UPPER LIMB FRACTURES

Dr VARUN SHARMARESIDENT IN ORTHOPEDICS AND TRAUMATOLOGY

OSMANIA GENERAL HOSPITAL

Topics

• Fractures of proximal end of radius.• Fractures of proximal end of ulna.• Fractures of both bones of the forearm.• Fractures around wrist• Injuries of hand.

Pulled elbow

• Traumatic subluxation• 2-6yrs age• Jerk on forearm• Pain in elbow n tenderness in proximal radius• Radiographs normal• Rx simple manipulation of FA into supination with

elbow stabilised• Palpable click, pain decreases n normal movement

restored.•

Proximal End of RADIUS

Types

• Fracture Head.• Fracture neck.• Epiphyseal injuries.

Fracture head of radius

• Mechanism: Forcible valgus strain, head against capitellum, loose fragments into joint.

• Masons classification

Symptoms

• Pain on the outside of the elbow• Swelling in the elbow joint• Difficulty in bending or straightening the

elbow accompanied by pain• Inability or difficulty in turning the forearm

(palm up to palm down or vice versa)

Treatment

• Type I Fractures• Type I fractures are generally small, like cracks, and the

bone pieces remain fitted together.• The fracture may not be visible on initial X-rays, but

can usually be seen if the X-ray is taken three weeks after the injury.

• Nonsurgical treatment involves using a splint or sling for a few days, followed by early motion.

• If too much motion is attempted too quickly, the bones may shift and become displaced.

Treatment• Type II Fractures• Type II fractures are slightly displaced and involve a larger piece of bone.• If displacement is minimal, splinting for one to two weeks, followed by

range of motion exercises, is usually successful.• Small fragments may be surgically removed.• If the fragment is large and can be fitted back to the bone, the

orthopaedic surgeon will first attempt to fix it with pins or screws. If this is not possible, however, the surgeon will remove the broken pieces or the radial head.

• For older, less active individuals, the surgeon may simply remove the broken piece, or perhaps the entire radial head.

• The surgeon will also correct any other soft-tissue injury, such as a torn ligament.

• Type III Fractures• Type III fractures have multiple broken pieces of bone, which

cannot be fitted back together for healing.• Usually, there is also significant damage to the joint and

ligaments.• Surgery is always required to remove the broken bits of bone,

including the radial head, and repair the soft-tissue damage.• Early movement to stretch and bend the elbow is necessary

to avoid stiffness.• A prosthesis (artificial radial head) can be used to prevent

deformity if elbow instability is severe.

Complications

• Myositis ossificans

Olecranon fracture

• Mechanism• A direct blow. This can happen in a fall (landing

directly on the elbow) or by being struck by a hard object (baseball bat, dashboard of a car during a crash).

• An indirect fracture. This can happen by landing on an outstretched arm. The person lands on the wrist with the elbow locked out straight. The triceps muscle on the back of the upper arm help "pull" the olecranon off of the ulna.

Symptoms

• Sudden, intense pain• Inability to straighten elbow• Swelling over the bone site• Bruising around the elbow• Tenderness to the touch• Numbness in one or more fingers• Pain with movement of the joint

• Radiographs– recommended views

• AP/lateral radiographs

– true lateral essential for determination of fracture pattern

– additional views• radiocapitellar may be helpful for

– radial head fracture– capitellar shear fracture

• CT– may be useful for preoperative planning in comminuted

fractures

Nonoperative

• immobilization– indications

• nondisplaced fractures• displaced fracture is low demand, elderly individuals

• Technique• immobilization in 45-90 degrees of flexion for

3 weeks• begin motion at 3 weeks

Operative

• tension band technique – indications

• transverse fracture with no comminution

– outcomes• excellent results with appropriate indications

• technique– converts distraction force of triceps into a compressive force– engaging anterior cortex of ulna with Kirschner wires may prevent wire migration– avoid overpenetration of wires through anterior cortex

