Fracture of upper limb and physical thet

Fracture of upper limb

1. Fracture of upper limb ( part 1 )

2. CLAVICLE FRACTURES Clavicle fractures account for approximately 2.6% of all fractures and for 44% to 66% of fractures about the shoulder. Middle third fractures account for 80% of all clavicle fractures, whereas fractures of the lateral and medial third of the clavicle account for 15% and 5%, respectively .

3. MECHANISM OF INJURY Falls onto the affected shoulder leading to a bending force account for most (87%) of clavicular fractures, with direct impact accounting for only 7% and falls onto an outstretched hand accountingfor 6%. Although rare, clavicle fractures can occur secondary to muscle contractions during seizures or econdary to minimal trauma due to pathologic bone or as stress fractures.

4. CLINICAL EVALUATION Patients usually present with splinting of the affected extremity, with the arm adducted across the chest and supported by the contralateral hand to unload the injured shoulder. A careful neurovascular examination is necessary to assess the integrity of neural and vascularelements lying posterior to the clavicle. The proximal fracture end is usually prominent and may tent the skin. Assessment of skin integrity is essential to rule out open fracture. The chest should be auscultated for symmetric breath sounds. Tachypnea may be present as a result of pain with inspiratory effort; this should not be confused with diminished breath sounds, which may be present from an ipsilateral pneumothorax caused by an apical lung injury.

5. ASSOCIATED INJURIES ■ Up to 9% of patients with clavicle fractures have additional fractures, most commonly rib fractures. ■ Most brachial plexus injuries are associated with proximal third clavicle fractures (traction injury). ■ The skin is often abraded as a result of the injury mechanism.

6. Nonoperative treatment ■ Most minimally displaced clavicle fractures can be successfully treated nonoperatively with some form of immobilization. ■ Comfort and pain relief are the main goals. A sling has been shown to provide the same results as a figure-of-eight bandage, providing more comfort and fewer skin problems.

7. Operative treatment The accepted indications for operative treatment of acute clavicle fractures are open fracture , associated neurovascular compromise, and skin tenting with the potential for progression to open fracture .

8. Humerus Fractures Proximal Humerus Fractures Common in elderly patients with osteoporosis Mechanism of Injury = Fall on outstretched hand with elbow extended Clinical Presentation Pain, swelling and tenderness around the shoulder Brachial plexus and axillary arteries injuries Higher incidence (>50%) in displaced fractures 8

9. Neer Classification guides treatment Fractures separate humerus into 4 fragments by epiphyseal lines Displacement > 1 cm or angulation > 45 degrees defines a fragment as a “separate part” when fractures occur If none of fragments are displaced > 1cm, fracture is termed 1 part Treatment One part fractures (85%) = immobilization in sling/swathe, ice, analgesics, orthopedic referral Two/Three/Four part fractures = Orthopedic Consultation

10. Proximal Humerus Fractures 10 Fragments of Humerus Head Articular surface of humeral head Greater tubercle Lesser tubercle Shaft of humerus 3 1 2 James Heilman , MD, Wikimedia Commons Gray’s Anatomy, Wikimedia Commons

11. Mid-shaft Humerus Fractures Typically involve middle 1/3 of the humeral shaft Mechanism of Injury Direct Blow (Most common) Fall on outstretched arm or elbow Pathologic Fracture (e.g. breast cancer) 11

12. Clinical Presentation Pain and deformity over affected region Associated Injuries Radial Nerve injury = Wrist Drop (10-20%) Neuropraxia will often resolve spontaneously Nerve palsy after manipulation or splinting is due to nerve entrapment and must be immediately explored by orthopedic surgery Ulnar and Median nerve injury (less common) Brachial Artery Injury 12

13. Mid-shaft Humerus Fractures Imaging = Standard x-ray imaging Treatment Non-operative Management (most common) Simple Sling and Swath adequate for ED patients Closed treatment options Hanging cast External fixation Operative management Neurovascular compromise, pathologic fractures 13 Bill Rhodes, Wikimedia Commons

