UE

CLAVICULAR
FRACTURES
Clavicle
- An S-shaped bone
- acts as a strut which provides
the only bony connection
between upper limb and the
thorax
- It protects major underlying
vessels, lung, and brachial
plexus. Displaced clavicle
fractures can injure these
structures because of their
proximity and sharp edges.

Most common fx in both
adults and children
The fx usually occurs in the
junction between the middle
third & the outer third of the
shaft
Can present in the newborn
period, especially following a
difficult delivery
Nearly half of all clavicle
fractures occur in children
younger than 7 years.

Fall onto
shoulder or
outstretche
d upper
extremity
Direct blow
to clavicle
Forceful
muscle
contraction
during
seizures

CLASS

Medial Third
(Group III) 5%
Middle Third
(Group I) 85%
Lateral Third
(Group II) 10%

Tenderness
Crepitus
Deformity & tenting of
skin
Ecchymosis, especially
when severe displacement
causes
Bleeding from open
fracture (rare)
Nonuse of arm on affected
side in neonates

breath sounds
on auscultation,
indicating
possible
pneumothorax
pulses or
evidence of
perfusion on
vascular exam,
suggesting
vascular
compromise
Diminished
sensation or
weakness on
distal
neurovascular
exam, suggesting
neurologic
compromise










best visualized w/ AP view & view
w/ beam angled 30 deg. cephalad
(angulated);


COMPLICATIONS:

Brachial plexus
compression resulting
from hypertrophic callus
formation
Delayed union or
nonunion (especially with
distal third fractures)
Poor cosmetic appearance
Posttraumatic arthritis
Intrathoracic injury
Pneumothorax
Subclavian artery and vein
injury
Internal jugular vein injury
Axillary artery injury
Closed tx
- It is difficult to reduce
and maintain the
reduction of clavicle
fractures
- Despite deformity,
healing usually
proceeds rapidly
- Union usually occurs
rapidly & produces
prominent callus

Figure-8 Bandage

Open Treatment
INDICATIONS FOR
SURGERY:
Open
fractures
Gross
displacement
of fracture w/
tenting of
skin
Presence of
neurovascular
injuries
SHOULDER
DISLOCATION
The shoulder is
the most
commonly
dislocated joint
in the body, 96%
of these
dislocations due
to trauma
Shoulder
dislocations
account for 45-
50% of all
dislocations.
Approximately
85% are anterior
dislocations

ANT
- Subglenoid
- Subclavicular
- Subcoracoid

the most frequent type of
shoulder dislocation (85-90%
of shoulder dislocations)
Anterior dislocations are
usually the result of direct or
indirect trauma, with the arm
forced into abduction and
external rotation
40% become recurrent as a
result of associated damage of
the surrounding ligamentous
and capsular structures that
stabilize the joint


POST
- Subspinous
- Subglenoid

Posterior dislocations
are rare (approximately
2-4%).
They may result from a
fall on the outstretched
hand, direct trauma to
the shoulder, or violent
muscle contractions
from electric shocks or
seizures.

Pain & tenderness
at shoulder;
Muscle
spasm/splinting
may be present
Limited motion of
shoulder joint due
to extreme pain
Deformity of
shoulder joint
Shoulder may be
locked in flexion
or extension

X-Rays:
Shoulder AP-Y
views, Axillary
view
CT scan
MRI
Arthrography

COMPLICATIONS:
High recurrence rate (re-
dislocations, joint instability)
High incidence of rotator
cuff tear in ages >40 years
old
Axillary nerve / artery
damage
Glenoid fossa fxs, labrum
tears

Closed
Closed reduction of
dislocation
Sling/Shoulder
immobilizer for 2
weeks
Rehabilitation
(mobilization,
strengthening)

STIMSON TECHNIQUE
MILCH MANEUVER
HIPPOCRATIC MANEUVER
TRACTION-COUNTER
TRACTION TECHNIQUE

ACROMIOCLA
VICULAR &
STERNOCLAV
ICULAR JOINT
DISLOCATION
S

Falling on the point of the
shoulder (sports-related or
due to vehicular
accidents,
falls)

Grades 1 & 2 can be treated
conservatively with sling
support. Grade 3 injuries are
usually treated with surgical
repair


Sternoclavicular Joint
Dislocation
Anterior dislocations are more common & can be reduced by closed means
Posterior dislocations are rare but are potentially more serious because the clavicle can
impinge on vital structures in the neck (esp. the trachea)



