UPPER EXTREMITIES RMO Training 2014

FRACTURES
GENERAL KNOWLEDGE
ABOUT FRACTURES
Assess neurovascular
Assess 1 joint above
Mechanism of injury related to type of fracture
Reassess patient after adequate pain management (distracting
injury)
If there’s no fracture, assess tendons, bursae
A 26 yo female sent a complain email after 8 weeks post ORIF of her
right Clavicle. She had follow up with her Orthopaedic in UK who
said that she might need repeat surgery. She was claiming that the
surgery done in our hospital was a failure that resulted non-healing
bone.
FRACTURE HEALING
Generally 8-12 weeks
Affected by :
 Mechanical factor : weight bearing, early mobilization
 Biological factor : smoking, alcohol, osteoporosis, Vitamin D, Calcium, Diabetes,
Steroid use, CKD

Delayed union : more than 3 months

Non-union : more than 9 months
Mal-union : deformed union
PRINCIPLES OF FRACTURE
Most displaced fractures must be reduced and stabilized, followed by
rehabilitation to restore function
Many fractures are suitable for non-operative treatment but major
long bones fractures are usually treated surgically
Periarticular fractures or intra-articular fractures that result
incongruity or malalignment are best treated with internal fixation
Most Paediatric fractures are amenable to non-operative treatment,
but fractures involving the growth plate require accurate reduction
and occasionally internal fixation.
Dislocations may be associated with neurovascular injury and require
urgent reduction
Trauma is the most common cause of compartment syndrome
Fractures and dislocations can be associated with nerve or vascular
injury
Early infection typically occurs in open fracures
Non-union affects about 5% of fractures
Mal-union is relatively common complication after a fracture,
especially following non-operative treatment
Post-traumatic osteoarthritis is associated with displaced intra-
articular fracture
Avascular necrosis is an occasional complication especially in
displaced fractures, where the blood supply is disrupted
Fat embolism is complication of long bone fractures
Lower limb DVT and PE occur in <1% of fractures.
PRINCIPLES OF TREATMENT
Non-operative treatment
Operative treatment
 External fixation
 Internal fixation
COMPLICATIONS OF
FRACTURES
Early Complications :
Compartment syndrome
Nerve injury
Vascular injury
Infection
Late local complication :
Non-union
Mal-union
Post Traumatic osteoarthritis
Avascular necrosis
Complex regional pain syndrome
General Complication of fracture
Fat embolism
DVT and Pulmonary embolism
Complications of immobility
 Muscle atrophy
 Respiratory tract infection
 Pressure sores
 Joint stiffness
A 38 yo female fell on the stairs.
She complains of pain on her left shoulder.

Her xray as shown.

What is the diagnosis ?

How would you manage the patient ?
CLAVICULAR FRACTURES
Common in adults and children
Majority after fall on the shoulder
Most fractures on the middle third of the bone
Treatment :
 Collar and cuff sling 4-6 weeks
 Plates and screw (skin tenting, comminuted, brachial plexus palsy, vascular injury)

Patient education :
 No overhead activity first 6 weeks
 No heavy manual work for 3 months

Follow up : xray 2 weeks, 6 weeks, and 3 months

SCAPULAR FRACTURES
Associated with High energy trauma
Well recognized associated with :
 Rib fractures
 Clavicle fractures
 Intra-thoracic injury
 Brachial plexus injuries

Management :
 Identification of associated injuries
 Sling 4-6 weeks
 If involve glenoid fossa with significant displacement -> Internal fixation
A 42 yo male surfer presents to ER
with Left Shoulder pain after he was
hit by a strong wave.
Xray is shown.

What is the diagnosis ?

What is the treatment ?

What Associated injury you need to

be aware of ?

What advise after the treatment will

you give to patient ?
OPTIONS FOR SHOULDER
XRAY
First projection : AP view
Second Projection :
 Axial
 Lateral Scapular Radiograph
 Apical Oblique
AP VIEW
AXIAL VIEW SHOULDER
XRAY
LATERAL SCAPULAR XRAY (Y-
VIEW)
APICAL OBLIQUE VIEW
SHOULDER XRAY
GLENOHUMERAL
DISLOCATION
Most frequently dislocated major joint
Mechanism : fall on the extended arm with shoulder extension
Type :
 Anterior dislocation : 95%
 Posterior dislocation : 5%

Posterior dislocation : associated with high energy trauma, epileptic

fit, electric shock
Very unusual injury in children
Physical Exam :
 Anterior : humeral head palpable on anterior sub-coracoid, loss of shoulder
roundness
 Posterior : glenohumeral joint is fixed in internal fixation
 Assess Axillary Nerve and Brachial plexus palsy

Complication :
 Axillary nerve palsy
 Brachial plexus palsy
 Rotator cuff tears
Treatment :
 Closed reduction
 Open reduction – more for posterior dislocation
 3-4 weeks immobilization

