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Fifth stage
Surgery-Ortho
Lec-4
هشام القطان
18/10/2015
Upper Limb Fracture
Fracture clavicle
Mechanism of injury
A fall on the shoulder or outstretched hand may break the clavicle in common mid shaft,
fracture outer end.
Clinical features
The arm is clasped to the chest to prevent movement.
Subcutaneous lump obvious.
Occasionally sharp fragment threatens the skin.
Vascular complication rare.
X-ray
We can see the site of the fractures.
Middle, outer third
Treatment
Accurate reduction is neither possible nor essential.
All that is needed is to support the arm in a sling (2-3 weeks).
Or figure of eight bandage.
Internal fixation rarely done.( in outer third fracture).
Then physiotherapy.
Complications
Early :
Pneumothorax,
damage to subclavian artery,
brachial plexus injures.
Late:
Non union,
Malunion
stiffness of the shoulder
Dislocation of the shoulder
Of the large joints the shoulder is the one that most commonly dislocate it is due to the
following .
Predisposing factors:
1. shallowness of the glenoid.
2. extraordinary range of movement.
3. ligament laxity, or glenoid dysplasia.
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Anterior dislocation
Pathology and mechanism
Caused by a fall on the hand
Humerus is driven forewards,tearing the capsule or avulsing the glenoid labrum.
Occasionally posteriolateral part of the head is crushed.
Clinical features
Pain sever.
Patient support the arm with the opposite hand and prevent any kind of examination.
Flattened lateral outline of shoulder
Bulge below the clavicle.
Examination for axillary nerve and nearby vessel is important
Radiological examination
Ap will show overlapping shadows of the humeral head and glenoid.
Head usually lying below and medial to the glenoid.
Treatment
Stimsons’ technique.
Hippocratic method.
Kochers’ method.
Spaso technique
Stimsons’ technique:
Patient is left prone with the arm hanging over the side of the bed. after 15-20 min the
shoulder may reduce.
Hippocratic method:
Gently increasing traction is applied to the arm with the shoulder is slight abduction
Counter traction either by assistant with towel slung or the foot of the examiner.
Kochers’ method:
Under G/A. with assistant
Elbow is bent 90 degree and held close to the body.
No traction.
The arm slowly rotated 75 degree externally.
The elbow is lifted forwards.
Finally the arm is rotated medially.
The arm rest in sling for 3 weeks
Then movement started with avoidance abduction and lateral rotation.
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Complications
Early:
– Rotator cuff tear.
– Nerve injury.
– Vascular injury.
– Fracture dislocation.
Late:
– Shoulder stiffness.
– Unreduced dislocation.
– Recurrent dislocation
Fractures of the humerus
Fracture proximal humerus.
Fracture shaft of the humerus.
Fractured shaft of humerus
Mechanism of injury:
A fall on the hand may twist the humerus.
A fall on the elbow.
A direct blow to the arm.
In elderly may be metastasis.
Clinical features
The arm is painful.
Bruised and swollen.
It is important to test the radial nerve (before and after treatment).
X - ray
Site of the fracture.
Type of the fracture
Degree of displacement.
Any evidence of pathological fracture.
Treatment
Fracture of the humerus heal readily.
External cast 2-3 weeks.
Replaced with polypropylene brace worn for 6 weeks more.
physiotherapy.
If failed surgery. internal fixation, external.
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Complications
Early :
Vascular injure
(brachial artery).
nerve injure ( radial nerve)
wrist drop.
Late
Delayed union.
joint stiffness.
non union.
fractures around elbow in children
Supracondylar fractures
1.Anterior displacement(Rare)
Mechanism of injury
2. posterior displacement or angulation(95%) of all cases.
Fall on outstretched hand.
Humerus break just above the condyles.
Distal segment pushed backwards and twisted inwards.
Some time injury to brachial artery or median nerve.
Clinical features
History of fall.
Sever pain
Swollen elbow.
( s shape deformity ).
Abnormal bony land mark.
It is important to feel distal pulse and capillary return.
Dorsiflexion wrist should pain free.
Distal nerve should be examined.
Radiological examination
AP AND LATERAL
We can see the degree of displacement.
Treatment
Depend on the degree of displacement.
Undisplaced :
In cast for at least 3 weeks.
Displaced
Under anesthesia.
Traction 2-3 min in the length with the length of the arm.
