Fractures and Dislocations- Upper-limb

Fractures and Dislocations- Upper-limb/ Anterior dislocation/ Posterior dislocation/ FOOSH/ Colles fracture / anatomy Movements Arteries nerves/ management / Reduction methods

1. Fractures and Dislocations
of Upper Limb
By :Darayus P.Gazder

2. Definition
Fracture: its a discontinuation in the continuity
of the bone.

3. Anatomy- Review

4. Shoulder:
(Anatomy Review)

10. Dislocation of shoulder
Head of humerus loses its articulation from the
glenoid cavity:
1.Anterior dislocation >95%
2.Posterior dislocation <5%
3.True Inferior dislocation (luxatio erecta) <1%

11. Anterior dislocation:
Causes: Frequently seen in younger patients after
trauma (Sports)
Symptoms: Pain, Arm is held abducted and slightly
externally rotated
Examination: Humeral head is prominent, asymmetry,
reduced ROM. Assess Neurovascular status. Commonly
the axillary nerve is affected, check for numbness over
the regimental patch (Skin over proximal arm) / Palpate
pulses (RA).
Posterior dislocation:
Causes: Usually the result of discoordinated rotator cuff
muscle contraction (Electric shock, Seizures, etc)

13. Shoulder Dislocations
Anterior Dislocation Recurrence Rate
Age 20: 80-92%
Age 30: 60%
> Age 40: 10-15%
Look for Concomitant Injuries
Bony: Bankart, Hill-Sachs Lesion, Glenoid Fracture,
Greater Tuberosity Fracture.
Soft Tissue: Subscapularis Tear.
Vascular: Axillary artery injury .
Nerve: Axillary nerve damage

16. Shoulder Dislocations
Clinical Evaluation
Examine axillary nerve (deltoid function, not
sensation over lateral shoulder)
Examine M/C nerve (biceps function and
anterolateral forearm sensation)
Radiographic Evaluation
True AP shoulder: Head of humerus can be seen
lying beneath coracoid
 Axillary view: Head of humerus lying anterior to
glenoid

23. Management of Anterior Shoulder
Dislocation
Is an Emergency
It should be reduced in less than 24 hours or
there may be Avascular Necrosis of head of
humerus
Check AXILLARY NERVE FUNCTION
Because the nerve is so vulnerable, it is
important to test the function of the nerve and
record it before
reduction is attempted.
Following reduction the shoulder should be
immobilised strapped to the trunk for 3-4
weeks and rested in a collar and cuff.

24. Methods of Reduction of anterior
shoulder Dislocation
Hippocrates Method(anesthesia required)
Stimpson’s technique (analgesia)
Kocher’s technique is the method used in
hospitals under general anesthesia and
muscle relaxation.
Milch technique is the method in which the
arm is abducted and externally rotated with
thumb pressure applied to the humeral head.

25. Hippocratic method
The doctor holds the patients affected arm by wrist
and applies traction at a 45 angle.
At the same time provides counter traction by
placing foot on the patients chest wall or having an
assistant wrap a sheet around the patient.

26. External rotation method
The patient is kept in
supine position on the
bed.
The affected arm is
adducted and flexed
at 90 at the elbow.
The arm is then slowly
externally rotated.
The shoulder should
be reduced before
reaching the coronal
plane.

27. Stimson's technique
The patient is kept in prone
position on bed.
The affected shoulder is supported
and the arm is left to hang over the
edge of the bed.
A weight is attached to the elbow
or wrist. It is usual to begin with
2kg up to 10 kg may be applied.
Gravity stretches the muscles and
reduction occurs.
Gentle internal humeral rotation
may be applied.
This method takes 15 to 20
minutes.

28. Immediate reduction
If the doctor witnesses an anterior dislocation of
the shoulder and they find no evidence of risk of
fracture then immediate reduction can be done.
This provides quick pain relief and requires less
force.
Local analgesic is injected into the joint.
The maneuver involves initial slight abduction
and internal rotation of the affected arm.
The shoulder is then immobilized using a sling.
An x-ray should be done post reduction to rule
out any fracture.

29. Leverage technique
KOCHER’S METHOD:
The affected arm in bend at 90 at elbow,
adducted against the body, the wrist and the
point of the elbow is grasped by the doctor,
slowly externally rotate between 70 to 85 until
resistance is felt. Lift the externally rotated arm
in the sagital plane as far as possible forwards
now internally rotate the shoulder this brings
the patient hand towards the opposite
shoulder. The humeral head is now slipped
back into the glenoid fossa with pain
eliminated during this process.
This method is not used frequently because of
risk of fracture of humeral neck or shaft.