FRACTURES
OF THE
PROXIMAL
HUMERUS
2-3% of all upper extremity
fractures occur in the
proximal humerus
75% of proximal humerus
fractures occur in the elderly
(60 years up), mostly women
Most fractures occur through
osteoporotic bone in elderly,
although high-energy trauma
may also be a cause

FOUR PARTS:
articulating surface
greater tuberosity
lesser tuberosity
humeral shaft





Fall on the
arm
Strong
muscular
contractions
(electric
shock,
seizures)
Direct blow
to the
shoulder


Pain, swelling,
tenderness
Ecchymosis &
edema
Decreased range of
motion (ROM)

Anteroposterior and lateral views
of the humerus, as well as
transthoracic and axillary views of
the shoulder, should be adequate
to visualize a fracture

Complications
Axillary nerve injury
Avascular necrosis of the humeral
head
Stiff shoulder/Frozen shoulder

Most fractures are displaced
minimally and treated
conservatively

Operative treatment decisions
are based primarily on the
number of segments involved
and degree of displacement.
Three- and 4-part fractures
often need operative repair

FRACTURES
OF
THE
HUMERAL
SHAFT
Fractures of the
humeral shaft
account for
approximately 3% of
all fractures
the humerus is also a
common site for
metastases and
pathologic fractures

Bending force
produces transverse
fx of the shaft;
Torsion force will
result in a spiral
fracture;
Combination of
bending and torsion
produce oblique fx w/
or w/o a butterfly
fragment;
Compression forces
will fracture either
proximal or distal
ends of humerus

Arm pain,
tenderness,
swelling
Deformity,
shortening of arm
Motion and
crepitus present on
manipulation

AP & lateral x-ray views of the arm
CT & MRI are rarely indicated

COMPLICATIONS
Radial nerve injury occurs in up to
16-18% of humeral shaft fractures
Brachial artery injury
Nonunion, Malunion, Delayed
union

Although most fractures of the
humeral shaft are inherently
unstable, nonoperative
treatment
remains the
standard

ORIF-
IM NAILING
ORIF PLATE & SCREWS

SUPRACOND
YLAR
FRACTURES
Supracondylar
fractures occur in
the distal humeral
metaphysis, above
the joint capsule, &
are completely extra
articular
Peak age of
occurrence is 5-7
years, usually boys

Usually occur from an
extension injury (Fall on
an outstretched hand)
Trauma: Fall from a height
(70%)
Fall onto an outstretched
hand with the elbow
extended

TYPE I undisplaced fracture

TYPE II Displaced, but with intact
posterior cortex

TYPE III Displaced, with no
cortical contact

Pain & swelling at
elbow area
Ecchymosis & edema
S-shaped deformity
Puckering of cubital
fossa
Limitation of motion /
splinting of the
affected
Elbow
Fat pad sign

CUBITUS VARUS
(GUNSTOCK
DEFORMITY)

Complications
Vascular injury (brachial
artery involvement)
Nerve injury (radial,
medial nerves; rarely
ulnar nn.)
Malunion (resulting in
cubitus varus)
Volkmanns ischemic
contracture
Myositis ossificans (very
rare)

IMMOBILIZATION BY
TRACTION
PERCUTANEOUS PINNING

CONDYLAR
FRACTURES
OF THE
DISTAL
HUMERUS
MEDIAL

Fall on outstretched arm
Avulsion fxs due to muscle pull

LATERAL
Avulsion due to pull of wrist extensors
Falling on outstretched hand



Cast Immobilization for undisplaced fractures
ORIF
PINNING OF MEDIAL CONDYLE
PLATE & SCREW FIXATION


Cast Immobilization for undisplaced or minimally displaced fractures
ORIF
INTERCONDY
LAR
FRACTURES
FRACTURES
INVOLVING BOTH
CONDYLES &
EPICONDYLES

High energy vehicular accidents
Fall from significant height
Gunshot



Complications
Elbow stiffness
Posttraumatic arthritis of the elbow
Tardy ulnar nerve palsy
Cubito valgus/varus deformity of
the elbow

Objectives: restoration of the
structural integrity of the
distal humerus (including
articular surface), & achieving
rigid stabilization of the
fracture