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Counter traction.
Correction of deformity.
Gradual flexion of the elbow with pronation of the forearm.
Then feel the pulse and capillary return.
If distal circulation suspicious immediate relaxing the elbow till improvement.
Back slab splint.
X-ray to confirm
Sever displaced
Open and internal fixation with k-wire
Complications
Early :
Vascular injury.
Compartment syndrome.
Nerve injury (median nerve, ulnar nerve).
Late:
Malunion is common .(gunstock deformity).
Elbow stiffness and Myositis ossificans
Fractures of the lateral condyle (capitellar)
Mechanism of injury:
Falls on the hand with the elbow extended and forced into Varus
A large fragment which includes the lateral condyle,breaks off and is pulled upon by the
attached wrist extensor.
The fracture line usually runs along the physis and in to the trochlea.
Clinical features
Swollen elbow.
Deformed.
Tenderness over the lateral condyle
Passive flexion of the wrist may be painful.
X -ray
Must include oblique view or the fracture may be missed.
Ap and lateral.
We can see the fracture.
Treatment
If no displacement
Splint applied and exercise after 2 weeks
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Displaced > 2mm
Open and k-wire applied.
With cast immobilization to be removed with the wire after 4 weeks.
Separation of the medial epicondylar apophysis
Mechanism of injury
Fall on the outstretched hand with the wrist and elbow extended.
Avulsion occurred.
Sometimes the apophysis is draged within the joint.
Clinical features
Swelling and bruising on the medial side of the elbow.
If elbow dislocated the deformity is obvious.
Sensation for the ulnar should be checked.
X ray
Ap and lateral to confirm
The epicondyle may sometime appeared within the joint.
Normal limb should be x-rayed for comparison.
Treatment
Minor displaced only slab.
If the epicondyle within the joint surgery advised.
If displaced fracture and the fracture not trapped within the joint. joint manipulation can
improve the position
Fractured neck of the radius
Mechanism of injury:
A fall on outstretched hand forces the elbow into valgus and pushes the radial head
against the capitellum.
Clinical features
Pain in the elbow.
Pain in rotating forearm.
Localized tenderness over the radial head.
X-ray
The fracture line transverse.
Treatment
Up to 30 degree radial head tilt and up to 3 mm displacement are acceptable.
So put arm in collar and cuff and exercise after a week.
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More than 30 reduction by
manipulation \ anesthesia.
If fail open and internal fixation
Then put in pop .for 2 weeks.
Pulled elbow
In young children the elbow may be injured by pulling on the arm. usually with the
forearm pronated.
It is due to slipping of the orbicular ligament over the head to the joint
Clinically
A child age with 2-3 years brought with a painful dangling arm.
History of jerky movement of the arm .
The forearm held with pronation and extension.
No x-ray changes.
Treatment
Dramatic cure obtained by forcefully supinating and then flexing the elbow
Fractures around elbow
in adult
Fractured head of the radius
Mechanism
A fall on outstretched hand with the elbow extended and forearm pronated causes
impaction of the radial head against the capitulum.
Clinical features
This fracture some time missed.
Pain on pronation and supination should suggest the diagnosis.
Tenderness over the head by direct pressure over the head.
X ray
Three types
Type 1 (vertical split)
Type 2 (single fragment laterally displaced).
Type 3 (comminuted head.)
Treatment
Type 1 analgesia with collar and cuff. then exercise.
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Type 2 :segment should reduced and fixed.
Type 3:excision radial head.
Complications
Joint stiffness.
Myositis ossificans.
Recurrent instability.
Fractures of the olecranon
Comminuted due to direct blow.
A clean transverse break (indirect force).
due to traction when the patient falls onto the hand while the triceps is contracted.
Clinical features
Painful swelling around elbow.
Localized tenderness.
Bruise over the elbow.
May be palpable gap and the patient unable to extend the elbow against resistance.
X-ray
Either comminuted or transverse.
The position of the radial head should be checked.
Treatment
Comminuted :
By holding and exercise after clinical improvement.
Undisplaced transverse:
Cast immobilization then exercise.
Displaced:
Operative fixation.
Complications
Stiffness.
Non union
Osteoarthritis.
Dislocation of the elbow
Mechanism of injury
In 90% posterior or posteriolateral .
The cause of posterior dislocation is usually a fall on the outstretched hand with elbow in
extension.
