Management of Fractures - DR Matthew Sherlock

Management of common
upper limb fractures in Adults

and Children
Dr Matthew Sherlock
Shoulder and Elbow
Orthopaedic Surgeon
Outline
Immobilisation
choices
Adults
Clavicle
Fractures
Proximal Humeral Fractures
Wrist Fractures
Children
Elbow
Fractures
Forearm Fractures
Immobilising Upper Limb #s

Immobilisation
choices
Slings
triangular, immobiliser
Collar and cuff
Plaster
Backslab, full cast (short arm, long arm), Uslab, hanging cast
Removable
splints
Braces
Choice is determined by forces displacement

Clavicle/AC
Weight
joint injuries
of arm displacement

Clavicle/AC
Weight
joint injuries
of arm displacement
Support
arm with sling +/waist strap
Proximal humerus
Involving tuberosities
Pull of rotator cuff displacement
Prevent active movement of arm,
Proximal humerus
Involving tuberosities
Pull of rotator cuff displacement
Prevent active movement of arm,
waist strap important.
Immobiliser
sling

Proximal
humerus
Metaphysis
Rotator
cuff balanced
Fracture angulation worsened
Axial load
Shoulder extension

Proximal
humerus
Metaphysis
Rotator
cuff balanced
Fracture angulation worsened
Axial load
Shoulder extension
Collar and
Cuff
Humeral Shaft
Muscle pull displacement
Pectoralis major/ lat dorsi

Deltoid
Humeral Shaft

Deltoid
Gravity
maintains alignment
Arm should hang
Plaster
immobilisation possible
Humeral Shaft

Deltoid
Gravity
Arm should hang
Plaster
U-Slab
plaster
maintains alignment
immobilisation possible
Humeral Shaft
U-Slab
plaster
U-slab
Uncomfortable, heavy
Temporary
Humeral Shaft
Functional
brace
U-slab
Uncomfortable, heavy
Temporary
Change to Sarmiento brace after
1-2 weeks.
Elbow Fractures
Adults
Ideally dont immobilise elbow for
more than 3 weeks!
Commonly surgery is indicated to
enable stable fixation and early
ROM
Elbow Fractures
Children
Supracondylar #
Stable in flexion
Elbow Fractures
Children
Supracondylar #
Stable in flexion
Positioning arm in flexion is more

important than the actual plaster
Elbow Fractures
Children
Supracondylar #
Stable in flexion
Positioning arm in flexion is more

important than the actual plaster
Forearm Fractures
Clavicle fractures
Midshaft
most common
Distal
Medial
- uncommon
Clavicle fractures
Mechanism
of injury
Clavicle fractures
Initial
treatment
Very
painful fracture
Arm immobiliser not
collar and cuff
Figure 8 bandage
Ice
Midshaft Clavicle fractures

All
undisplaced fractures can be

treated conservatively
Immobiliser
sling
Discontinued once pain subsides (3-5
weeks)
Self administered ROM and strengthening

Indications
for surgery
Absolute
Open fracture, skin compromise

Progressive neurological deficit
Relative
Shortening
Displacement/comminution
Non-union

How
much shortening?
Ledger
et al. JSES 2004
Biomechanical and anatomical CT study

Patients with clavicular malunion >15mm
Reduction of muscular strength of adduction,

extension, and internal rotation
Reduced peak abduction velocity
Increased upward angulation of clavicle at SCJ and
increased anterior scapular version

How
much shortening?
Assessment
Clinical measurement

How
much shortening?
Assessment
Assess scapular position

How
much shortening?
Assessment
Assess scapular position
Radiology Xray/CT

Surgical
Plate
Options
fixation
Intramedullary screw

Plate
fixation
Comminution
Soft
bone/smokers
Less compliant patients

Intramedullary
2
screw
part fractures
Young patients (girls)
Avoid above shoulder
ROM first 6 wks
Distal Clavicle Fractures

Beware
of these fractures!
High non-union rate

when displaced
Displacement often
missed
Treatment also determined by relationship to

and the integrity of the CC ligs

Displaced
fractures require surgery in all

but the elderly (low demand) patient.

