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

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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

• 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

• 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

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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

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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

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Distal Humeral Fracture; Holstein-Lewis Fracture: 

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

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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

Ulna: Nightstick:

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

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

Radial: Galeazzi:

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

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Distal Radial Fractures:

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

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

• 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

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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%)

• 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)

• 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)

 

 

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Download the PDF version: here

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References:

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