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There might be associated fracture to the near by structure, and near by soft tissue
disruption.
Clinical features:
His or her forearm with the elbow in slight flexion.
Sever swelling
Obvious deformity
The bony landmark around elbow abnormally displaced (olecranon and epicondyle)
x ray:
is essential to confirm dx
to identify any associated fractures.
Treatment
Uncomplicated dislocation.
Under anesthesia, elbow is slightly flexed olecranon process is pushed forward with the
thumb.
Distal neurovascular reexamination should be done.
and x-ray to confirm diagnosis.
Arm hold in a collar with flexed elbow in 90 degree
Then 1 week after start physiotherapy.
Dislocation with associated fractures:
Might need open and correction accordingly.
Complications
Early:
Vascular (brachial artery may be damaged.
Nerve injury median or ulnar
Late
Stiffness
Heterotopic ossification
Unreduced dislocation.
Recurrent dislocation.
Osteoarthritis.
Injuries of the forearm and wrist
Fractures of the radius and ulna:
Mechanism :
Fractures of the shafts of both forearm bones occur quite commonly in road accident.
Twisting force (usually a fall on the hand) produce spiral fractures.
Direct blow produce transverse fracture.
Additional rotation deformity may produced by muscle pull (biceps and supinator )to the
upper third.
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Pronator teres to the middle
Pronator quadratus to the lower third
Bleeding and swelling of the muscle compartment of the forearm may cause circulatory
impairment
Clinical features
Pain
obvious deformity.
Swelling
Distal neural and vascular examination is essential
Repeated examination is necessary to detect an impeding compartment syndrome
x-ray
different type of fracture appeared.
Treatment:
In children
Closed reduction is usually successful because the periostum tends to guide and then
control reduction.
Immobilization with pop cast.(6-8 weeks).
Proximal to Pronator teres limb held in supination
Distal to it in pronation.
If failed surgery done.
Adults:
Unless the fragments are held in close apposition reduction is difficult
and open and internal fixation done.
Complications:
Early .
Nerve injury
Vascular injury
Compartment syndrome
Late:
Delayed union.
non union.
Malunion
Mo
n
teggia fracture – dislocation of the ulna:
Fracture of the ul
n
a upper third associated with dislocation of the proximal radioulnar
joint,radiocapitellar subluxation.
Mechanism of injury:
A fall on the hand with the body twisting.
Clinical features:
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Pain
Obvious deformity
Tenderness on the lateral side of the elbow.
Distal neurovascular examinations should be done.
X ray:
AP and lateral view.
Either there were forward bowing, backward or lateral bowing of the ulna.
Posterior or lateral displacement of the radial head may appear.
Treatment:
The clue to successful treatment is to restore the length of the fractured ulna.
This mean operation.
Complications:
Nerve injury.
Malunion
Non union
G
a
leazzi
fracture – dislocation of the r
a
dius
Mechanism
A fall on the hand with superimposed rotation, the radius fractures in its lower third and
the inferior radioulnar joint subluxates or dislocation.
Clinical features
Much more common than Monteggia.
Prominence or tenderness over the lower end of the ulna is the striking feature.
Balloting the distal end of the ulna (piano – key sign)
Distal ulnar nerve examination is important.
X ray
A transverse or short oblique fracture is seen in the lower third of the radius, with
angulations or overlap.
The inferior radioulnar joint is subluxated or dislocated.
Treatment
In children closed is often successful
In adult open and internal fixation.
Smith's fracture
The distal fragment is displaced anteriorly (reverse colles')
Clinical features
Fall on the back of the hand.
Pain
No dinner fork deformity.
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X ray
Fracture through distal radial metaphysis
The distal fragment is displaced and tilted anteriorly opposite colles'
Treatment
Under anesthesia
Traction
And extension of the wrist
The forearm is immobilized in a cast for 6 weeks.
Colles' fracture
Is a transverse fracture of the radius just above the wrist ,with dorsal displacement of
the distal fragment.
Mechanism
Force is applied in the length of the forearm with the wrist in extension.
The bone fracture at the corticocancellous junction and the distal fragment collapses into
extension, dorsal displacement, radial tilt and shortening.
Clinical features
History fall on outstretched hand
Pain deformity in form of dinner - fork shape .
Local tenderness.
x-ray
there is transverse fracture, often ulnar styloid process fracture, there might be
impaction of the distal piece ,some time severely comminuted or crushed.