Beware
of inadequate imaging

Beware

Beware

Initial
management
with immobiliser sling
Non-operative
Rx for
undisplaced fractures
with intact CC ligs

Surgical
management

Surgical
management
Proximal Humerus Fractures

Third
most common fracture after hip

fracture and Colles fractures
More common in females
Historically 15-20% required surgery
They generally result in some long term
functional disability
Classification Systems
Neer
Classification Systems
AO/ASIF
Surgical decision making

Not bad enough
for surgery
Too bad to fix

Not bad enough
for surgery
Sling/ Collar & Cuff
Too bad to fix

Hemi/Reverse TSA

Not bad enough
for surgery
Too bad to fix
ORIF
Hemi/Reverse TSA

Not bad enough
for surgery
Too bad to fix
ORIF
Hemi/Reverse TSA
Goal is maximum shoulder function and minimal shoulder pain.

Displacement and angulation
Painful Impingement
Significant ROM loss
Risk of non-union
Neer 1cm and or 45

degrees???

Non-op
vs ORIF vs Prosthesis
Determined
by
risk of AVN
age of patient
Medical comorbidities
Bone quality
Functional demands

Non-op
vs ORIF vs Prosthesis
Determined
by
risk of AVN
age of patient
Medical comorbidities
Bone quality
Functional demands
Greater Tuberosity Fracture
Usually displaced
posteriorly (by infraspinatus) and

superiorly (by supraspinatus)
>5mm requires reduction
previously 1cm shown to have poor

outcomes.
Depends on fragment size and
articular involvement
Superior displacement impingment in

abduction
Undisplaced
Immobiliser sling for 5-6 wks until

healed
Elbow ROM
Watch closely for displacement

Large
fragment
Screw
fixation open/arthroscopic
Tension band suturing
Anchors

Large
fragment
Screw
Anchors

Large
fragment
Approach:
Screw fixation
mini deltoid split/
Tension band suturing arthroscopic
Anchors
Advanced Fracture Management

Course

Large
fragment
Screw
Anchors
Small
fragment
Treat
like a cuff tear
Arthroscopic repair

My
Preference
Large
fragment good bone
Screw fixation (mini-open or

arthroscopic)
Small
fragment or large with

soft bone
Suture anchor fixation

(Intraosseous equivalent/bridge)
Lesser Tuberosity Fracture

Rare
If large and displaced block
internal rotation
Open reduction and screw
fixation +/- biceps tenodesis.
Surgical Neck Fracture

Acceptable
displacement and
angulation depends on:
patients
age
activity level
functional demands
Surgical Neck Fracture

Skeletally
immature
Patient Age (yr)
Allowable Displacement or Angulation
<5
Up to 70 degrees angulation, 100% displacement
512
Up to 4070 degrees angulation
>12
Up to 40 degrees angulation, <50% displacement
Adults
2 Part Surgical Neck Fracture

Options
Closed
reduction + Kwires
Intramedullary nail
Circlage sutures
Plate fixation

Closed
reduction + Kwires

Plate
fixation

Plate
fixation
3 and 4 Part Fractures

Surgical
Treatment Options
Open
reduction + K wires
Circlage wires/sutures + Rush pins/Enders
rods
CRKW (Resch)
Intramedullary nail
Locking plate
(hemiarthroplasty/reverse)

Surgical
Treatment Options
Open
reduction + K wires
l
a
c
i
r
Circlage
Histowires/sutures + Rush pins/Enders
rods
Technically difficult
CRKW (Resch)
Intramedullary nail
Locking plate
(hemiarthroplasty/reverse)

Approach
Deltopectoral
Mini-deltoid
(Extensile
split Percutaneous plating
lateral)
Percutaneous Plating
Beach chair
Spider arm holder
Beach chair
Spider arm holder
II opposite side
Beach chair
Spider arm holder
II opposite side
Lateral deltoid
split
Get control of
tuberosities
LT + biceps
tenodesis
GT
Get control of
tuberosities
LT + biceps
tenodesis
GT
Elevate head if
impacted
Get control of
tuberosities
LT + biceps
tenodesis
GT
Elevate head if
impacted
Insert plate under

