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