Upper Limb Fractures

Clavicle Fractures:

  • Most common sites: middle (80%) > distal (15%) > proximal (5%)
  • Look for skin tenting -> results in open fracture by perforating the skin or creating a necrotic area
  • X-ray: AP, 45° cephalic tilt (shows sup\inf displacement)
  • NVS (brachial plexus) of the UL runs below the clavicles -> evaluate it!
  • Treatment:
    • Non-operative: if non-displaced -> sling
    • Operative: ORIF w\ plate & screws more commonly, IM nailing
      • Absolute indications: open fractures, neurovascular
      • Relative indications: skin tenting, shortening of 2 cm, 100% displacement, interfragmentary piece, ligament injury

Shoulder Dislocations:

  • Anterior: (most common)
    • MOI abduction, extension, ext rotation of the arm
    • O\E: pt’s arm will be abducted and externally rotated (can’t internally rotate), “squared off” shoulders
  • Posterior:
    • MOI: 3E’s: epilepstic seizures, EtOH, electrocution
    • O\E: pt will present w\ the arm locked in internal rotation (can’t externally rotate)
  • Inferior: aka “luxiatio erecta” (rare)
    • O\E: pt will be in saluting position
  • Clinical evaluation: apprehension test, axillary N exam (sensory patch over deltoid + abduction)
  • Hill-sachs lesion: indentation of humeral head against glenoid edge
    • Anterior dislocation -> Hill-sachs in the back
    • Posterior dislocation -> Hill-sachs in the front

UL fractures 4

  • Bankart lesion: tear in the labrum of the glenoid rim -> associated w\ high recurrence rate of shoulder dislocations esp in young pts. While in elderly, shoulder dislocations are associated w\ rotator cuff tears

UL fractures 5

  • X-ray:
    • “True” AP view
    • Axillary view -> lateral arm abduction (most imp, esp to dx post dislocation)
    • Trans-scapular Y “Mercedes-Benz sign”
    • Hill-sachs (done after 2-3 wks, not acutely)
  • Treatment methods: kocher’s (method of choice), traction-countertraction, Stimson (hanging the arm), Hippocratic method
UL fractures 8
Kocher method

Proximal Humerus Fractures:

  • Neer classification: a part is a piece w\:
    • > 1 cm displacement
    • > 45° angulation
  • Anatomic neck is closer to the head -> higher incidence of AVN
  • Examine the axillary N!
  • What’s the difference of an impression fx and Hill-sachs? Position. Impression fx is directly on the articular surface which indicates a high energy mechanism, Hill-sachs is either post or ant
  • Treatment:
    • Non-\minimally displaced: sling immobilization for 2-3 wks
    • Two or three-part fracture: ORIF
    • Four-part fracture: ORIF in young, hemiarthroplasty in elderly
UL fractures 9
Neer classification

Humeral Shaft Fractures: 

  • Examine the radial N!
  • Treatment:
    • Non-operative: initially sugar tong\hanging cast followed by Sarmiento functional brace 2 wks later
    • Operative: ORIF (open fx, neurovascular, unacceptable alignment, segmental, obesity):
      • Plate & screws most commonly

Distal Humeral Fracture; Holstein-Lewis Fracture: 

  • May entrap or lacerate radial N (fix it even if no radial N sx)

UL fractures 12

Forearm Fractures:

  • Contralateral X-ray are a must esp in bone loss? to recreate the normal side while fixation: alignment, length, and rotation -> it becomes your template
  • How to check rotation? Supination\pronation
  • Ulna can be negative, positive, neutral

UL fractures 13

Ulna: Nightstick:

  • Isolated ulnar fx w\out radial head dislocation
  • Direct blow to forearm -> holding up arm to protect face

UL fractures 14

Ulna: Monteggia:

  • Prox ulnar fx + radial head dislocation (PRUJ injury)
  • Bado classification:
    • Type I: anterior radial head dislocation
    • Type II: posterior radial head dislocation
    • Type III: lateral radial head dislocation
    • Type IV: both ulna and radius are fractured

UL fractures 15

Radial: Galeazzi:

  • Distal radial fx + DRUJ dislocation
  • Reverse Galeazzi: ulnar fx + DRUJ dislocation
  • MOI: FOOSH on pronation

UL fractures 16

Distal Radial Fractures:

  • Most common upper limb fx
  • Clinical evaluation: check ipsilateral elbow and shoulder, carpal tunnel syndrome

UL fractures 17

  • X-ray: AP (radial inclination and radial length) + lateral (volar tilt)

UL fractures 21

  • Treatment:
    • Non-operative:
      • Manual closed reduction under hematoma block
      • Traction w\ finger traps -> ulnar deviation volar flex to max length of radius to use the force on the radial column
      • Sugar tong, full circular cast
    • Operative: if open fx, neurovascular, failed closed reduction, loss of reduction

Scaphoid Fractures: 

  • Most common carpal bone fx
  • Site: waist > proximal (worst prognosis, highest risk of AVN) > distal
  • MOI: hyper-extended + radially diverted wrist
  • Blood supply: 
    • Dorsal: radial A -> dorsal carpal branch (80%, retrograde)
    • Volar: radial A -> superficial palmar branch (20%)

UL fractures 22

  • Clinical evaluation:
    • Dorsally: snuff box tenderness
    • Volarlly: scaphoid tubercle tenderness
    • Pain w\ resisted pronation
  • X-ray: AP, lateral, scaphoid-specific views (wrist ext w\ ulnar deviation -> shows fx in a clear line)

UL fractures 23

  • Treatment:
    • Non-operative: usually non-displaced -> long-arm thumb spica cast for 4 wks then short arm cast until radiological evidence of healing (2-3 mo)
    • Operative:
      • Minimal displacement -> percutaneous fixation w\ headless (countersink) screw
      • Severe displacement, humpback deformity -> ORIF w\ headless (countersink) screw
  • If the pt’s presenting w\ a clinical picture of scaphoid fracture but no radiological signs? Manage it as scaphoid fx. Bc it might be a hairline fx which doesn’t appear until 2-3 wks when bone resorption happens, so treat as scaphoid fx and repeat X-ray 2 wks later to r\o fx. (or do CT from the beginning and you can see it clearly)



Download the PDF version: here


  • Dr. Khalid Alsheikh’s lecture
  • Toronto notes
  • Orthobullets

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