Risk :
 < 20 yo – 80% of recurrent dislocation
 > 40 yo – rotator cuff tears and nerve injury more frequent

Warning :
 If after 4-6 weeks no active abduction -> MRI to diagnose rotator tear
ANTERIOR SHOULDER
DISLOCATION
ASSOCIATED COMMON
FRACTURES AND DEFOMITIES
WITH ANTERIOR SHOULDER
DISLOCATION
OPTIONS FOR SHOULDER
REDUCTION
Matson’s Traction Counteraction Stimson’s Methode Hippocratic Methode
CUNNINGHAM TECHNIQUE
Massage on the shoulder and arm while pulling down the arm
A 29 yo female, after an episode of
convulsion, she complains of pain on her right
shoulder.

Her Xray as shown

What is the diagnosis ?

What would be the recommended treatment ?
POSTERIOR DISLOCATION
A 32 yo male, was slipped by
the side of the pool, fell and
hit his right shoulder.
Xray as shown.

What would be the

diagnosis ?
What would be expectant
management ?
ACROMIO-CLAVICULAR JOINT
INJURY
Fall directly on to the shoulder
Grades :
I
 II
 III

Treatment :
 I and II - > non-operative, sling
 III -> best surgically, coraco-clavicular screw
ACROMIOCLAVICULAR JOINT
INJURY Inferior cortex
of acromion
process and
Inferior cortex
of clavicle
should be in
one line
 CORACOCLAVICULAR
LIGAMENT INJURY

Normal distance coracoid-clavicle on AP view is less

than 1.3 cm

If suspect rupture -> weight-bearing view of both

sides xray

Difference more than 5mm as compared to normal

side -> rupture of the ligament
PROXIMAL HUMERAL
FRACTURES
Most frequent in elder women
PE : bruising and swelling of the shoulder
Bruising migrates down the arm in the first 10-14 days after injury
Neurological injury 20-30% : axillary nerve or brachial plexus
Treatment :
 Non-displaced : sling
 Displaced : ORIF or humeral head replacement

Complication :
 Mal-union
 Shoulder stiffness
 Troublesome if osteoporotic
HUMERAL SHAFT
FRACTURES
Direct or indirect trauma to upper arm
High energy, elderly patient or drunk patient who fell
12% Radial nerve palsy
Treatment :
 Non-operative : U-slab, after 2-4 weeks replaced with functional brace
 ORIF (plating or intramedullary nailing
DISTAL HUMERAL
FRACTURES
Not common, but difficult to treat in adults
After a fall directly on to the elbow
Treatment :
 Non-operative : above-elbow cast
 ORIF – most common treatment

Complication :
 Stiffness – most common
 Ulnar nerve palsy
 Heterotopic offication
 Post-traumatic arthritis
 Infection
A 19 yo male fell down while playing
basketball, hitting his left elbow.

He complain of pain on the elbow. Xray

as shown.

What is the diagnosis ? Why ?

What is the expectant management ?

ELBOW XRAY
Xray Options :
 AP in full extension
 Lateral with 90’ of flexion
TYPE OF
ELBOW
FRACTURE
STEPS FOR ELBOW XRAYS
Fat Pads
Radiocapitellar Line
Anterior Humeral Line
Ossification centres (For children only)
FAT PADS OF ELBOW
Visible anterior is normal, but if
displaced anteriorly is abnormal
(SAIL sign)
Posterior fat pad always SAIL sign
Anterior Fat Pad
abnormal
RADIOCAPITELLAR LINE

Always pass through the

Capitellium
If not -> dislocation Radial
Head suspected
ANTERIOR HUMERAL LINE

Pass the Anterior cortex of

humerus
At least 1/3 of capitellium
anterior to it
OSSIFICATIONS CENTRE
CRITOL:
 Capitellium
 Radial Head
 Internal Epicondyle
 Trochlea
 Olecranon
 Lateral Epicondyle

The age at which each ossification

centre appears is not important
The ORDER in which the centre
ossify is important
SUPRA CONDYLAR
FRACTURES IN CHILDREN
Commonest Elbow injury in children 5-7 years old
Fall on to the outstretched hand
Type :
 Extension type : 95%
 Flexion type

Xray :
 If no obvious fracture, check fat pad signs

Treatment :
 Surgery

Rapid healing, can begin mobilizing elbow after 3 weeks

LATERAL CONDYLE
FRACTURES IN CHILDREN
Second commonest injury of elbow aged 5-7 years
Complication :
 Progressive lateral drift of the forearm
 Tardy ulnar nerve palsy as an adult (due to stretched ulnar nerve at elbow)
A 29 yo female while playing
volley ball, hit her right elbow.
Pain immediately felt on her
elbow.

Xray as shown.