30. Kocher’s Technique

32. Care after closed reduction
Neurovascular assessment should be
repeated
A post-reduction x-ray should be taken.
After reduction immobilized for 3-4 weeks.
Analgesics for pain
Physiotherapy should be done.

33. Shoulder Dislocations
Postreduction
Post reduction films are a must to confirm the
position of the humeral head
Pain control
Immobilization for 7-10 days then begin
progressive ROM
Operative Indications
Irreducible shoulder (soft tissue interposition)
Displaced greater tuberosity fractures
Glenoid rim fractures bigger than 5 mm
Elective repair for younger patients

34. Complications of anterior Shoulder
Dislocation : Early
Neuro vascular injury ( rare )
Axillary nerve injury
Associated Fracture of neck of humerus or
greater or lesser tuberosities

35. Axillary Nerve Injury
Also called circumflex nerve
It is a branch from posterior
cord of Brachial plexus
It hooks close round neck of
humerus from posterior to
anterior
It pierces the deep surface
of deltoid and supply it and
the part of skin over it

36. Complications of anterior shoulder
Dislocation : Late
Avascular necrosis of the head of the
Humerus (high risk with delayed reduction)
Heterotopic calcification ( used to be called
Myositis Ossificans )
Recurrent dislocation

37. Fractures of The Humerus
Remember the anatomy, to understand pain, nerves, vasculature/ Nerve palsies

38. Proximal Humerus Fractures

39. Proximal Humerus Fractures
Epidemiology
Most common fracture of the humerus
Higher incidence in the elderly, thought to be
related to osteoporosis
Females 2:1 greater incidence than males
Mechanism of Injury
Most commonly a fall onto an outstretched arm
from standing height
Younger patient typically present after high energy
trauma such as MVA

40. Proximal Humerus Fractures
Clinical Evaluation
Patients typically present with arm held close to
chest by contralateral hand.Pain and crepitus
detected on palpation.
Careful NV exam is essential, particularly with
regards to the axillary nerve. Test sensation
over the deltoid. Deltoid atony does not
necessarily confirm an axillary nerve injury.

42. Proximal Humerus Fractures
Neer Classification
Four parts
Greater and lesser
tuberosities,
Humeral shaft
Humeral head
A part is displaced if >1
cm displacement or
>45 degrees of
angulation is seen

43. Proximal Humerus Fractures
Treatment
Minimally displaced fractures- Sling immobilization, early
motion
Two-part fractures-
Anatomic neck fractures likely require ORIF. High incidence of
osteonecrosis
Surgical neck fractures that are minimally displaced can be
treated conservatively. Displacement usually requires ORIF
Three-part fractures
Due to disruption of opposing muscle forces, these are unstable
so closed treatment is difficult. Displacement requires ORIF.
Four-part fractures
In general for displacement or unstable injuries ORIF in the
young and hemiarthroplasty in the elderly and those with severe
comminution. High rate of AVN (13-34%)
Generally recovery takes atleast one year but union is expected
at 6 to 8 weeks.

44. Fracture Proximal Humerus :
Plating or Rush Nail insertion

45. Intra-medullary wire fixation

46. Humeral Shaft Fractures

47. Mid- Shaft Fracture
Fracture of diaphysis of the humerus
Causes: Usual cause is direct trauma/ Fall on an
outstretched hand/ Fracture pattern depends on the
stress applied)
Symptoms: Pain, swelling, decreased ROM
Examination: Assess Neurovascular status. Most
commonly the radial nerve is affected (Supplies
motor innervation to the wrist extensors and sensory
innervation to lateral dorsal hand)

50. Humeral Shaft Fractures
Holstein-Lewis Fractures
Distal 1/3 fractures
May entrap or lacerate radial nerve as the fracture
passes through the intermuscular septum

51. Humeral Shaft Fractures
Clinical evaluation
Thorough history and
physical
Patients typically present
with pain, swelling, and
deformity of the upper arm
Careful NV exam
important as the radial
nerve is in close proximity
to the humerus and can be
injured

52. Humeral Shaft Fractures
Conservative Treatment
Goal of treatment is to establish
union with acceptable alignment
>90% of humeral shaft fractures
heal with nonsurgical
management

53. Humeral Shaft Fractures
Treatment
 Operative Treatment
Indications for operative treatment
include inadequate reduction,
nonunion, associated injuries, open
fractures, segmental fractures,
associated vascular or nerve injuries
Most commonly treated with plates
and screws but also Intermedullary
nails.

