Download Fractures and Dislocation of the Upper Extremity

Upper Extremity
Fractures and Dislocations
Clavicle Fracture
• Epidemiology:
– Clavicle fractures account for 2.6% to 12% of all fractures and for 44% to
66% of fractures about the shoulder.
– Middle third fractures account for 80% of all clavicle fractures, whereas
fractures of the lateral and medial third of the clavicle account for 15%
and 5%, respectively.
• Anatomy:
– The clavicle is the first bone to ossify (fifth week of gestation) and the last
ossification center (sternal end) to fuse, at 22 to 25 years of age.
– The clavicle is S-shaped, with the medial end convex forward and the
lateral end concave forward.
– The junction between the two cross-sectional configurations occurs in the
middle third and constitutes a vulnerable area to fracture, especially with
axial loading. Moreover, the middle third lacks reinforcement by muscles
or ligaments distal to the subclavius insertion, resulting in additional
vulnerability.
Clavicle Fracture
• Mechanism of injury:
– Falls onto the affected shoulder account for most (87%) of clavicular
fractures, with direct impact accounting for only 7% and falls onto an
outstretched hand accounting for 6%.
Clavicle Fracture
• Clinical Evaluation
– Patients usually present with splinting of the affected
extremity, with the arm adducted across the chest and
supported by the contralateral hand to unload the
injured shoulder.
– A careful neurovascular examination is necessary to
assess the integrity of neural and vascular elements
lying posterior to the clavicle.
– The proximal fracture end is usually prominent and
may tent the skin. Assessment of skin integrity is
essential to rule out open fracture.
Clavicle Fracture
• Radiographic Evaluation
– Standard anteroposterior radiographs are generally sufficient to
confirm the presence of a clavicle fracture and the degree of fracture
displacement.
– A 30-degree cephalad tilt view provides an image without the overlap
of the thoracic anatomy.
Clavicle Fracture
Most clavicle fractures can be successfully treated
nonoperatively with some form of immobilization.
Glenohumeral Dislocation
• Epidemiology
– The shoulder is the most commonly dislocated major joint
of the body, accounting for up to 45% of dislocations.
– Most shoulder dislocations are anterior; this occurs
between eight and nine times more frequently than
posterior dislocation, the second most common direction
of dislocation.
– Inferior and superior shoulder dislocations are rare.
Anterior glenohumeral dislocation
represent 90% of shoulder dislocations
• Mechanism of Injury
– Anterior glenohumeral dislocation may occur as a
result of trauma, secondary to either direct or indirect
forces.
– Indirect trauma to the upper extremity with the
shoulder in abduction, extension, and external
rotation is the most common mechanism.
– Direct, anteriorly directed impact to the posterior
shoulder may produce an anterior dislocation.
– Convulsive mechanisms and electrical shock typically
produce posterior shoulder dislocations, but they may
also result in an anterior dislocation.
Glenohumeral Dislocation
• Clinical Evaluation
– The patient typically presents with the injured shoulder held in
slight abduction and external rotation. The acutely dislocated
shoulder is painful, with muscular spasm.
– Examination typically reveals squaring of the shoulder owing to
a relative prominence of the acromion, a relative hollow
beneath the acromion posteriorly, and a palpable mass
anteriorly.
– A careful neurovascular examination is important, with attention
to axillary nerve integrity. Deltoid muscle testing is usually not
possible, but sensation over the deltoid may be assessed.
Deltoid atony may be present and should not be confused with
axillary nerve injury. Musculocutaneous nerve integrity can be
assessed by the presence of sensation on the anterolateral
forearm.
Glenohumeral Dislocation
• Radiographic Evaluation
– Trauma series of the affected shoulder: Anteroposterior (AP),
scapular-Y, and axillary views taken in the plane of the scapula.
Glenohumeral Dislocation
Glenohumeral Dislocation
Treatment – Closed Reduction
Glenohumeral Dislocation
Treatment – Closed Reduction
Humeral Shaft Fracture
• Mechanism of injury:
– Direct (most common): Direct trauma to the arm from a
blow or motor vehicle accident results in transverse or
comminuted fractures.
– Indirect: A fall on an outstretched arm results in spiral or
oblique fractures, especially in elderly patients.
Uncommonly, throwing injuries with extreme muscular
contraction have been reported to cause humeral shaft
fractures.
