Download EN 13 Fractures of the upper extremity

DEPARTMENT OF TRAUMATOLOGY AND HAND
SURGERY
INSTITUTE OF MUSCULOSKELETAL SURGERY
UPPER EXTREMITY TRAUMA
Presenter:
Dr Laszlo G Nöt
ENGLISH PROGRAM LECTURES – EN_12 - 2014
CHARACTERISTICS OF UPPER EXRTEMITY TRAUMAS
• Injuries of the upper extremities impairs
peoples‟ ability to handle and get
contact properly with their environment.
• The upper extremity is basically „designed‟
for motion, not for the support of large
loads!!
TOPICS
• Scapula
• Clavicle and AC-joint
• Shoulder Dislocation
• Humerus
• Elbow
• Forearm
fractures)
fractures
(except
distal
radius
CLAVICLE FRACTURE
Mechanism:
• Fall
onto shoulder (87%)
• Direct blow (7%)
• Fall onto outstretched hand (6%)
Trimodal distribution:
80
70
60
50
40
Percent
30
20
10
0
Group I
(13yrs)
Group 2
(47yrs)
Group 3
(59yrs)
Notably: the clavicle is the last ossification center to complete (sternal end)
at about 22-25yo.
CLAVICLE FRACTURE
EXAMINATION OF CLAVICLE FRACTURES
Clinical Evaluation:
• Inspect and palpate for deformity/abnormal motion
• Thorough distal neurovascular exam
• Auscultate the chest for the possibility of lung injury
pneumothorax
Radiographic Exam
• AP (PA) chest radiographs
• Clavicular 45deg A/P oblique X-rays
•Traction pictures may be used as well
CLAVICLE FRACTURE
CLASSIFICATION OF CLAVICLE FRACTURES
Allman Classification of Clavicle Fractures:
- Type I: Middle Third (80%)
- Type II: Distal Third (15%) /Differentiate whether ligaments attached to
lateral or medial fragment/
- Type III: Medial Third (5%)
CLAVICLE FRACTURE
TREATMENT OF CLAVICLE FRACTURES
I. Non-operative treatment
• closed reduction, „backpack‟ („8-shaped‟) bandage; sling
immobilization or Gilchrist / Desault bandage for 3 weeks.
II. Operative treatment
• TEN (Titanium Elastic Nail) fixation
• plate OS, „hook‟ – plate, clavicle - plate
• distal end frx: usually operative
• open fracture
• associated with NV injury or severe chest injury
• cosmetic reason, uncontrolled deformity, nonunion, etc…
CLAVICLE FRACTURE
MIDDLE SHAFT CLAVICLE FRACTURE
CLAVICLE FRACTURE
TEN (Titanium Elastic Nail) fixation
FRACTURES OF THE SCAPULA
• relatively
rare injuries
• usually: neck or the glenoid cavity
are involved
• facture of the body of the scapula:
generally requires conservative
treatment (3-4 weeks of
immobilization: splint, bandage, etc…)
• operative treatment:
- displaced neck fracture
- closed reduction is not possible
- involvement of glenoid cavity (articular surface!)
`FLOATING SHOULDER`
Definition: refers to ipsilateral fracture of scapula
(neck) and clavicle (or AC joint injury)
Indication of operation!!
SC (sternoclavicular) DISLOCATIONS
Mechanism:
• indirect (presternal dislocation)
• direct (retrosternal dislocation) – accompanied with a
possibly of artery, nerve or esophagus.
Treatment:
• reduction: easy BUT retention: difficult
• nonoperative: 3-4 weeks immobilization
• operative: K-wire, resection of clavicle proximal end
AC (acromioclavicular) DISLOCATIONS
Tossy – Rockwood Classification
DESCRIPTION OF ACROMIOCLAVICULAR JOINT DISRUPTIONS
Tossy & Rockwood Classification *
Type I - joint sprained without tear of either ligament
Type II - AC ligaments torn but CC ligaments intact. Lateral end of
clavicle is not elevated.
Type III - AC and CC ligaments torn, >5 mm elevation of AC joint in
unstressed X-ray. Take care to distinguish from type III (distal)
clavicular fracture. Typical symptom: piano key effect!!
Type IV - lateral clavicle separated and impaled posteriorly into
trapezial fascia.
Type V - complete separation of clavicle and scapula with gross upward
clavicular displacement.