14. Complications Neurovascular injury Delayed union Adhesive capsulitis

15. Biceps Rupture Proximal or distal biceps tendon rupture Mechanism of Injury = Sudden or prolonged contraction against resistance in middle aged or elderly patients Clinical Presentation “Snap” or “Pop” typically described Pain, swelling, tenderness over site of tendon rupture Flexion of elbow = Mid-arm ball Loss of strength sometimes minimal X-rays to exclude avulsion fracture 15 Patenthalse , Wikimedia Commons Gray’s Anatomy, Wikimedia Commons

16. ED Treatment Sling, Ice, Analgesia, Orthopedic referral Surgical repair for young, active patients

17. Radiographic Evaluation of the Elbow 17 Source Undetermined

18. 18 Anterior Fat Pad “Sail Sign” Posterior Fat Pad (Never normal) Anterior Humeral Line Normal = Middle of capitellum Abnormal = Anterior 1/3 of capitellum or completely anterior Radial- Capitellar Line Normal = Transects middle of capitellum Radiographic Evaluation of the Elbow Hellerhoff , Wikimedia Commons Source Undetermined Source Undetermined

19. Supracondylar Fractures Supracondylar Extension Fractures Most Common Type Mechanism of injury Fall on outstretched arm with elbow in extension Imaging Distal humerus fractures and humeral fragment displaced posteriorly Sharp fracture fragments displaced anteriorly with potential for injury of brachial artery and median nerve 19

20. Treatment Non-displaced fracture (Rare) = Immobilization in posterior splint May be discharged home with close follow-up Displaced fracture Orthopedic Consultation and reduction Patients with displaced fractures or significant soft tissue swelling require admission for observation

21. Supracondylar Fractures Supracondylar Flexion Fractures (rare) Mechanism of Injury Direct blow to posterior aspect of flexed elbow Fractures are frequently open Imaging = Distal humerus fracture displaced anteriorly 21

22. Treatment Non-displaced fractures Splint immobilization and early orthopedic follow-up Displaced fractures Orthopedic consultation for reduction Patients with displacement and soft tissue swelling require admission

23. Supracondylar Fractures 23 Extension Type Fracture Flexion Type Fracture Source Undetermined Source Undetermined Source Undetermined

24. Supracondylar fractures Early Complications Neurologic (7%) Results from traction, direct trauma or nerve ischemia Radial Nerve (Posterior-medial displacement) Median Nerve (Posterior-lateral displacement) Ulnar Nerve (Uncommon) Anterior Interosseous Nerve Injuries High incidence with supracondylar fractures No sensory component, Motor component must be tested (“OK sign”) Vascular Entrapment (Brachial Artery) Late Complications Non-union/Mal-union Loss of mobility 24

25. Volkmann’s Ischemic Contracture Compartment syndrome of the forearm Complication of elbow/forearm fractures Increased compartment pressure results in ischemia of muscles of forearm, typically flexor compartment Patient complains of pain out of proportion of injury, digit swelling and paresthesias Also consider in any patient presenting with pain and numbness in hand after casting has been performed Irreversible damage in 6 hours (see image) Treatment Removal of cast Surgical decompression with fasciotomy 25 Source Undetermined

26. Radial Head Fracture Most common fractures of the elbow Mechanism of Injury = Fall on outstretched hand Clinical Finding = Tenderness and swelling over the radial head Imaging May not be seen on initial x-ray or may be subtle on x-ray Evaluate for anterior or posterior fat pad which suggests diagnosis 26 Source Undetermined

27. Associated Injuries Essex- Lopresti Lesion Disruption of fibrocartilage of the wrist and interosseus membrane Distal radial-ulnar dissociation Articular surface of capitellum frequently also injured Treatment Non-displaced = Sling, Ortho follow-up Comminuted/Displaced Fractures require urgent orthopedic referral within 24 hours

28. Radial Head Subluxation Nursemaid’s elbow = Subluxation of radial head beneath the annular ligament Mechanism of injury = Longitudinal traction on hand or forearm with arm in pronation X-rays not necessary Treatment = Reduction Thumb over radial head with concurrent supination of forearm and flexion of elbow Extension and pronation (another option for reduction) 28 David Tan, Flickr

29. Radial Head Subluxation 29 Therese Clutario , Wikimedia Commons hyperpronation supination flexion

30. Thanks