54. Plating fracture Shaft of humerus

55. Intra- medullary K Wire Fixation

56. Supra- condylar Fracture of
Humerus

57. Pediatric Supra-Condylar Humeral
fracture

58. Pediatric Supra-condylar fracture

59. Reduction of supra-condylar
Fracture
Absolute Emergency
Should de done under G A by experienced
doctor as soon as possible
In the past the arm was held in flexed elbow
position in back-slab POP after reduction
At present time Percutaneous K wire
fixation is ALWAYS carried out after
reduction

60. Complications Supra-Condylar
Fractures
A.Early= Compartment syndrome
Brachial Artery injury ( Acute
Volkmann's Ischemia )
Nerve Injury
B.Late= Stiffness
Volkmann's Ischemic contracture
Malunion

61. Volkmann's Ischemic
Contracture

62. Supracondylar fracture.

64. Radial Head Fracture
Result from fall on
outstretched hand
May occur in elbow
dislocation
Swelling lat aspect
Limited ROM
Maximal tenderness
over radial head

65. Radial Head Fracture
Radiographic:
AP and lat
Fat pad may be only
clue
(occurs as a result of
distension of the
capsule by an intra-
articular
hemarthrosis)
Large sail shape
abnormal
Posterior abnormal

66. Radial Head Fracture
Most common complication
10º to 15º limit to ROM
Does not limit function
Immediate ortho referral criteria:
fracture dislocation
brachial artery or nerve injury
2mm displacement
1/3 of articulating surface
Angulated > 30º
Depressed > 3mm
Severely comminuted

67. Radial Head Fracture
Treatment non-
displaced fracture:
Immob in long-arm
posterior splint with
elbow flexed 90º.
Ice and elevation for
48 hours
Analgesia
Forearm rotation out
of splint 3-5 days
1 week – sling for
comfort only
Active ROM

68. Colles’ Fracture
Most common fracture
of the distal radius
Results from a fall on
an outstretched hand
(FOOSH)
Dorsal swelling
Eccymosis
“Silver fork” deformity of
the hand and wrist

69. Silver fork Deformity
ELEMENTS INVOLVED:
1. Backward angulation.
2. Backward displacement.
3. Radial deviation.
4. Supination.
5. Proximal impaction.

70. Colles’ Fracture
Radiographs
(AP, lat, & oblique)
Apex volar fracture
with dorsal
comminution and
shortening of the
radius
Typically occurs
within 2cm of distal
radius articular
surface

71. Colles’ Fracture
Definitive care may
be provided by
primary care
provider
Reduction of fracture
Splinting
Ortho referral
Inter-articular
fracture needs ortho
follow up

72. Smith’s Fracture
Less common fracture
of distal radius
Unstable fracture
Distal fragment is
displaced volarly and
proximally (apex dorsal)
Direct blow to dorsum
of the wrist
Splint and immediate
ortho referral

74. Galeazzi’s Fracture
Radial shaft fracture at
junction of middle and
distal thirds with
disruption of distal
radioulnar joint
Fall on extended
pronated wrist
Suspect if tenderness at
distal radius and distal
radial ulnar joint (DRUJ)
disruption

75. Galeazzi’s Fracture
Radiographic:
Transverse or oblique
fracture at junction of
middle and distal thirds
seen on AP view
Widening of DRUJ on AP
view
Fracture of base of the
ulnar styloid
Radial shortening > 5mm
Dislocation of radius
relative to ulna on lat
view

76. GALEAZZI FRACTURE-
DISLOCATION

77. Monteggia’s Fracture
Fracture of ulnar shaft
with dislocation of radial
head
Fall on outstretched,
extended, and pronated
elbow is usual
mechanism
Radial head may be
palpated in antecubital
fossa
Radial nerve
neuropraxia

78. Monteggia’s Fracture
Radiographic:
Ulnar fracture
Dislocation of radial
head
High index of
suspension required

79. MONTEGGIA FRACTURE-
DISLOCATION

80. MONTEGGIA FRACTURE-
DISLOCATION

81. Both slip after an initial good result, both are
mistaken for other fractures, and both may need
internal fixation.
Complication: MALUNION Because the distal
fragment has no longitudinal stability, the fracture is
unstable and is notorious for slipping in plaster after
an initial good position.
The fracture is best treated by internal fixation of the radius