UPPER LIMB

FRACTURE
Clavicle Fracture
• Mechanism = Fall on the shoulder / Fall on outstretched hand
• Most common at the junction of outer and middle third
• Thinnest part of bone
• Not protected by muscle / ligamentous attachments
• Proximal fragment pulled superiorly and posteriorly by SCM
• Distal fragment pulled medially and inferiorly by weight of arm
& pectoralis muscle
• Treatment
• Arm sling
• ORIF
• Complication
• Pneumothorax
• Neurovascular injury: Subclavian vessels & Brachial
plexus
• Non-union / Malunion
• Shoulder stiffness
 Proximal Humerus Fracture
• Elderly Female with Osteoporosis
• Children, maybe a pathological fracture due to bone
cyst / tumour
• Mechanism = Fall on outstretched arm
• Neer’s classification
• Treatment:
• Collar & Cuff
• ORIF
• Complication:
• Neurovascular injury
(Brachial plexus / Axillary Nerve)
• Humerus head avascular necrosis
• Malunion / Non-union
• Shoulder dislocation
• Joint stiffness
Midshaft Humerus Fracture
• Mechanism = Fall on hand with humerus twisted
= Fall on elbow with arm abducted
= Direct blow
• Treatment:
• Hanging cast / U-slab
• ORIF
• Complication:
• Neurovascular injury (Brachial artery, Radial Nerve)
• Holstein-Lewis fracture
• Delayed / Non-union
• Joint stiffness
Distal Humerus Fracture
• AO-ASIF classification
• Treatment:
• Undisplaced: Backslab at 90’
• Displaced: ORIF
• Complication
- Neurovascular (Ulnar nerve)
- Stiffness
- Heterotropic ossification
- Nonunion / Malunion
Olecranon Fracture
• Comminuted fracture: due to direct blow / fall on elbow
• Transverse break: due to traction when fall onto hand and triceps muscle
contracted
• Xray (Lateral Elbow) = look for radial head dislocation
• Treatment: Cast / Tension-band wiring
• Complication
• Stiffness
• Non-union
• Ulnar nerve symptoms
• Post-traumatic OA
Head of Radius Fracture
• Mechanism = Fall on outstretched hand with elbow extended & forearm
pronated (Impact radial head against capitulum)
• Symptoms = Tender over radial head
Pain on pronation & supination
• Mason classification I-IV
• Treatment:
• Collar and cuff / Splint at 90’
• ORIF
• Complication
• Posterior interroseous nerve (Finger drop)
• Joint stiffness
• Myositis ossificans
• Recurrent instability
Monteggia Fracture
• Ulnar fracture + Proximal radio-ulnar joint dislocation
• Mechanism = Fall on hand, arm in hyperextension, causing ulnar fracture bow
forward and radial head dislocate forward
• Treatment
- ORIF: Radial head reduce once ulnar has been fixed
• Complication:
• Nerve injury (Interosseus palsy, fail to supinate / pronate)
• Malunion / Non-union
Galeazzi Fracture
• Radius distal third fracture and distal radio-ulnar joint dislocation
• Symptoms = Prominence / tender over distal end Ulnar
= Distal RUJ instability, balloting “Piano-key sign”
• Treatment
• CMR for children
• Adult: ORIF (compression plating)
• Complication: Nerve injury (Ulnar nerve)
TFCC tear (Radio-ulnar instability)
Colles’ Fracture
• Extra-articular, osteoporotic fracture, in elderly female
• Distal fragment dorsally displaced “Dinner fork deformity”
• Mechanism: Fall on outstretched hand, dorsiflexed hand
• Treatment:
• CMR + Dorsal slab
• Percutaneous K-wire
• Volar locking plate
• Complication:
• Median nerve entrapment in carpal tunnel
• Reflex sympathetic dystrophy / Sudeck’s atrophy
• TFCC injury
• Malunion / Delayed union
• Stiffness
• Tendon rupture (EPL)
Smith Fracture
• Reversed Colles’
• Distal fragment replaced volarly
• “Garden spade” deformity
• Treatment = Reduced by traction, supination, extension
= Cast 6w
Barton Fracture
• Volar fracture of distal radius + Volar subluxation of the
carpus
• Intra-articular, unstable
• Treatment: Internal fixation (Anterior buttress plate)

• Dorsal Barton’s fracture

Treated by CMR + Cast for 6w
• Complication:
• Chronic carpal instability
• Secondary OA
Scaphoid Fracture
• Mechanism: Fall on dorsiflexed hand
• Symptoms : Fullness & tender over anatomical snuffbox
DISI deformity / Hump-backed deformity
• Treatment:
• Glass holding cast
• ORIF = Compression screw
• Complication:
• AVN of the proximal fragment
• Non-union
• Secondary OA
• SNAC
Scaphoid non-union advanced collapse
Fracture of Thumb Metacarpal
• Boxer’s fracture:
• Impacted fracture of the base of thumb metacarpal (extra-articular)
• Treatment: Thumb spica cast
• Bennett’s fracture
• Fracture extend into CMC joint (intra-articular)
• Thumb subluxated proximally, pulled by APL
• Treatment: K-wire / Lag screw
• Rolando
• Intra-articular comminuted fracture
• Treatment: Closed reduction + K-wire
ORIF
Thank You