– Fracture pattern depends on the type of force applied:
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Compressive: proximal or distal humeral fractures
Bending: transverse fractures of the humeral shaft
Torsional: spiral fractures of the humeral shaft
Torsional and bending: oblique fracture, often accompanied by a
butterfly fragment
Humeral Shaft Fracture
• Clinical Evaluation:
– Patients with humeral shaft fractures typically present with
pain, swelling, deformity, and shortening of the affected
arm.
– A careful neurovascular examination is essential, with
particular attention to radial nerve function. In cases of
extreme swelling, serial neurovascular examinations are
indicated with possible measurement of compartment
pressures.
– Physical examination frequently reveals gross instability
with crepitus on gentle manipulation.
– Soft tissue abrasions and minor lacerations must be
differentiated from open fractures.
Humeral Shaft Fracture
• Radiographic Evaluation:
– AP and lateral radiographs of the humerus should
be obtained, including the shoulder and elbow
joints on each view. To obtain views at 90° from
each other, the patient, NOT the arm, should be
rotated, as manipulation of the injured extremity
will typically result in distal fragment rotation only.
– Radiographs of the contralateral humerus may aid
in preoperative planning.
Humeral Shaft Fracture
Humeral Shaft Fracture
• Treatment:
– The goal is to establish union with an acceptable
humeral alignment and to restore the patient to
preinjury level of function.
– Both patient and fracture characteristics, including
patient age and functional level, presence of
associated injuries, soft tissue status, and fracture
pattern, need to be considered when selecting an
appropriate treatment option.
Supracondylar Humerus Fracture
Elbow Dislocation
• Epidemiology:
– Accounts for 11% to 28% of injuries to the elbow.
– Posterior dislocation is most common.
– Simple dislocations are those without fracture.
– Complex dislocations are those that occur with an
associated fracture and represent just under 50%
of elbow dislocations.
– Highest incidence in the 10- to 20-year old age
group associated with sports injuries, although
recurrent dislocation is uncommon.
Elbow Dislocation
• Mechanism of injury:
– Most commonly, injury is caused by a fall onto an
outstretched hand or elbow, resulting in a levering
force to unlock the olecranon from the trochlea
combined with translation of the articular surfaces
to produce the dislocation.
– Posterior dislocation: This is a combination of
elbow hyperextension, valgus stress, arm
abduction, and forearm supination.
Elbow Dislocation
• Mechanism of injury:
– Most commonly, injury is caused by a fall onto an
outstretched hand or elbow, resulting in a levering
force to unlock the olecranon from the trochlea
combined with translation of the articular surfaces
to produce the dislocation.
– Posterior dislocation: This is a combination of
elbow hyperextension, valgus stress, arm
abduction, and forearm supination.
Elbow Dislocation
• Clinical Evaluation:
– Patients typically guard the injured upper extremity, which
shows variable gross instability and swelling.
– A careful neurovascular examination is essential and
should be performed before radiography or manipulation.
– Following manipulation or reduction, repeat neurovascular
examination should be performed to assess neurovascular
status.
– Serial neurovascular examinations should be performed
when massive antecubital swelling exists or when the
patient is felt to be at risk for compartment syndrome.
Elbow Dislocation
Elbow Dislocation
• Treatment:
– Acute simple elbow dislocations should undergo closed reduction with the
patient under sedation and adequate analgesia. Alternatively, general or
regional anesthesia may be used.
– Correction of medial or lateral displacement followed by longitudinal traction
and flexion is usually successful for posterior dislocations.
– For posterior dislocations, reduction should be performed with the elbow
flexed while providing distal traction.
– Neurovascular status should be reassessed, followed by evaluation of stable
range of elbow motion.
– Postreduction radiographs are essential.
– Postreduction management should consist of a posterior splint at 90 degrees
and elevation.
– Early, gentle, active range of elbow motion is associated with better long-term
results. Prolonged immobilization is associated with unsatisfactory results and
greater flexion contracture.
– Recovery of motion and strength may require 3 to 6 months.
Elbow Dislocation
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(A) Parvin’s method of closed reduction of an elbow dislocation. The patient lies prone on a
stretcher, and the physician applies gentle downward traction of the wrist for a few minutes. As the
olecranon begins to slip distally, the physician lifts up gently on the arm. No assistant is required,
and if the maneuver is done gently, no anesthesia is required.