deltoid/axillary nerve
Lock proximally and

distally
Lock proximally and

distally
Final images
AP
Lateral
Axillary view
Final images
AP
Lateral
Axillary view
Bone grafting
Elevation of valgus
impacted fracture
Cancellous bone defect
?possible cause of late
failure and collapse
Injectible bone graft
Ca PO4
Sets hard support
head, fixation for
screws
Deltopectoral Approach
I use DP approach
when:
Extensive medial
calcar/shaft extension
Excessive rotation of
head fragment
Head split (access
through rotator interval)
Fracture reduction techniques
Double plating method
Some fractures are too comminuted to

get stable fixation with 1 plate
Fracture reduction techniques
Double plating method
Some fractures are too comminuted to

get stable fixation with 1 plate
Use orthogonal plates

for increased strength
Distal Humeral Fractures

Supracondylar
Extension
Type COMMON!!
Flexion Type (rare)
Epiphyseal
Epicondylar
Condylar
Supracondylar Fractures
Extension
Type
Grade
1
(Undisplaced)
Grade
2
(Partially)
Grade
3
(Completely)
Extension
Type
Unstable
in
extension
Reduction is
maintained with
elbow held FLEXED!!!
FLEXION
IS MORE IMPORTANT THAN

PLASTER IMMOBILISATION
This treatment is worse

than nothing at all!
Plaster is dead weight

on fracture!!
This treatment is worse

than nothing at all!
Plaster is dead weight

on fracture!!
Apply collar and cuff in

flexion.
Leave on until fracture
union (3-4 wks)
Shirts over the top!
Supracondylar Fractures Mx
Grade
Collar
& Cuff in
flexion for 3/52
+/-
Backslab
Grade
Closed
If
Reduction under anaesthetic
unstable (rotationally) add K-wires
Immobilize
in flexion
Grade
Usually severely
swollen
delay increases
difficulty of reduction
Vascular compromise
Neurological deficit AIN
Occasionally open
reduction required!
Complications
Early
Arterial Injury
Compartment Syndrome
Nerve Palsy
Late
Volkmanns Ischaemic Contracture

Malunion
Complications: Cubitus Varus

Residual Posteromedial
displacement results in
internal rotation and
varus deformity of the
distal fragment.
This results in loss of
the normal carrying
angle, the so-called
gunstock deformity.
Complications: Cubitus Varus
Baumans angle
Lateral Condyle Fractures

15%
of elbow fractures in children

Mechanism:
Avulsion
secondary to FOOSH with

forearm supinated.
Compression injury secondary to FOOSH
with elbow flexed.
Lateral Condyle Fractures:

Milch Classification
Type I
Type II

Treatment
Can
be confused sometimes with a

supracondylar fx - cannot make this
mistake.

Treatment
Nondisplaced:
Immobilization in simple
backslab
Displaced: Reduce and pin.
Why
reduce?
Congruent joint surface

Prevent nonunion
Prevent growth arrest
Usually
Open Reduction, then 2 pins

Immobilize 6 weeks, then remove pins.
Lateral Condyle Fracture
Elbow Dislocations
Reduce
Immobilise
in backslab
for 3 weeks
Elbow Dislocations
Reduce
Immobilise
in backslab
for 3 weeks
Make
sure radial head

reduced
Elbow Dislocations
Reduce
Immobilise
in backslab
for 3 weeks
Make
sure radial head

reduced
and medial epicondyle
is not in joint!
Medial epicondyle fractures

Incarcerated
Incarcerated
medial epicondyle
Medial epicondyle fractures

Incarcerated
Open
medial epicondyle
reduction internal fixation
Elbow dislocation
Displaced
radial neck fracture
Elbow dislocation
Displaced
Open
radial neck fracture
reduction K-wire fixation
Forearm Fractures
Distal
radius fractures most common

upper limb paediatric fracture >
supracondylar fractures >shaft fractures
Forearm fracture most commonly
associated with the trampoline!
Treatment more difficult the more
proximal the fracture
Forearm Fractures
Treatment
is determined by:
Age
of patient (remodelling potential)

Displacement
Angulation, translation, rotation, shortening
Cosmetic
appearance
Aim to restore forearm rotation
Forearm Fractures
Plastering
techniques
Maintenance
moulding
of reduction requires 3 point
Forearm Fractures
Plastering
techniques
Maintenance
moulding
of reduction requires 3 point
Distal Third Fractures

