Common upper limb fractures
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COMMON UPPER LIMB FRACTURES
Dr Tarif Alakhras Orthopedic surgeon
KFMC
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Clavicle Fracture
Clavicle injuries affect 1 in 1000 people per year.The most common of all pediatric fractures. 10-16% of all fractures in this age group.
can present even in the newborn period, especially following a difficult delivery .
A large peak incidence occurs in males younger than 30 years due to sports injuries.
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Clavicle Fracture
• Etiology
It may be caused by direct or indirect trauma. Or from fall onto an outstretched hand.
• Clinically
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Clavicle Fracture
The most common injury is a type 1 fracture , which affects the middle third of the clavicle.
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Clavicle Fracture :Management
• typically included the use of either a shoulder sling or a figure-of-eight brace.
Surgical indications• Severe displacement causing tenting
of the skin with the risk of puncture• Fractures with 2 cm of shortening• Comminuted fractures with a
displaced (or Z-shaped) fragment• Neurovascular compromise or
mediastinal structures at risk[5]
• Open fractures• (floating shoulder)
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Fracture Humerus
Humerus can be divided into
• Proximal end• Mid shaft• Distal end
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the proximal end fracture
The upper end:• The head• Surgical neck• Greater tuberosity• Lesser tuberosity
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The axillary nerve can be damaged in this type of fractures.
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Mid shaft fracture
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Management
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FRACTURE DISTAL HUMERUS
• Elbow fractures are the most common fractures in children. An understanding of the basic anatomy and x-ray landmarks of the elbow is essential in choosing appropriate treatment to avoid complications.
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Four important questions
• Is there a sign of Joint effusion?
• Is there a Normal alignment between the bone ?
• Are the Ossification centers normal?
• Is there a Subtle fracture?
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There are 6 ossification centres around the elbow joint.
• 1. Capitellum 2. Radial Head 3. Internal epicondyle 4. Trochlea 5. Olecranon 6. Lateral Epicondyle
• 1-3-5-7-9-11 years C-R-I-T-O- L
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An elevated anterior lucency or a visible posterior lucency on a true lateral radiograph of an elbow flexed at 90° is described as a positive fat pad sign
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• Radiocapitellar line • Anterior humeral line.
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• Supracondylar fracture• Lateral condyle fracture• Fracture radial head• Position of the medial epicondyle.
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Supracondylar fracture
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Supracondylar fracture• consists of more than half of all pediatric elbow
fractures• extension type most common (95-98%)• Physical exam– nerve exam
• Anterior Interosseus N neurapraxia – unable to make “OK sign”
• Radial nerve neurapraxia– inability to extend wrist or digits
– vascular status• vascular insufficiency at presentation is present in 5 -17%• defined as cold, pale, and pulseless hand
– a warm, pink, pulseless hand does not qualify as vascular insufficiency
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S/C frx: Management • Nonoperative
– posterior molded splint then long arm casting at at 90° or less• indications
– Type I (non-displaced) fractures– Type II fractures that meet the following criteria
» anterior humeral line intersects capitellum» minimal swelling present» no medial comminution
• Operative– closed reduction and percutanous pinning
• indications - in most supracondylar fractures
-- open reduction with percutaneous pinning (If close reducion failed)
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S/C complications
• Cubitus valgus– can lead to tardy ulnar nerve palsy
• Cubitus varus (gunstock deformity) – usually a cosmetic issue with little functional limitations
• Recurvatum– common with non-operative treatement of Type II and Type III
fractures• Nerve palsy
– usually resolve• Vascular Injury and Volkmann ischemic contracture• Postoperative Stiffness
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Lateral Condyle Fracture - Pediatric
17% of all distal humerus fractures in the pediatric population
typically occurs in patients aged 5-10 years o
mechanism of injury pull-off theory
avulsion fracture that results from the pull of the common extensor
push-off theory impaction of the radial head into the
lateral condyle
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Lateral Condyle Fracture: treatment
• Nonoperative– long arm casting
• indications– only indicated if < 2 mm of displacement, which indicates the cartilaginous hinge is most
likely intact– sub-acute presentation (>4 weeks)
• Operative– Close reduction & Percut fixation
• indications– some authors suggest CRPP for all lateral condylar fractures with < 2 mm of
displacement
– open reduction and fixation• indications
– if > 2mm of displacement– any joint incongruity – fracture non-union
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Complications: of delayed or inadequate reduction
non union: AVN of capitellum
cubitus varus: a more common complication than
cubitus valgus; may be due to over-stimulation of the lateral condylar physis.
cubitus valgus: premature growth arrest of lateral
condyle.ulnar nerve palsy may appear as a late
complication.
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Fracture head and neck of radius • frx of the radial head
occurs primarily in adults, whereas fractures of the radial neck are more common in children.
• frx of the radial head and neck of the radius generally results from a hard fall on an outstretched hand.
