By Chris Pullen

Common Upper LimbFractures

Common Fractures

• Clavicle • Proximal Humerus• Distal radius• Scaphoid

Clavicle

• 4% to 15% of all fractures • 35% of fractures about the shoulder• middle third++• Mechanism

– Direct trauma – indirect - fall onto the outstretched hand

Clavicle – Middle 1/3

• Most are treated non-surgically with a sling for 3 - 4 weeks

• Thereafter ROM exercises

Clavicle – Middle 1/3

• ORIF– Indications

• open fractures• neurovascular injury/compromise• displaced fractures with impending skin compromise • widely displaced midclavicular fractures

• shortening (20 mm) or gross displacement are risk factors for the development of nonunion

Clavicle – Middle 1/3

Clavicle – Lateral 1/3

• Displaced – secondary to a fracture

medial to the coracoclavicular ligaments

• ORIF (30% nonunion)• Sling 6 weeks

Proximal Humerus• 4% to 5% of all fractures• ↑ age ↑ incidence

– Elderly - fall osteoporotic bone– Young – significant trauma

• ~ 85% are minimally displaced

Proximal Humerus - Imaging

• Imaging– Plain XR

• scapular anteroposterior (AP)• lateral• axillary radiographs

– +/- CT scan

Proximal Humerus - Classification

• 4 parts (anatomic fragments)– humeral head– greater tuberosity– lesser tuberosity– humeral shaft

• Determination of – displacement >1 cm – angulation > 45°

Proximal Humerus - Nonsurgical• Minimally or non-displaced fractures• Sling or collar & cuff• Rpt XR 1 & 2 weeks• Early passive motion within 14 days• Active range of motion is started at 4 to 6

weeks– A recent report indicated that functional

outcome was inferior to previously reported results

Proximal Humerus - Surgical

• Two-part fractures of the surgical neck – most common displaced proximal humeral

fracture– closed reduction - if stable– ORIF - if cannot be reduced closed

Proximal Humerus - Surgical

• Two-part fractures of the greater tuberosity – commonly occur with

a shoulder dislocation– After reduction the

tuberosity may return to its anatomic position

– ORIF if displaced (=/- repair of the rotator cuff tear)

Proximal Humerus - Surgical

• Three-part fractures– ORIF

• functional results better

Proximal Humerus - Surgical

• Four-part fractures – ORIF

• young patients• good bone quality

– Humeral head replacement • preferred method in the

elderly• better functional scores

Distal Radius

• common • incidence ~ 1 in 500 people• bimodal age distribution

– adolescents and young adults• high-energy injuries

– postmenopausal elderly women

Distal Radius - Imaging

• Plain XR– posteroanterior (PA)– Lateral– oblique radiographs

• +/- CT scan

Distal radius - Nonsurgical• Minimally or non-displaced fractures• Elderly

–Below elbow POP 6 weeks• Young adult

–Above elbow POP 6 weeks• Rpt XR 1 & 2 weeks• ROM exercises

Distal Radius - Surgical

• Indications– Radial shortening of < 5mm at DRUJ– Dorsal tilt >/= 15° or Volar tilt >/= 20°– Intra-articular incongruity of >/= 2mm

• anatomic reduction is critical

Distal Radius - Surgical

Distal Radius - Surgical

• Options– closed reduction +/- K

wire fixation– external fixation– ORIF– arthroscopically-

assisted reduction

– bone defect filling

Distal Radius - Surgical

Distal Radius - Surgical

Scaphoid

• most common fractures of the carpus

• 75% of all carpal injuries

• Rare elderly or children

Scaphoid - Imaging

• Plain XR– Some are XR apparent at presentation– many a fracture line is not visible until bony

resorption at the fracture advances

• Rpt XR at 10 days +/- bone scan used for diagnosis of occult scaphoid fractures

Scaphoid - Nonsurgical

• Tubercle– +/- splintage for analgesia– Early ROM exercises

• Nondisplaced – immobilization until clinical or radiographic

healing occurs– ‘Glass-holding’ POP– 8 to 26 weeks

Scaphoid - Surgical

• Indications– > 10° of angular

deviation – 1 mm of displacement – Proximal pole fractures

• ORIF (compression screw)

THE END