Treatment
Undisplaced fracture.
Dorsal cast applied for 4 weeks then physiotherapy.
Displaced fracture
Must reduced under anesthesia
The hand is grasped and traction is applied in the length of the bone some time with
wrist extension for disimpaction
The distal segment is then pushed into place by pressing on the dorsum while
manipulating the wrist into flexion
Ulnar deviation
And pronation.
Dorsal slab applied from just below the elbow to the metacarpal necks.
Elevation of the arm2-3 days
Shoulder and finger exercise are started as soon as possible.
Check up after 10 days by x ray
If any redisplacement to be corrected.
Treatment completed for about 6 weeks.
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Comminuted fracture:
Plaster in addition with k-wire
Or external fixation with bone graft.
Complications
Early
The circulation of the finger.
Nerve injury median nerve compression is fairly common
Reflex sympathetic dystrophy.
Late
Malunion is common.
Delayed union and non-union are rare
Stiffness of the shoulder, elbow and finger.
Tendon rupture (of extensor pollicis longus). occur after weeks
Fractured scaphoid:
It is account for 75% of all carpal fractures.
Mechanism
Combination of forced carpal movement and compression as a fall on dorsiflexed hand,
exerts severe stress on the bone and is liable to fracture.
The blood supply is diminished proximally and is result into non union or a vascular
necrosis.
Clinical features
History of fallen on the ground.
Pain around wrist
The appearance may be normal.
Tenderness at snuffbox
Some time observer can detect fullness in the anatomical snuffbox
Proximal pressure along the axis of the thumb may be painful.
Ap, lat, oblique, all essential.
A recent fracture show only in oblique view as transverse line (through the waist)
But may be proximally.
or tubercle of the scaphoid.
A few weeks after the injury evidence of non union
or a vascular necrosis appear of the proximal segment.
Treatment
Undisplaced fracture:
Need no reduction
Treated in plaster. the cast is applied from the upper forearm to just short of the mp
joints of the fingers but incorporating the proximal phalanx of the thumb
The wrist hold dorsiflexion and the thumb forward (glass-holding) position.
After 6 weeks the plaster opened
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If no pain and tenderness so finished
If pain and tenderness re applying of the pop for another 6 weeks.
Displaced fracture:
Can be treated by pop
If failed open and fixation with compression screw
Complications:
Avascular necrosis (the proximal segment die).
Non union appeared by 3 months.
Osteoarthritis
Metacarpal fractures
Fracture of the metacarpal shaft:
Direct blow may fracture one or several bones transversely.
Twisting force may cause spiral fracture.
Clinically:
Pain
swelling
some time local hump.
Treatment:
Oblique or transverse fracture with slight displacement only crepe bandage
Transverse
fracture with displacement may need slight manipulation if failed may need k-wire
Spiral
may need k- wire or plate.
Fracture metacarpal neck
A direct blow usually the fifth finger (boxer's fracture )and occasionally one of the others
Clinically
Pain
local swelling,
flattening of the knuckle.
x- ray show an impacted transverse fracture with volar Angulation of the distal fragment.
Treatment
Flexion deformity about 40 deg is accepted, and a good outcome can be accepted
Hand is splinted with gutter splint.
BENNETT'S
Fracture –Dislocation
This fracture occurs at the base of the first metacarpal bone and is commonly due to
punching
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Fracture is oblique and extends into the carpometacarpal joint and is unstable.
The thumb looks short and carpo metacarpal region swollen.
x-rays show the fracture at the base of the metacarpal bone
Treatment
Perfect reduction is essential
by pulling the thumb then abducting and extending it
then reduction held by pop or internal fixation.
MALLET FINGER INJURY
There are three types of mallet finger:
1.A tendinous avulsion
2.A small flake of bone
3.A large dorsal bone fragment.
After as sudden flexion injury the terminal phalanx droops and cannot be straight
Treatment
Immobilizing the terminal joint in slight hyperextension by special mallet splint
Occasionally k-wire used.
Fractures of the phalanges
Direct blow
This will lead to considerable swelling .
Treatment
Undisplaced by functional splint (finger is strapped to its neighbour and movement is
encouraged.
Displaced fracture must reduced and immobilized. with either splint or (k-wire).
Treatment may result to stiff finger which in some time can be worse than no finger.
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