Upper limb fractures

Dr.Abdirahman Adan
Intrduction
Fractures of the upper limb are very common injuries
in all age groups.
In adults, between the ages of 15—49, these injuries
are more common in males and are usually due to
high-energy mechanisms such as road traffic
accidents.
Between the ages of 65and 89 there is a considerable
increase in the incidence of fractures, particularly in
females.
These are associated with osteoporosis and may follow
minor trauma such as a fall from a standing height
Clavicle fractures
The clavicle is the first bone to ossify (fifth week of
gestation) and the last ossification center (sternal end)
to fuse, at 22 to 25 years of age.
The clavicle is S-shaped
Function
“strut”, only bony connection to axial skeleton
Mechanism
fall on shoulder (87%), direct trauma to clavicle (7%),
fell on out stretch hand (FOOSH (6%)
Clinical Evaluation
pain and tenting of skin
arm is clasped to chest to splint shoulder and
prevent movement
 Inspect and palpate for deformity/abnormal motion
 Thorough distal neurovascular exam
 Auscultate the chest for the possibility of lung injury
or pneumothorax
 Radiographic Exam
 AP chest radiographs.
 Clavicular 45deg A/P oblique X-rays
 Traction pictures may be used as well
Allman Classification of Clavicle Fractures
Type I: Middle Third (80%)

Type II: Distal Third (15%)

Differentiate whether ligaments
attached to lateral or medial
fragment
I: minimal displacement
II: torn CC ligament, prone to non-union
III: articular surface (may mistake for 1st
AC)

Type III: Medial Third (5%)

Treatment
Evaluate neurovascular status of entire upper limb
Medial and middle third clavicle fractures: figure-
of-eight sling x 1-2 wk
Early ROM and strengthening once pain subsides
If ends overlap >2 cm consider ORIF
Distal third clavicle fractures
Undisplaced (with ligaments intact): sling x 1-2 wk
Displaced (CC ligament injury): ORIF
Sling and
Swathe

Velpeau
 Clavicle Fractures
Associated Injuries
Brachial Plexus Injuries
Contusions most common, penetrating (rare)
Vascular Injury
Rib Fractures
Scapula Fractures
Pneumothorax
Scapula fracture
Rare, high energy
Males ~30 y.o.
Associated with other injuries
(lung, rib, clavicle)
Symptoms:
If awake, arm adducted
Tender, crepitus, hematoma
Scapular fracture Classification
Type I
Type II
Body and spine
Type II
Acromion or coracoid
process
Type III
Type III
Type I
Scapular neck or
glenoid fossa
Management
Conservative
Open Reduction (ORIF)
Displaced acromial or impinging on joint
Associated coracoid or if CC ligament
disrupted
Scapular neck/glenoid fossa
Humerus Fractures
Proximal
Mid shaft
Proximal Humerus Fractures
Epidemiology
Most common fracture of the humerus
Higher incidence in the elderly, thought to be related to
osteoporosis
Females 2:1 greater incidence than males
Mechanism of Injury
Most commonly a fall onto an outstretched arm from
standing height
Younger patient typically present after high energy
trauma such as MVA
Neer Classification
Based on 4 parts of humerus
• Greater Tuberosity
• Lesser Tuberosity
• Humeral Head
• Shaft
Two-part fracture: any of the 4 parts
with 1 displaced
Three-part fracture: displaced fracture
of surgical neck + displaced greater tuberosity or lesser
tuberosity
Four-part fracture: displaced fracture surgical neck + both
tuberosities
PHF
Proximal Humeral Fractures Neer’s Classification
Proximal Humerus Fractures
Treatment
Minimally displaced fractures- Arm Sling
immobilization, early motion
Two-part fractures-
 Anatomic neck fractures likely require ORIF. High incidence of
osteonecrosis
 Surgical neck fractures that are minimally displaced can be
treated conservatively. Displacement usually requires ORIF
Three-part fractures
 Due to disruption of opposing muscle forces, these are unstable
so closed treatment is difficult. Displacement requires ORIF.
Four-part fractures
 In general for displacement or unstable injuries ORIF in the
young and hemiarthroplasty in the elderly and those with severe
comminution. High rate of AVN (13-34%)
Midshaft Humerus Fractures
Mechanism
Direct blow, severe twisting,
FOOSH
Obvious deformity, crepitus
Shortened limb, rotated
Assess radial nerve
Exam shoulder and elbow
Humeral Shaft Fractures
Holstein-Lewis Fractures
Distal 1/3 fractures
May entrap or lacerate radial nerve as the fracture
passes through the intermuscular septum
Midshaft Humerus Fractures
Management
>90% of humeral shaft fractures heal with
nonsurgical management
Cast splint or brace with collar and cuff sling
immobilization until swelling subsides
ORIF
Un acceptable alignment, radial nerve
involvement, segmental #, other upper
extremity injuries, pathological #, limited to
bedrest
Elbow fractures
Supra condylar fracture
Radial head fracture
Olecranon fracture
Supracondylar Fracture
Usually < 8yo
Extension (95%) vs flexion
<4%
symptoms
Mild swelling to gross
deformity
arm held to side, immobile,
extension
S-shaped configuration
Supracondylar Fracture-
Classification