Type VI - as type V but with clavicle detached inferiorly and displaced
behind tendons of biceps and brachioradialis.
* Prybyla D et al; Acromioclavicular Joint Separations, Medscape, Feb 2012
DIAGNOSTICS OF ACROMIOCLAVICULAR JOINT DISRUPTIONS
• Physical examination – Type III: Typical symptom: piano key effect!!
• Plain radiographs are the initial choice.
• Type I and II injuries may be differentiated using stressed radiographs
where weights are hung from the patient's wrists, although many
consider this technique to be unhelpful.
• Carefully inspect the scapula to rule out associated scapular fracture.
• Be cautious to avoid overlooking a possible distal clavicle fracture.
• CT or MRI only in special, selected cases, regularly to rule out malignant
bone / soft tissue lesions.
THERAPY OF ACROMIOCLAVICULAR JOINT DISRUPTIONS
Types I and II injuries:
- managed conservatively with ice, a sling for 1-3 weeks and
non-steroidal anti-inflammatory drugs (NSAIDs) followed by
physiotherapy to strengthen muscles and ligaments after the
acute phase.
Type III injuries:
- selected cases may benefit from surgical intervention (K-wire,
tension band, hook-plate)
Types IV to VI injuries:
- nearly always treated with open reduction and internal fixation.
There is controversy about the efficacy of surgical reconstruction versus nonoperative intervention for grade III type injuries. However grade I and II separations
seem to respond favorably to conservative management. Grade IV, V, and VI
separations often require surgical reconstruction. Cote MP et al; Rehabilitation of
acromioclavicular joint separations.. Clin Sports Med. 2010 Apr;29(2):213-28.
AC-DISPRUPTION – K-WIRE FIXATION
LATERAL CLAVICLE FRACTURE – TENSION BAND
LATERAL CLAVICLE FRACTURE – HOOK-PLATE OS
SHOULDER ANATOMY
Rotator cuff:
- subscapularis
- supraspinatus
- infraspinatus
- teres minor
Primary source of stability
to the shoulder.
SHOULDER DISCLOCATIONS
SHOULDER DISCLOCATIONS
SHOULDER DISCLOCATIONS
EPIDEMIOLOGY
• Anterior: most common
• Posterior: uncommon, <10%, electrocutions & seizures
• Inferior (Luxatio Erecta): rare, „hyperabduction‟ injury
CLINICAL EVALUATION
• Examine axillary nerve (deltoid function, not sensation over lateral
shoulder)
• Examine M/C nerve (biceps function and anterolateral forearm
sensation)
• Radiographic Evaluation: True AP shoulder, Axillary Lateral,
• Scapular Y, Stryker Notch View (Bony Bankart), etc..
• CT-scan: to detect accompanied injuries
SHOULDER DISCLOCATIONS
• Anterior Dislocation Recurrence Rate:
- Age
20: 80-92%
- Age 30: 60%
- > Age 40: 10-15%
• Look for Concomitant Injuries!!
A, Bone: Bankart, Hill-Sachs Lesion, Glenoid Fracture,
Greater Tuberosity Fracture
B, Soft Tissue: Subscapularis Tear, Rotator Cuff Tear (RCT)
C, Vascular: Axillary artery injury (older pts with atherosclerosis)
D, Nerve: Axillary nerve neuropraxia
SHOULDER DISCLOCATIONS
Anterior Dislocation
• Traumatic
• Atraumatic
(Congenital Laxity)
• Acquired
(Repeated Microtrauma)
SHOULDER DISCLOCATIONS
Posterior Dislocation
• Adduction/Flexion/IR at time of
injury
• Electrocution and seizures cause
overpull of subscapularis and
latissimus dorsi
• Look for “lightbulb sign” and
“vacant glenoid” sign
• Reduce with traction and gentle
anterior translation
SHOULDER DISCLOCATIONS
Inferior Dislocations – ‘Luxatio erecta’
• Hyperabduction injury
• Arm presents in a flexed
“asking a question” posture
• High rate of nerve and
vascular injury
•Reduce with in-line traction
and
gentle adduction
SHOULDER DISCLOCATIONS
Inferior Dislocations – ‘Luxatio erecta’
SHOULDER DISCLOCATIONS
Treatment
I. Nonoperative treatment: closed reduction should be
performed after adequate clinical evaluation and appropriate
sedation
- Hippocratic, Kocher, Stimson, eskimo technique
(see next slides)
II. Operative Indications: irreducible shoulder (interposition),
displaced greater tuberosity fractures, glenoid rim fractures
bigger than 5 mm, elective repair for younger patients
Postoperative management: post reduction films to confirm
the position of the humeral head, pain control,
immobilization for 7-21 days; then begin progressive ROM.
