mechanism
trice p

9/6/20
 MAYO CLASSIFICATION

o_O
41 no humeral
joint owjoi

ulno.hu neral joint

displacement
9/6/20
 TREATMENT convert avulsion force → compression force
p

Conservative treatment
- Nondisplaced with intact extensor mechanism
- Long arm slab 1-2 wk

Operative treatment
- Displaced fractureÉaiowiuni
- Transverse/oblique: Tension band wiring
- Comminuted: Plate & screws Txation

comminute →
plate of screw
9/6/20
 SIMPLE ELBOW DISLOCATION 7
É
"
hlténñov
"

complex -

2nd most commonly dislocated joint

The result of sports during football, gymnastics

skating
Three separate articulations
1. Ulnotrochlear (hinge)
proximal
2. Radiocapitellar (rotation)
3. Proximal radioulnar (rotation)
A. distill into Urdu distal
\
9/6/20 proximal post .
dislocation
 EVALUATION
in u wit'd
'

subluxation

Unni vimeo.li suw

Pain, swelling, deformity

Limit ROM

With the elbow kexed to 90 degrees

Medial, lateral epicondyles and olecranon process
should form an isosceles triangle

Radial and ulnar pulses should be compared to the opposite side

9/6/20
 CLASSIFICATION

Based on the direction of dislocation

The majority of dislocations are posterior or posterolateral

hip posterior
-

shoulder -

anterior

9/6/20
 TREATMENT
ooiñirwir
longitudinal traction
Conscious IV sedation with vital sign monitoring
-

Closed reduction

Immobilization elbow stiff in

- Long arm slab for 1-2 wks
nm

- Isometric exercises to promote muscle activation

and improved dynamic stability contract forearm
bicep
deltoid ÑoÑoñw olecranon

* slow
9/6/20 of steady
 Thank you
For
Your attention