• may injury anterior interosseous nerve (AIN) • may lead to decreased forearm rotation

– use 18-gauge wire in figure-of-eight fashion through drill holes in ulna• cons

– high % of second surgeries for hardware removal (40-80%) – does not provide axial stability in comminuted fractures

Olecranon Fracture

ORIF with Tension Band Wiring

• plate and screw fixation indications – comminuted fractures– Monteggia fractures– fracture-dislocations– oblique fractures that extend distal to coronoid

• technique– place plate on dorsal (tension) side– oblique fractures benefit from lag screws in addition to plate

fixation– one-third tubular plates may not provide sufficient strength in

comminuted fractures– may advance distal triceps tendon over plate to avoid hardware

prominence• pros

– more stable than tension band technique• cons

– 20% need second surgery for plate removal

• intramedullary fixation indications

– transverse fracture with no comminution (same as tension band technique)

• excision and triceps advancementindications

– elderly patients with osteoporotic bone– fracture must involve <50% of joint surface– nonunions

• outcomes– salvage procedure that leads to decreased extension strength– may result in instability if ligamentous injury is not diagnosed before

operation

Complications• Symptomatic hardware

– most frequent reported complication• Stiffness

– occurs in ~50% of patients– usually doesn't alter functional capabilities

• Heterotopic ossification– more common with associated head injury

• Posttraumatic arthritis• Nonunion

– rare• Ulnar nerve symptoms• Anterior interosseous nerve injury• Loss of extension strength

Terrible triad of elbow

• A traumatic injury pattern of the elbow characterized by– posterolateral dislocation– radial head fx– coronoid fracture

• Mechanism is fall on extended arm that leads to– valgus stress produces posterolateral dislocation– structures of elbow fail from lateral to medial

• anterior bundle of MCL last to fail• LCL disrupted in most cases

• Nonoperativeimmobilize in 90 deg of flexion for 7-10 days

• Operativeacute radial head stabilization, coronoid ORIF, and LCL reconstruction, MCL reconstuction if needed

Monteggia fracture

• Injury defined as– proximal 1/3 ulnar fracture with associated radial

head dislocation• Epidemiology

– rare in adults– more common in children with peak incidence

between 4 and 10 years of age• different treatment protocol for children

classification

• Symptoms– pain and swelling at elbow joint

• Physical exam– inspection

• may or may not be obvious dislocation at radiocapitellar joint• should include skin integrity

– ROM & instability• may be loss of ROM at elbow due to dislocation

– neurovascular exam• PIN neuropathy

– radial deviation of hand with wrist extension– weakness of thumb extension– weakness of MCP extension– most likely nerve injury

• Radiographs– recommended view

• AP and Lateral of elbow, wrist, and forearm

• CT scan– helpful in fractures involving coronoid, olecranon,

and radial head

Rx

• Operative• ORIF of ulna shaft fracture• ORIF of ulna shaft fracture, open reduction of

radial head• IM Nailing of ulna

complications

• PIN neuropathy– up to 10% in acute injuries– treatment

• observation for 2-3 months– spontaneously resolves in most cases– if no improvement obtain nerve conduction studies

• Malunion with radial head dislocation– caused by failure to obtain anatomic alignment of ulna– treatment

• ulnar osteotomy and open reduction of the radial head

Fracture both bones of forearm

BB FA Fracture

• Mechanismdirect trauma– often while protecting one's head

• indirect trauma– motor vehicle accidents– falls from height– athletic competition

• closed versus open• location• comminuted, segmental, multifragmented• displacement• angulation• rotational alignment

• Radiographsrecommended views– AP and lateral views of the forearm

• additional views– oblique forearm views for further fracture

definition– ipsilateral wrist and elbow

• to evaluate for associated fractures or dislocation• radial head must be aligned with the capitellum on all

views

Nonoperative

• functional fx brace with good interosseous mold – indications

• isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx) with

– < 50% displacement and– < 10° of angulation

– outcomes• union rates > 96%• acceptable to fix surgically due to long time to union