SHOULDER DISCLOCATIONS
Traction technique: Hippocratic - method
SHOULDER DISCLOCATIONS
Traction technique: Stimson - method
SHOULDER DISCLOCATIONS
Traction technique: Snowbird Reduction - method
SHOULDER DISCLOCATIONS
Leverage technique: Kocher - method
PROXIMAL HUMERUS FRACTURES
PROXIMAL HUMERUS FRACTURES
Epidemiology:
• Most common fracture of the humerus
• Higher incidence in the elderly, thought to be
related to osteoporosis
• Females 2:1 greater incidence than males
Mechanism of Injury:
• Most commonly a fall onto an outstretched arm
from standing height
• Younger patient typically present after high energy
trauma such as MVA (motor vehicle accident)
PROXIMAL HUMERUS FRACTURES
Clinical Evaluation
• Patients typically present with arm held close
to chest by contralateral hand.
• Pain and crepitus detected on palpation
• Careful NV exam is essential, particularly with
regards to the axillary nerve. Test sensation
over the deltoid. Deltoid atony does not
necessarily confirm an axillary nerve injury.
PROXIMAL HUMERUS FRACTURES
Neer – classification
/Neer et al, JBJS, 1970/
Four parts:
- Greater and lesser
tuberosities
- Humeral shaft
- Humeral head
/A part is displaced if >1 cm
displacement or >45 degrees of
angulation is see/
PROXIMAL HUMERUS FRACTURES
Treatment
• Minimally displaced fractures:
- Sling immobilization (1-3 weeks), early motion
• Two-part fractures:
- Anatomic neck fractures likely require ORIF.
(High incidence of osteonecrosis)
- Surgical neck fractures that are minimally displaced can be
treated conservatively. Displacement usually requires ORIF.
• Three-part fractures:
- Due to disruption of opposing muscle forces, these are
unstable so closed treatment is difficult.
- Displacement requires ORIF. Elderly: consider Pölchen-th.
• Four-part fractures:
- In general for displacement or unstable injuries ORIF in the
young and hemiarthroplasty in the elderly and those with
severe comminution. High rate of AVN (13-34%).
PROXIMAL HUMERUS FRACTURES
Treatment
• Nonoperative treatment:
- sling, Desault-bandage, Gilchrist-bandage
- early physiotherapy, Pölchen-therapy
- immobilization: 1-3 weeks (frozen shoulder!!)
• Operative treatment:
- Screw fixation
- K-wires + external immobilization
- ORIF: plate fixation
- intramedullary nailing
- hemiarthroplasty
PROXIMAL HUMERUS FRACTURES
Type Neer VI
PROXIMAL HUMERUS FRACTURES
Type Neer VI
PROXIMAL HUMERUS FRACTURES
Type Neer VI
PROXIMAL HUMERUS FRACTURES
Hemiarthroplasty
FRACTURES OF THE HUMERUS SHAFT
FRACTURES OF THE HUMERUS SHAFT
Special characteristics of the humerus:
• The humerus is not a weightbearing
bone
• bordered by the two most mobile joint
• good muscle coverage
• the relationship between the humerus
and the
• radial nerve
These characteristics are needed to
be considered in the planning of the
treatment.
FRACTURES OF THE HUMERUS SHAFT
Mechanism of Injury
• Direct trauma is the most common especially MVA
(motor vehicle accident)
• Indirect trauma such as fall on an outstretched hand
• Fracture pattern depends on stress applied:
- Compressive: proximal or distal humerus
- Bending: transverse fracture of the shaft
- Torsional: spiral fracture of the shaft
- Torsion and bending: oblique fracture usually
associated with a butterfly fragment
FRACTURES OF THE HUMERUS SHAFT
Evaluation of Humerus Shaft Fractures
Clinical evaluation:
• Thorough history and physical
• Patients typically present with pain, swelling, and
deformity of the upper arm
• Careful NV exam important as the radial nerve is in
close proximity to the humerus and can be injured.