(B) In Meyn and Quigley’s method of reduction, only the forearm hangs from the side of the
stretcher. As gentle downward traction is applied on the wrist, the physician guides reduction of the
olecranon with the opposite hand.
Radius and ulna shaft fracture
• Clinical Evaluation:
– Patients typically present with gross deformity of
the involved forearm, pain, swelling, and loss of
hand and forearm function.
– A careful neurovascular examination is essential,
with assessment of radial and ulnar pulses, as well
as median, radial, and ulnar nerve function.
– One must carefully assess open wounds because
the ulna border is subcutaneous, and even
superficial wounds can expose the bone.
Radius and ulna shaft fracture
• Operative treatment:
– Open reduction and internal fixation is the procedure of choice
for displaced forearm fractures involving the radius and ulna in
adults.
– Internal fixation involves use of compression plating (3.5-mm
dynamic compression plate) with or without bone grafting.
– Principles of plate fixation:
• Restore ulnar and radial length (prevents subluxation of either the
proximal or distal radioulnar joint).
• Restore rotational alignment.
• Restore radial bow (essential for rotational function of the forearm).
– External fixation may be used in cases with severe bone or soft
tissue loss, gross contamination, infected nonunion, or in cases
of open elbow fracture-dislocations with soft tissue loss.
Distal Radius Fracture
• Epidemiology:
– Distal radius fractures are among the most common
fractures of the upper extremity.
– Fractures of the distal radius represent approximately onesixth of all fractures treated in emergency departments.
– The incidence of distal radius fractures in the elderly
correlates with osteopenia and rises in incidence with
increasing age, nearly in parallel with the increased
incidence of hip fractures.
– Risk factors for fractures of the distal radius in the elderly
include decreased bone mineral density, female sex, white
race, family history, and early menopause.
Distal Radius Fracture
• Mechanism of injury:
– Common mechanisms in younger individuals include falls from a
height, motor vehicle accident, or injuries sustained during athletic
participation. In elderly individuals, distal radial fractures may arise
from low-energy mechanisms, such as a simple fall from a standing
height.
– The most common mechanism of injury is a fall onto an outstretched
hand with the wrist in dorsiflexion.
– Fractures of the distal radius are produced when the dorsiflexion of
the wrist varies between 40 and 90 degrees, with lesser degrees of
force required at smaller angles.
– The radius initially fails in tension on the volar aspect, with the
fracture propagating dorsally, whereas bending moment forces induce
compression stresses resulting in dorsal comminution. Cancellous
impaction of the metaphysis further compromises dorsal stability.
Additionally, shearing forces influence the injury pattern, often
resulting in articular surface involvement.
– High-energy injuries (e.g., vehicular trauma) may result in significantly
displaced or highly comminuted unstable fractures to the distal radius.
Distal Radius Fractures
Distal Radius Fracture
Distal Radius Fracture
• Treatment:
– All fractures should undergo closed reduction, even if it is
expected that surgical management will be needed.
• Fracture reduction helps to limit postinjury swelling, provides pain
relief, and relieves compression on the median nerve.
– Cast immobilization is indicated for:
• Nondisplaced or minimally displaced fractures.
• Displaced fractures with a stable fracture pattern which can be
expected to unite within acceptable radiographic parameters.
• Low-demand elderly patients in whom future functional impairment is
less of a priority than immediate health concerns and/or operative
risks.
– Hematoma block with supplemental intravenous sedation, Bier
block, or conscious sedation can be used to provide analgesia
for closed reduction.
Distal Radius Fracture
– Technique of closed reduction (dorsally tilted fracture):
• The distal fragment is hyperextended.
• Traction is applied to reduce the distal to the proximal fragment with pressure
applied to the distal radius.
• A well-molded long arm (sugar-tong) splint is applied, with the wrist in neutral
to slight flexion.
• One must avoid extreme positions of the wrist and hand.
• The cast should leave the metacarpophalangeal joints free.
– Once swelling has subsided, a well-molded cast is applied.
– Extreme wrist flexion should be avoided, because it increases carpal
canal pressure (and thus median nerve compression) as well as digital
stiffness. Fractures that require extreme wrist flexion to maintain
reduction may require operative fixation.
– The cast should be worn for approximately 6 weeks or until
radiographic evidence of union has occurred.
– Frequent radiographic examination is necessary to detect loss of
reduction.