Gartland
I - nondisplaced
II - displaced with intact posterior cortex
III - displaced fracture, no intact cortex
A: postermedial rotation of distal fragment
B: posterolateral rotation
Supracondylar Fracture-
Management
If NV compromise - urgent ortho
consult
if no response in 60 min may attempt 1
reduction
watch brachial artery and median nerve
Gartland I - splint and ortho for 24h
Gartland II - controversy but most get
pinned
Gartland III - closed reduction and pin
Radial head fracture
a common fracture of the upper limb in young adults
Mechanism
• FOOSH with elbow extended and forearm pronated
Clinical Features
marked local tenderness on palpation over radial
head (lateral elbow)
decreased ROM at elbow, mechanical block to
forearm pronation and supination
pain on pronation/supination
x-ray: enlarged anterior fat pad (“sail sign”) or the
presence of a posterior fat pad indicates
occult radial head fractures
Mason classification
Type 1: undisplaced segmental fracture usually normal
ROM
Type 2: displaced segmental fracture ROM
compromised
Type 3: comminuted fracture
Type 4: type3 with posterior dislocation
Treaments
Type1: elbow slap, sling 3 to 5 days early ROM
Type2: ORIF radial head
Type 3/4: excision of radial head +/- prostesis
Olecranon Fracture
Mechanism
direct trauma to posterior aspect of elbow (fall onto the
point of the elbow)
Clinical Features
 ± loss of active extension due to avulsion of triceps tendon
Treatment
undisplaced (<2 mm, stable): cast x 10-14 d (elbow in 90°
flexion) then gentle ROM
 displaced: ORIF (plate and screws or tension band wiring)
and early ROM if stable
Forearm fracture
Radius and Ulna
Fracture
Monteggia Fracture
Galeazzi Fracture
Nightstick Fracture
Radius and Ulna Fracture
Mechanism
commonly a FOOSH or high-energy direct blow
fractures usually accompanied by displacement
due to high force
Investigations
 x-ray (AP, lateral ,oblique) or CT if fracture is
close to joint
Treatment
Cast or splint if no dislocation
 ORIF with plates and screws;
closed reduction with immobilization usually
yields poor results for displaced forearm fractures
(except in children)
Monteggia Fracture
Fracture of ulna with
associated dislocation of radius
head.
Treatment
ORIF- recommended
Open reduction of ulna is
usually followed by indirect
reduction of radius
Galeazzi Fracture
Fracture of distal radius
Dislocation of distal radio
ulnar joint at the wrist
Treatments
Immobilize in supination to
reduce distal radio ulnar
joint ,ORIF
Nightstick Fracture
Definition
isolated fracture of ulna without
dislocation of radial head
Mechanism
direct blow to forearm (e.g. holding arm
up to protect face)
Treatment
non-displaced: below elbow cast (x 10 d)
followed by forearm brace (~8 wk)
displaced: ORIF if >50% shaft
displacement or >10° angulation
Wrist fractures
Colles’ Fracture
Smith’s Fracture
Scaphoid Fracture
Colles’ Fracture
Definition
extra-articular transverse distal radius fracture (about
2 cm proximal to the radiocarpal joint)
with dorsal displacement ± ulnar styloid fracture
More commen >40 yr, especially in women and those
with osteoporotic bone
Mechanism
FOOSH
Clinical Features
“dinner fork” deformity
Swelling, ecchymoses, tenderness
Investigations
x-ray: AP and lateral wrist
Treatments
closed reduction(hematoma block): 1) traction with
extension (exaggerate injury), 2) traction with ulnar
deviation, pronation, flexion (of distal fragment – not
at wrist)
dorsal slab/below elbow cast for 5-6 wk
ORIF if failure of adequate closed reduction
Smith’s Fracture
Definition
volar displacement of the distal radius (i.e. reverse Colles’ fracture)
Mechanism
fall onto the back of the flexed hand
Treatment
usually unstable and needs ORIF
 if patient is poor operative candidate, may attempt non-operative
treatment
closed reduction with hematoma block (reduction opposite of
Colles’)
long-arm cast in supination x 6 wk
Scaphoid Fracture
common in young men and most common carpal bone
injured
may be associated with other carpal or wrist injuries (e.g.
Colle's fracture)
Mechanism: FOOSH:
Clinical Features
pain with wrist movement
tenderness in the anatomical “snuff box”,
 usually undisplaced
fracture may not be radiologically evident up to 2 wk after
acute injury, repeat x-ray
 Treatment
early treatment critical for improving
outcomes
non-displaced (<1 mm
displacement/<15° angulation): long-
arm thumb spica cast x 4 wk then
short arm cast until radiographic
evidence of healing is seen (2-3 mo)
displaced: ORIF with screw or
subcutaneous K-wire
Complication: non union, AVN of the
proximal fragment, delayed union
The end