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Fracture head of radius
pain, effusion in the elbow, & tenderness on palpation directly over radial head are typical manifestations
associated injuries: • distal radius fracture • dislocation of the distal RU joint (Essex Lopresti Fracture) • valgus instability (MCL rupture) • rupture of the triceps tendon• Elbow dislocation: terrible triad: RHF + MCL + coronoid process frcture
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Fracture head and neck of radius
• An x-ray of the elbow will confirm the diagnosis and help determine the severity of the fracture .
• CT scan may also be indicated in order to choose the best treatment option.
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Fracture head and neck of radius • Nonsurgical treatment of radial head fractures is
indicated if minimal displacement, minimal angulation, and minimal head involvement.
Early motion with a functional brace is encouraged to minimize elbow stiffness.
• Surgery is required if the fracture involves more than 33% of the articular surface, is angulated more than 30°, or is displaced more than 3 mm.
• excision of radial head & radial head implants: For
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Four Pearls for frx Head of Radius
• A visible posterior fat pad on the lateral view of the elbow is a sign of occult intraarticular pathology.
• Early elbow ROM is needed to prevent stiffness. • Examine the wrist when examining all elbow injuries; a
radial head fracture may be accompanied by a tear of the interosseous membrane and disruption of the distal radioulnar joint.
• The posterior interosseous nerve can be damaged by a radial head injury or by the surgery performed to treat the fracture. Therefore, document functional status preoperatively.
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Galeazzi fracture• is a fracture of the radius
with dislocation of the distal radioulnar joint.
• Ricardo Galeazzi (1866–1952), an Italian surgeon
• It was first described in 1842, by Cooper, 92 years before Galeazzi reported his results.
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Galeazzi fracture :Treatment
It has been called the “fracture of necessity“because it necessitates
open surgical treatment in the adult.
in skeletally immature patients the fracture is typically treated with closed reduction.
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Monteggia fracture : Giovanni Battista Monteggia
• is a fracture of the proximal third of the ulna with dislocation of the head of the radius.
• (hyper-pronation injury)• isolated ulnar shaft fractures
(most commonly seen in defense against blunt trauma) is not a Monteggia fracture. It is called a 'nightstick fracture'.
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Management• open reduction and internal fixation of the
ulnar shaft is considered the standard treatment in adults.
• Monteggia fractures may be managed conservatively in children with closed reduction but due to high risk of displacement causing malunion, open reduction internal fixation is typically performed.
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Distal radius fracture
• Colles' fracture• Smith's fracture • Barton's fracture• Chauffeur's fracture
The Universal classification • Type I: extra articular,
undisplaced• Type II: extra articular,
displaced• Type III intra articular,
undisplaced• Type IV: intra articular,
displaced
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Colles’fracture
• Is an extra-articular fracture of the distal radius with dorsal and radial displacement of the wrist and hand. The fracture is sometimes referred to as a "dinner fork" or "bayonet" deformity.
• often seen in elderly people with osteoporosis.
• most commonly caused by people falling onto a hard surface with outstretched arms
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Smith's fracture reverse Colles' fracture
Robert William Smith (1807–1873)
• is an extra-articular fracture of the distal radius. It is caused by falling onto flexed wrists, as opposed to a Colles' fracture.
• The distal fracture fragment is displaced volarly . There may be one or many fragments and it may or may not involve the articular surface of the wrist joint.
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TreatmentColles’ & Smith
• Treatment depends on severity:– Undisplaced fracture may be treated with a cast
alone– Fractures with angulation and displacement
require closed reduction and above elbow casting• Position in cast:– In colles’ frx the wrist immobilized in flexion– In smith frx the immobilization should be in
extension
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Barton's fracture
• Is an intra articular fracture of the distal radius with dislocation of the radiocarpal joint.
• Intra-articular component distinguishes this fracture from a Smith's or a Colles' fracture.
• caused by a fall on an extended and pronated wrist
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Barton's fracture :treatment
• is best treated by closed reduction, application of external fixation, followed by percutaneous pin insertion.
• tendency to redisplace may require ORIF by buttres plate
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Chauffeur's fracture
•An isolated fracture of the radial styloid process. Displacement of the fragment is uncommon.
•There can be associated injury to the scapholunate ligament.
•In most cases a fracture of the radial styloid process is part of a comminuted intraarticular fracture
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Scaphoid fracture
• Scaphoid is the most frequently fractured
carpal bone.• It usually cause pain
and tenderness in the snuffbox area at the
base of the thumb
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Scaphoid fracture
• Fractures of scaphoid can occur from fall on the palm on an outstretched hand.
• Often diagnosed by X-rays However not all fractures are apparent initially .repeat x ray
Complications• Avascular necrosis (AVN): mainly proximal 1/3• Non union: occur from undiagnosed or undertreated
scaphoid• wrist osteoarthritis.
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Scaphoid fracture
Complications• Avascular necrosis (AVN):
mainly proximal 1/3• Non union: occur from
undiagnosed or undertreated scaphoid fracture
• wrist osteoarthritis.
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Scaphoid fracture
TreatmentNon displaced or minimally displaced waist and distal fractures have a high rate of union with closed cast management.
it is generally accepted to use a short arm thumb spica for non displaced fractures