Fractures of

upper extremity
Fracture of the clavicle
 The clavicle
serves as protector of
brachial plexus
acts as a strut which
provides the only bony
connection between upper
limb and the thorax.
mechanism of injury
indirect injury: a fall on
the outstretched hand,
the most common cause
a direct blow
 diagnosis
history of injury
clinical features
symptoms:pain with the motion of sho
ulder joint , swelling, ecchymosis,
sign: deformity,tenderness,bony crepit
us
x-ray
Treatment
 Non Operative Treatment
figure-of-eight bandage fixation
it is difficult to reduce and maintain the
reduction of clavicle fractures
despite deformity, healing usually proce
eds rapidly;
Even when heal in overlapped or bayon
et position with a substantial bony promi
nence, this will largely be resorbed with
time and the mass will decrease in size.
 Indications of open
reduction and internal
fixation
Nonunion: the most frequent
indication
Neurovascular involvement
A persistent wide separation of
the fragments with interposition
of soft tissue
Fracture of the distal end with torn o
f coracoclavicular ligaments in an ad
ult
Floating shoulder: Fractures of both
the clavicle and the surgical neck of t
he scapula
A patient that cannot endure the suff
er of figure-of-eight bandage fixation
Redisplacement after reduction that
cannot be accepted by the patient
FRACTURE OF
THE HUMERAL
SHAFT
 Anatomy
The radial nerve is the nerve most freq
uently injured with fractures of the hu
merus
spiral course across the back of the mi
dshaft (spiral groove) of the bone
It is relatively fixed in the distal arm as
it penetrates the lateral intermuscular
septum anteriorly to enter the forearm
.
 mechanism
bending force produces transverse fract
ure
torsion force will result in a spiral fractu
re
combination of bending and torsion prod
uce oblique fracture or a butterfly fragm
ent
compression forces will lead to either pr
oximal or distal ends of humerus fractur
e
 diagnosis
history of injury
clinical features: swelling, subcutaneous ecchymo
sis, pain , limitation of upper extremity motion,de
formity,tenderness,
bony crepitus, abnormal motion
x-ray
rule out radial nerve palsy
 Treatment
Most humeral shaft fractur
es can be treated nonoperati
vely
Method: the hanging arm c
ast method or coaptation spl
int
 Notes
these injuries are often very
painful and that good initial
immobilization is required
long arm splint needs to be
applied from shoulder to wrist
to fully immobilize the extremity
Indications for Operative
Treatment
satisfactory position and
alignment cannot be achieved
by conservative measures
associated injuries in the
extremity require early
mobilization
 open humeral fractures withi
n 8-12 hours after injury
pathological fracture
fractures that associated wit
h major vascular injuries
a fracture is segmental
Malunion that influence the f
unction
Nounion of a delayed fracture
 a spiral fracture of the distal
humerus, radial nerve palsy d
evelops after manipulation or
application of a cast or splint
when treatment of associated
injuries makes bed rest necess
ary
fractures associated with vascular injuries
a spiral fracture with radial nerve injury
exploration of the nerve
function has not returned in 3to 4 months
and the fracture has healed.
radial nerve palsy occurs with open
fractures of the humeral shaft
Early exploration when evidence suggests
that the radial nerve is impaled on a bone
fragment or is caught between the fragments
Early exploration if the humeral fracture is
to be repaired early by open reduction and
internal fixation
 Operative method
Fractures of the humeral shaft
can be fixed internally by plat
es and screws, intramedullary
nails, or external fixation devi
ces.
Humeral shaft fracture treated by closed in
tramedullary nailing
Humeral shaft fracture fixed with
compression plate
SUPRACONDYLAR
FRACTURES
 classification
extension type
2 types: (95%)
flexion type
 diagnosis
history of injury
clinical features: swelling, subcutan
eous ecchymosis,pain , deformity,te
nderness,bony crepitus, limitation
of upper extremity motion
x-ray
rule out nerve and vascular injury
Careful neurovascular examination of the
arm is essential, especially in extension-ty
pe supracondylar fractures .
The brachial artery may be lacerated by t
he proximal fracture fragment and a com
partment syndrome may develop.
All three major nerves that cross the elbo
w can be injured, but the radial and medi
an nerves are those most commonly affect
ed.
 treatment
similarly to humeral shaft fractures
with a hanging arm cast or coaptatio
n splint
Open reduction and internal fixation
are used only in the presence of neuro
vascular damage or when a satisfacto
ry position of the fracture is not obtai
ned by closed methods
 FRACTURES OF
SHAFT OF RADIUS
AND ULNA
 Anatomy
radius & ulna lie parallel to eac
h other when forearm is supinat
ed
interosseous membrane: join ra
dius and ulna, which is directed
obliquely downward from radiu
s to ulna and is relaxant at the n
eutral position of forearm
 special type
Monteggia fracture-dislocation
fractures of proximal third of ulna w
ith dislocation of radial head
Galeazzi fracture-dislocation
fracture of distal third of radius with
dislocation of distal radioulnar joint
Monteggia fracture-dislocation
Galeazzi fracture-dislocation
 diagnosis
history of injury
clinical features: swelling, pain , sub
cutaneous ecchymosis, limitation of
upper extremity motion, deformity,
tenderness, bony crepitus ,
normal postelbow triangle
x-ray
 Treatment
Fractures of the forearm bones ma
y result in severe loss of function u
nless adequately treated
Open reduction and internal fixati
on for displaced diaphyseal fractur
es in the adult are generally accepte
d as the best method of treatment.
 Internal fixation
A satisfactory device for internal
fixation must hold the fracture ri
gidly, eliminating as completely a
s possible angular as well as rotar
y motions
method: intramedullary nail or
the AO compression plate
FRACTURES
OF DISTAL
RADIUS
 Classification
extension type
Colles fracture
flexion type
Smith fracture
Colles fracture
Smith fracture
Mechanism of Colles fr
acture
fractureis caused by a forced
dorsiextention of the wrist
occurs in > 50 years of age w
ho fall on out stretched hand
Diagnosis of Colles fra
cture
history of injury:fall on out stret
ched hand
clinical features: swelling, subcut
aneous ecchymosis,pain , limitati
on of wrist joint, tenderness, for
k deformity
x-ray
 Treatment
Most distal radial fractures ca
n be successfully treated nono
peratively （ Manual reductio
n）
 Barton fracture
A special type of fractures of dis
tal radius which is intraarticula
r and is produced by shearing.  
 HAND INJURY
Y
The posture of the
hand
rest posture
function posture
 skin activility
color and temperature of skin   
 capillary reflux test
 shape and size of flap
ratio between length and width of
flap
direction of flap
bleeding state of skin edge
 Tendons injury
the posture of the hand often provides
clues as to which flexor tendons are
severed
When both flexor tendons of a finger are
severed, the finger lies in an unnatural
position of hyperextension, especially
when compared with uninjured fingers.
If middle finger remains extended when hand is at
rest, its flexor tendons have been severed
This finger becomes normally flexed after its profu
ndus tendon or both this tendon and sublimis have
been repaired
 Distribution of major nerves
innervating hand for sensory function.