Operative

• ORIF without bone grafting• ORIF with bone grafting• external fixation• IM nailing

ORIF with DCP CRIF or ORIF with Rush/ Square Nail

Complications

• Synostosis • Infection• Compartment syndrome• Nonunion• Malunion• Neurovascular injury

Refracture

Galeazzi Fractures

• Defined as• distal 1/3 radius shaft fx AND• associated distal radioulnar joint (DRUJ) injury

• Mechanism• direct wrist trauma

– typically dorsolateral aspect• fall onto outstretched hand with forearm in

pronation

• Symptoms– pain, swelling, deformity

• Physical exam– point tenderness over fracture site– ROM

• test forearm supination and pronation for instability

– DRUJ stress• causes wrist or midline forearm pain

• Radiographsrecomended views– AP and lateral views of forearm, elbow, and wrist

• findings– signs of DRUJ injury

• ulnar styloid fx• widening of joint on AP view• dorsal or volar displacement on lateral view• radial shortening (≥5mm)

Rx

• Operative• ORIF of radius with reduction and

stabilization of DRUJ– indications

• all cases, as anatomic reduction of DRUJ is required• acute operative treatment far superior to late

reconstruction

Complications

• Compartment syndrome

• Neurovascular injury

• Refracture

• Nonunion• Malunion• DRUJ subluxation

Monteggia Fracture Dislocation

Dislocation

Fracture

Dislocation

Fracture

GALEAZZI FRACTURE DISLOCATION

• Most common orthopaedic injury with a bimodal distribution– younger patients - high energy– older patients - low energy / falls

• 50% intra-articular• Associated injuries

– DRUJ injuries must be evaluated– radial styloid fx - indication of higher energy

• Osteoporosis– high incidence of distal radius fractures in women >50– distal radius fractures are a predictor of subsequent fractures

• DEXA scan is recommended in woman with a distal radius fracture

Distal Radius Fractures

Dinner fork Deformity

• Transverse fracture at the cortico-cancellous junction of distal radius often associated with ulnar styloid fracture

Colles’ Fracture

Displacements• Impaction• Dorsal shift • Dorsal tilt• Radial shift• Radial tilt• Supination

Colles’ fracture

Eponyms

Die-punch

fxs

A depressed fracture of the lunate fossa of the articular surface of the distal radius   

Barton's fx

Fx dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip

(volar Barton or dorsal Barton fx)

Chauffer's fx

Radial styloid fxx

Colles' fx

Low energy, dorsally displaced, extra-articular fx

Smith's fx

Low energy, volar displaced, extra-articular fx

• Successful outcomes correlate with– accuracy of articular reduction– restoration of anatomic relationships– early efforts to regain motion of wrist and fingers

• Nonoperative– closed reduction and cast immobilization

• indications– extra-articular– <5mm radial shortening– dorsal angulation <5° or within 20° of contralateral distal radius

• technique (see below)

• Indications– most extra-articular fxs

• Technique– rehabilitation

• no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization

• Outcomes– repeat closed reductions have 50% less than satisfactory results

• Complications– acute carpal tunnel syndrome

• (see complications below)

– EPL rupture• (see complications below)

Colles cast

• Operative• surgical fixation • CRPP,• External Fixation,• ORIF)

Complications

• Median nerve neuropathy (CTS)Ulnar nerve neuropathy EPL rupture Radiocarpal arthrosis (2-30%)Malunion and NonunionECU or EDM entrapmentCompartment syndrome