Buckle
or Torus Injuries
Minimally
displaced
Stable
3-4/52
in cast short arm

sufficient

Displaced
?
Greenstick Fractures
Reduce
If
20 Degrees of
tilt or
If
clinically deformed
Complete Fractures
CR & POP +/- wires
Above elbow cast
Redisplacement
common
Careful FU
Remodel well

Epiphyseal
Injuries
Usually Salter Harris I or

II
Displaced reduction
and short arm cast
Remodel well
Dont manipulate late
Forearm Shaft Fractures
Less remodelling
Accept less than 10 degrees angulation
Closed reduction under GA
Always above elbow moulded cast
Recheck Xray 1 week
Warn parents the cast will look bent!
5% redisplacement rate
Plaster for upto 6 weeks
Isolated radius fracture
Isolated radius fracture
Both bones shaft fracture
Monteggia Fracture
Dislocation
Ulna fracture mid to

proximal 1/3
Radial head dislocation
Line through radial shaft

and head BISECTS
capitellum in ANY VIEW
Never accept ISOLATED

ulna fracture
Examine & X-ray joint

above and below
Monteggia Fracture
Dislocation
Ulna fracture mid to

proximal 1/3
Radial head dislocation
Line through radial shaft

and head BISECTS
capitellum in ANY VIEW
Never accept ISOLATED

ulna fracture
Examine & X-ray joint

above and below
Adult Distal Radius Fractures

Most common adult fracture
Usually in elderly due to
osteopenia/porosis
Usually associated with high energy
trauma in young adults
Types:
Colles
Smiths
Bartons
Chauffeurs
Intraarticular
Generally plain Xray adequate

CT scan if intraarticular involvement
Surgical Indications:
Loss radial length 3mm or more

Decreased radial inclination

Dorsal tilt >20 degrees

Step in articular surface 2mm or more

Step in articular surface 2mm or more
Other indications: open #, progressive

neurological deficit.
If redisplacement outside these limits can

be avoided with plaster best
outcomes.
Factors that make failure of

conservative management more
likely:
Dorsal comminution
Osteopenia
High energy injury
Conservative management:
Plaster for 6 week

Short arm cast only
Physiotherapy
Locking plate fixation
New locking plates have dramatically improved

surgical outcomes
Early therapy has improved patients return in

range of motion and function
New locking plates have dramatically improved

surgical outcomes
Early therapy has improved patients return in

range of motion and function
Recommended treatment for displaced

unstable fractures in adults is:

Early range of motion, with removable splint
THANK YOU

Management of Fractures - DR Matthew Sherlock

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Management of common

upper limb fractures in Adults

Immobilising Upper Limb #s

Choice is determined by forces displacement

Immobilising Upper Limb #s

Immobilising Upper Limb #s

arm with sling +/waist strap

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Muscle pull displacement

Pectoralis major/ lat dorsi

Immobilising Upper Limb #s

Muscle pull displacement

Pectoralis major/ lat dorsi

Arm should hang

Immobilising Upper Limb #s

Muscle pull displacement

Pectoralis major/ lat dorsi

Arm should hang

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Immobilising Upper Limb #s

Positioning arm in flexion is more

Immobilising Upper Limb #s

Positioning arm in flexion is more

Immobilising Upper Limb #s

Midshaft Clavicle fractures

undisplaced fractures can be

Midshaft Clavicle fractures

Open fracture, skin compromise

Midshaft Clavicle fractures

et al. JSES 2004

Biomechanical and anatomical CT study

Reduction of muscular strength of adduction,

Midshaft Clavicle fractures

Midshaft Clavicle fractures

Midshaft Clavicle fractures

Midshaft Clavicle fractures

Midshaft Clavicle fractures

Midshaft Clavicle fractures

Distal Clavicle Fractures

High non-union rate

Treatment also determined by relationship to

Distal Clavicle Fractures

fractures require surgery in all

Distal Clavicle Fractures

Distal Clavicle Fractures

Distal Clavicle Fractures

Distal Clavicle Fractures

Distal Clavicle Fractures

Distal Clavicle Fractures

Proximal Humerus Fractures

most common fracture after hip

Surgical decision making

Too bad to fix

Surgical decision making

Too bad to fix