ORIF using combination of
implants

DISLOCATION
S
OF THE
ELBOW JOINT
Elbow dislocation is the
second most common
major joint dislocation
The elbow is more stable
than the shoulder,
requiring a considerable
force to dislocate.
30% of elbow
dislocations are
associated with fractures
of bony components of
the elbow
Dislocations occur more
commonly in adults,
since the same force in
children more often
results in a
supracondylar fracture


ANTERIOR
Due to a
strong blow
to the
posterior
aspect of a
flexed elbow
Drives the
olecranon
forward in
relation to
the humerus
Less
common

POSTERIOR
Due to a fall
on an
extended
abducted
arm
Drives the
olecranon
backward in
relation to
the humerus
Much more
common





Pain
Ecchymosis
Swelling around
elbow joint;
effusion
Extremely limited
range of motion
Joint deformity

AP & Lateral views of the elbow are usually
sufficient to diagnose a dislocation

Complications
Brachial artery injury
Medial nerve injury
Ulnar nerve injury
Concomitant fractures
Avulsion of the triceps mechanism
insertion (anterior dislocation only)
Entrapment of bone fragments
within the joint space
Joint stiffness with decreased range
of motion (particularly in extension)
Myositis ossificans

CLOSED REDUCTION OF
DISLOCATION,
WITH SUBSEQUENT
IMMOBILIZATION

SURGICAL MANAGEMENT IS
REQUIRED IF
There is
malalignment of the
fragments.
There is joint
incongruity.
The elbow is
unstable after
reduction
Associated fractures
requiring surgery

FRACTURES
OF THE
OLECRANON
Despite that the olecranon is a
very heavy strong process of
bone, it is fractured rather
frequently in adults (rarely in
children)
Low energy injury usually in
the elderly; high energy
injuries occur in younger age
groups


Fall on the
semiflexed
supinated
forearm (most
common)
Direct trauma, as
in falls on, or
blows to, the
point of the
elbow.
Occasionally, the
olecranon may
be fractured by
hyperextension
injuries
Rarely, the
olecranon
broken by
muscular
violence, as in
throwing

Type I fractures are generally
stable with little
displacement. These
fractures can generally be
treated nonsurgically

Type II fractures are the most
common. They are relatively
stable, although there is
displacement of the bone pieces

Type III fractures are displaced
and involve more than 50
percent of the joint surface,
resulting in joint instability.

Ss/s
Pain, tenderness, &
swelling of elbow
Effusion of elbow joint
(usually hemorrhagic)
Inability to extend the
elbow actively against
gravity (indicates the
discontinuity of the
triceps mechanism)






Complications
Painful hardware
(due to thin soft
tissue coverage)
Ulnar nerve
paresthesia
Nonunion
Loss of extension
(Extension Lag, usu.
10-15 deg)
Heterotopic
ossification (rare)

Closed

For stable, undisplaced
fractures

Open Treatment
For displaced fractures &
those with extensor lag

FRACTURES
OF THE
RADIAL HEAD
Radial head fractures are
common injuries, occurring in
about 20 percent of all acute
elbow injuries.
More frequent in women than
Most frequently caused by direct longitudinal loadinga
fall on the outstretched hand

TYPE I nondisplaced or minimally displaced fracture of
the head or neck
AP & Lateral x-ray
views are usually
sufficient
CT scan to better
visualize complicated
Closed Treatment
Undisplaced or
minimally displaced
fractures (TYPE I) are
usually treated by
in men and occur most often
between 30 and 40 years of
age.
Approx 10% of all elbow
dislocations involve a fracture
of the radial head.


TYPE II displaced fracture of the head or neck
TYPE III severely comminuted


fracture
configurations

immobilization in a
long arm cast/splint
Open Treatment
Displaced or
comminuted
fractures are treated
by surgery (ORIF)
The presence of an
acute mechanical
block to rotation or
flexion may also
warrant surgery
FRACTURES
OF THE
FOREARM
In the US: The upper
extremity is involved in nearly
half of all fractures seen, and
wrist fractures account for
about one third of these
Postmenopausal women have
a higher rate of forearm
fractures than other adults
due to osteoporosis
Forearm fractures are less
common in blacks because of
a lower incidence of
osteoporosis


Fractures of the wrist
and elbow usually
involve a fall onto the
outstretched arm, while
forearm shaft fractures
more commonly are the
result of a direct blow
Sports, particularly in-
line skating,
skateboarding, mountain
biking, and contact
sports
Trauma, commonly from
vehicle collisions,
blows
with a blunt object, or
child abuse
Swelling about the
elbow
Deformity
Crepitus
Pain on movement