What is the diagnosis ?

OLECRANON PROCESS
FRACTURE
Falls on the elbow
Triceps inserts on the olecranon -> distraction of fracture
Treatment :
 Internal fixation with tension-band wire system

Immobilization for 10-14 days, followed with cautious mobilization

RADIAL HEAD AND NECK
FRACTURES
Fall on outstretched hand
Often minimally displaced
Treatment :
 Angle < 30’ – no specific treatment
 Angle > 30’ – Manipulated or Open reduction and fixation
 Complete dislocation – radial head replacement
A 52 yo female, slipped on her
hotel bathroom floor.
She complained of pain on her
right elbow, and unable to move
her right arm.

Xray as shown.

What is the diagnosis ?

What is the expectant

management ?
ELBOW DISLOCATION
Fall on the outstretched hand with elbow extended

Treatment :
 Closed reduction with sedation
 10-14 days of immobilization in back-slab plaster

Association : avulsion of medial epicondyle

A 2 yo boy was brought by his mother. He complains of pain and
stiffness on his right elbow after his right arm being pulled by his
mother
PULLED ELBOW
FRACTURES OF FOREARM
Very common in children, less in adults
Type :
 Plastic Deformation
 Greenstick
 Complete fracture

Treatment :
 Cast 3-5 weeks
 Radiograph 1 and 2 weeks after reduction
A 42 yo male fell on his left arm during motorbike accident
His xray as shown

What is the diagnosis ?

MONTEGGIA FRACTURE
Ulnar Shaft Fracture + Radial head Dislocation
What is the xray
?
 GALLEAZI FRACTURE
Radial Shaft Fracture + Dislocation of
Distal Radio-ulnar Joint
WRIST AND DISTAL
FOREARM
Options :
 AP
 Lateral
 Scaphoid Series (4 xrays) – if there’s tenderness in the anatomical snuff box
BARTON FRACTURE
Intraarticular fracture of distal radius
with dislocation of radiocarpal joint
Fall on extended and pronated wrist
DD:/ Colle’s or Smith -> no carpal
displacement
TORUS FRACTURE
DISTAL RADIUS FRACTURES
Plaster cast 5-6 weeks
Radiograph 1 and 2 weeks after reduction
Complication :
 Mal-union
 Carpal Tunnel Syndrome
 SCAPHOID FRACTURE
Commonest carpal bone fractures
Usually young adult males
Fall on the wrist
Clue : Tenderness in the anatomical snuffbox

Standard Xray : 4 Scaphoid series

Location of Fractures : mostly middle third (80%)
Risk : Avascular necrosis
Treatment :
 Undisplaced : cast 8-12 weeks
 Displaced, or with lunate dislocations, radial styloid fracture, or complex carpal fracture
dislocations : surgery
SCAPHOID XRAY SERIES
LUNATE DISLOCATION
PERILUNATE DISLOCATION
CARPAL SUBLUXATION
Intercarpal joints measure
no more than 2 mm
During basketball game, a
23 yo male injured his
right middle finger when
he receive the ball. His
presentation and xray as
shown
What is the diagnosis ?
What is the expectant
management ?
MALLET FINGER / BASEBALL
FINGER
Injury of extensor digitorum tendon at Distal Interphalangeal Joint
(DIP)
Treatment :
Mallet splint 6-8 weeks
Extension block K-wire 4 weeks
An 18 yo male was having a fight in his
school. After the fight, he complains of
pain on his right hand.
Xray as shown.

What is the diagnosis ?

What is the expectant management ?
 BOXER’S FRACTURE
Fracture of the 4th of 5th Metacarpal bone to
indirect force with closed fist
BENNET’S FRACTURE

Fracture of the base of first metacarpal

extend to the Carpometacarpal joint

There’s tension of the abductor pollicis

longus tendon

Treatment : Surgery
ROLANDO FRACTURE

The Rolando fracture is a comminuted intra-

articular fracturethrough the base of the first
metacarpal bonefirst

This is a fracture consisting of 3 distinct fragments;

it is typically T- or Y-shaped.
A 19 yo male complain of pain on his right
thumb after playing soccer as the goal keeper

What is the diagnosis ?

 GAMEKEEPER’S/SKIERS
THUMB
Gamekeeper's thumb (also known as skier's
thumb or UCL tear) is a type of injury to the ulnar
collateral ligament (UCL) of the thumb.
The UCL is torn at (or in some cases even avulsed
from) its insertion site into the proximal phalanx of
the thumb in the vast majority (approximately
90%) of cases.[1]

This condition is commonly observed among

gamekeepers and Scottish fowlhunters, as well as
athletes (such as volleyballers).
It also occurs among ordinary people who sustain
a fall onto an outstretched hand.

Sometimes can’t be seen by xray. May need xray

with resistant on the thumb
THANK YOU