Radiographic evaluation:
• AP and lateral views of the humerus
• Traction radiographs may be indicated for
hard to classify secondary to severe
displacement or a lot of comminution.
FRACTURES OF THE HUMERUS SHAFT
Treatment I.
Conservative Treatment:
• Goal of treatment is to establish union
with acceptable alignment
• >90% of humeral shaft fractures heal
with nonsurgical management
• 20 degrees of anterior angulation, 30
degrees of varus angulation and up to 3
cm of shortening are acceptable
• Most treatment begins with application of
a coaptation spint or a hanging arm cast
followed by placement of a fracture brace:
Sarmiento-type brace.
FRACTURES OF THE HUMERUS SHAFT
Treatment II.
Operative Treatment:
• Indications
for operative treatment include:
- inadequate reduction,
- nonunion,
- associated injuries,
- segmental fractures,
- open fractures,
- associated vascular or nerve injuries
• Most commonly treated with plates and
screws but also IM (intramedullary nails);
in selected cases: external fixator.
FRACTURES OF THE HUMERUS SHAFT
Preoperative X-rays
FRACTURES OF THE HUMERUS SHAFT
Postoperative X-rays
FRACTURES OF THE DISTAL HUMERUS
Supracondylar humerus fractures:
COMPLICATIONS:
- Neurovascular
complications (brachial artery,
median nerve)
- Compartment-syndrome,
- Volkmann‟s Contracture
- Myositis ossificans or calcific tendinitis
FRACTURES OF THE DISTAL HUMERUS
Holstein-Lewis Fractures
COMPLICATIONS:
- Distal 1/3 fractures
- May entrap or lacerate radial nerve as the
fracture passes through the intermuscular septum
FRACTURES OF THE DISTAL HUMERUS
Bicondylar intraarticular humerus fractures:
• Intra-articular fracture
• Complications:*
- heterotopic ossification (4%),
- infection (4%),
- ulnar nerve palsy (7%),
- failure of fixation (5%),
- non-union (2%).
* Helfet DL, Schmeling GJ: Bicondylar intraarticular
fractures of the distal humerus in adults.
Clin Orthop Relat Res. 1993 Jul;(292):26-36.
FRACTURES OF THE HUMERUS SHAFT
AO - Classification
FRACTURES OF THE DISTAL HUMERUS
Treatment
Nonoperative treatment:
- Splint / cast fixation, brace fixation
Operative treatment:
- ORIF: plate + screw fixation
- Retrograde intramedullary nail
- K-wire + additional fixation
- External fixation
Special importance: in case of an intraarticular fracture,
anatomic restoration of the articular surface, stable fixation,
and early motion are the optimal treatment goals.
FRACTURES OF THE DISTAL HUMERUS
Treatment – postoperative X-ray
Olecranon osteotomy
ELBOW DISCLOCATIONS
ELBOW DISCLOCATIONS
Epidemiology
• Accounts for 11-28% of injuries to the elbow
• Posterior dislocations are the most common
• Highest incidence in the young 10-20 years and usually
sports injuries
Mechanism of injury:
• Most commonly due to fall on outstretched hand or
elbow resulting in force to unlock the olecranon from the
trochlea
• Posterior dislocation following hyperextension, valgus
stress, arm abduction, and forearm supination
• Anterior dislocation ensuing from direct force to the
posterior forearm with elbow flexed
ELBOW DISCLOCATIONS
Evaluation
Clinical Evaluation:
- Patients typically present guarding the injured extremity
- Usually has gross deformity and swelling
- Careful NV exam in important and should be done prior to
radiographs or manipulation
- Repeat after reduction
Radiographic Evaluation:
- AP and lateral elbow films should be obtained both pre and
post reduction
- CT-scan, MRI may be requested after reduction
- Careful examination for associated fractures
ELBOW DISCLOCATIONS
Treatment
Posterior Dislocation:
- Closed reduction under sedation
- Reduction should be performed with the elbow flexed while
providing distal traction
- Post reduction management includes a posterior splint with
the elbow at 90 degrees
- Open reduction for severe soft tissue injuries or bony
entrapment
Anterior Dislocation:
- Closed reduction under sedation
- Distal traction to the flexed forearm followed by dorsally
direct pressure on the volar forearm with anterior pressure
on the humerus
ELBOW DISCLOCATIONS / FRACTURES
Associated Injuries – Radial Head Fracture
Radial head fx (5-11%)
• Mason-classification
• Treatment:
-Type I: conservative
-Type II/III: attempt ORIF vs.
radial head replacement
- No role for solely excision of
radial head in 2006. This
question is still debated.