Complications
PIN (posterior
interosseous nerve)
or radial nerve palsy
from anterior
displacement of
radial head
Nonunion of frx of
ulnar shaft
Radiohumeral
ankylosis
Radioulnar
synostosis
Recurrent radial
head dislocation


Fracture of both
shafts of the radius &
ulna
Isolated ulna fracture
(Nightstick)
Monteggias Fracture
Galleazzis fracture
Wrist & distal
forearm fractures
Colles fracture
Smiths fracture
Bartons fracture

FRACTURES
OF THE
SHAFTS OF
BOTH
RADIUS &
ULNA
Fractures of both the radius &
ulna are classified according
to:
Level of fracture
Pattern of the fracture
Degree of displacement
Presence or absence of
comminution or segmental
bone loss
Whether they are open or
closed

Fracture of both
shafts of the radius
& ulna
Isolated ulna
fracture (Nightstick)
Monteggias
Fracture
Galleazzis fracture
Wrist & distal
forearm fractures
Colles fracture
Smiths fracture
Bartons fracture


Pain & tenderness
over the forearm
Deformity, usually
obvious in displaced
fractures
Loss of function
Crepitus

AP & Lateral x-
ray views are
usually
sufficient
X-ray films must
include the
elbow & wrist





INDICATIONS FOR CLOSED
TREATMENT:
Nondisplaced fractures
INDICATIONS FOR OPEN TX
All displaced fractures of
radius and ulna in adults
All isolated displaced fractures
of the radius
Isolated fractures of the ulna
with angulation greater than
10
Open fractures
Fractures associated with
compartment syndrome

NIGHTSTICK
FRACTURE
Defined as an
isolated midshaft
ulnar fracture
Nightstick
fractures have no
associated radial
head instability
Usually due to
direct blows (with
the patient using
the forearm as a
shield
Closed Treatment
With undisplaced or
slightly displaced
fractures, a plaster
cast or fracture brace
is adequate

Open
Treatment
ORIF) becomes
necessary when
displacement greater
than 5 mm or
angulation greater
than 10 persists
MONTEGGIA
FRACTURE
A fracture of the
ulna with
associated
dislocation of the
radial head
(proximal
radioulnar
joint)
Type I ( extension type) - 60% of
cases:
- anterior dislocation of radial
head (or frx) and fracture of ulnar
diaphysis at any level w/ anterior
angulation (usually proximal third)
Type II (flexion type) - 15%
- posterior or posterolateral
dislocation of radial head (or frx);
- frx of proximal ulnar diaphysis
with posterior angulation
Type III - 20%
- lateral or anterolateral
dislocation of the radial head;
- fracture of ulnar metaphysis;
- frx of ulna just distal to
coronoid process w/ lateral
dislocation of radial head
Type IV (5%)
- anterior dislocation of the
radial head;
- frx of proximal 1/3 of radius &
frx of ulna at the same level

Closed Treatment
Historically, Monteggia
fractures have been treated by
closed reduction & casting
Today, closed methods are
considered as options in only
pediatric patients
Open
Closed reduction of the
dislocated radial head & ORIF of
the ulnar fracture is advocated

Complications
Nonunion, delayed union,
malunion
Infection (open fractures)
Nerve injury (rare)
closed fx ulnar nerve
iatrogenic anterior
interosseous nerve
Vascular injury
Compartment syndrome
Post-traumatic radio-ulnar
synostosis


GALEAZZI FRACTURE
Defined as a fracture of the
distal one third of the radius
with dislocation of the distal
radioulnar joint (DRUJ).
Reverse Monteggia
fracture.
Galeazzi fracture is 3 times
more common than
Monteggia lesion.
Disruption of DRUJ when
overlooked results in a
higher rate of morbidity

Mech
Direct blows
on the
dorsolateral
side of
the wrist
Fall on the
outstretched
hand
combined with
marked
pronation of
the forearm

Open Treatment
To regain functional
motion and avoid
arthritic changes in the
distal radioulnar joint,
the fracture must unite
in an anatomical
position. For these
reasons, open
reduction and internal
fixation is almost
always the preferred
form of treatment
COMPLICATIONS
Nonunion, delayed union
Malunion
Infection
Subluxation and dislocation
of the distal radioulnar joint
Extensor carpi ulnaris
tendon entrapment
Hardware failure and RU joint
subluxation