• RSD/CRPS

• Conservative most of the cases Manual reduction and below elbow cast

Techinque of reduction Disimpaction Palmar flexion Ulnar deviation Pronation

• Surgery- Unstable/Communited/intraarticular- ORIF or External Fixation

Treatment

ORIF

K wire fixation

External fixation

• Fracture of distal end of radius involving articular surface

• Types Dorsal barton Volar Barton

Barton’s fracture

• Reversed Colles’ fracture• GARDEN SPADE DEFORMITY

TREATMENT:• Reduction held in 30 degree Dorsiflexion of

wrist and supination of Forearm with above elbow plaster

Smith’s Fracture

Pain in the snuff box after FOOSH

Scaphoid fracture

• Scaphoid is most commonly fractured carpal bone.• Most common mechanism is axial load across hyper-

extended and radially deviated wrist. – common in contact sports

• Incidence of fracture by location– waist -65%– proximal third - 25%– distal third - 10%

• distal pole is most common location in kids due to ossification sequence

• Incidence of AVN with fracture location– proximal 5th AVN rate of 100%– proximal 3rd AVN rate of 33%

Blood supply

• major blood supply is dorsal carpal branch (branch of the radial artery) – enters scaphoid in a nonarticular ridge on the

dorsal surface and supplies proximal 80% of scaphoid via retrograde blood flow

• minor blood supply from superficial palmar arch (branch of volar radial artery) – enters distal tubercle and supplies distal 20% of

scaphoid

• Radiographs should include– AP and lateral– AP view of the scaphoid with the hand in ulnar

deviation– 45° pronation view

• Bone scan– effective to diagnose ocult fractures

• specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72 hours

• positive within 24 hours, perform at 72 hours

• MRI– effective diagnose ocult fractures– allows immediate identification of fractures and ligamentous injuries in

addition to assessment of vascular status of bone (vascularity of proximal pole)

• CT scan with 1mm cuts– less effective than bone scan and MRI to diagnose occult fracture– can be used to evaluate location of fracture, size of fragments, extent of

collapse, and progression of nonunion

• Most commonly fractured of carpal bones• Any fracture at the waist or proximal third of bone

cuts off blood supply to the proximal pole leading to AVN of prox pole or Non Union of fracture

TREATMENT Scaphoid Cast immobilsation for undisplaced

fracture ORIF with HERBERT’s screw for displaced fracture

Scaphoid Fracture

Scaphoid Cast

Herbert Screw Fixation

Intraarticular # base of 1st Metacarpal with carpometacarpal dislocation

A K A Bennett’s Fracture Dislocation

Bennett fracture

• Intra-articular fracture/dislocation of base of 1st metacarpalsmall fragment of 1st metacarpal continues to articulate with trapezium

• lateral retraction of 1st metacarpal shaft by APL and adductor pollicis

Treatment

• closed reduction & cast immobilization– indications

• nondisplaced fractures

– technique• reduction maneuver with traction, extension, pronation, and abduction

• reduction and percutaneous K wire stabilization to adjacent metacarpals– indications

• displaced fractures in which a adequare reduction is obtains

• ORIF– indications

• reduction and percutaneous K wire stabilization to adjacent metacarpals

Often requires ORIF with K wires

• Communited Intra-articular fracture of base of first metacarpal

• Similar to a Bennett fracture but more extensive comminution and displacement – less common than Bennet's fx– worse prognosis

• Treatment– ORIF

• indications– most cases

ROLANDO’s fracture

Mallet finger

• A finger deformity caused by disruption of the terminal extensor tendon distal to DIP joint– the disruption may be bony or tendinous

• Mechanism– traumatic impaction blow

• usually caused by a traumatic impaction blow to the tip of the finger in the extended position.

• forces the DIP joint into forced flexion

– dorsal laceration• a less common mechanism of injury is a sharp or crushing-type

laceration to the dorsal DIP joint

• Flexion deformity of DIP jt due to injury of extensor digitorum tendon often with a chip of bone

Mallet finger

Rx

• Nonoperativeextension splinting of DIP joint for 6-8 weeks

• OperativeCRPP vs ORIF• surgical reconstruction of terminal tendon