ELBOW DISCLOCATIONS / FRACTURES
Associated Injuries
Coronoid process
fractures
(5-10%)
Medial or lateral
epicondylar fx
(12-34%)
ELBOW DISCLOCATIONS / FRACTURES
Instability Scale
Type I
Posterolateral rotary instability, lateral
ulnar collateral ligament disrupted
Type II
Perched condyles, varus instability, ant
and post capsule disrupted
Type III
A: posterior dislocation with valgus
instability, medial collateral ligament
disruption
B: posterior dislocation, grossly unstable,
lateral, medial, anterior, and posterior
disruption
ELBOW DISCLOCATIONS / FRACTURES
Olecranon Fracture
ELBOW DISCLOCATIONS / FRACTURES
Tension Band Fixation
ELBOW DISCLOCATIONS / FRACTURES
Radial Head Fracture
ELBOW DISCLOCATIONS / FRACTURES
Titanium Screw Fixation
ELBOW DISCLOCATIONS / FRACTURES
Elbow Dislocation
ELBOW DISCLOCATIONS / FRACTURES
After Closed Reduction
FOREARM FRACTURES
Epidemiology
Epidemiology:
• Highest ratio of open to closed than any other fracture
except
the tibia
• More common in males than females, most likely secondary
MVA, contact sports, altercations, and falls
Mechanism of Injury:
• Commonly associated with MVA, direct trauma missile
projectiles, and falls.
FOREARM FRACTURES
Evaluation
Clinical Evaluation:
• Patients typically present with gross deformity of the forearm
and with pain, swelling, and loss of function at the hand
• Careful exam is essential, with specific assessment of radial,
ulnar, and median nerves and radial and ulnar pulses
• Tense compartments, unremitting pain, and pain with passive
motion should raise suspicion for compartment syndrome
Radiographic Evaluation:
• AP and lateral radiographs of the forearm
• Don’t forget to examine and x-ray the elbow and wrist
FOREARM FRACTURES
Ulna Diaphysis Fractures
• These include nightstick and Monteggia fractures
• Monteggia denotes a fracture of the proximal ulna with an
associated radial head dislocation
• Monteggia fractures classification:
Type I: Anterior Dislocation of the radial head with fracture of
ulna at any level- produced by forced pronation
Type II: Posterior/posterolateral dislocation of the radial headproduced by axial loading with the forearm flexed
Type III: Lateral/anterolateral dislocation of the radial head
with fracture of the ulnar metaphysis- forced abduction of the
elbow
Type IV: anterior dislocation of the radial head with fracture of
radius and ulna at the same level- forced pronation with radial
shaft failure
FOREARM FRACTURES
Radius Diaphysis Fractures
• Fractures of the proximal two-thirds can be considered truly
isolated
• Galeazzi or Piedmont fractures refer to fracture of the radius
with disruption of the distal radial ulnar joint
• A reverse Galeazzi denotes a fracture of the distal ulna with
disruption of radioulnar joint
Mechanism:
• Usually caused by direct or indirect trauma, such as fall onto
outstretched hand
• Galeazzi fractures may result from direct trauma to the wrist,
typically on the dorsolateral aspect, or fall onto outstretched
hand with pronation
• Reverse Galeazzi results from fall with hand in supination
COMBINED FOREARM FRACTURES
COMBINATION OF INJURIES - BONE AND SOFT TISSUE
1. Galeazzi fracture dislocation:
radial shaft fracture with dislocation
of the distal radioulnar joint.
2. Monteggia fracture dislocation:
ulnar shaft fracture with dislocation
of the radial head.
3. Essex Lopresti lesion: proximal
radial fracture, disruption of the
interosseous membrane, disruption
of the distal radioulnar joint.
accompanied with dislocation and interosseal membrane rupture
FOREARM FRACTURES
Preoperative X-rays: Forearm Fracture
FOREARM FRACTURES
Postoperative X-rays: ORIF – plate OS
COMBINED FOREARM FRACTURES
Preoperative X-ray I: Essex-Lopresti Injury
Radio-ulnar dissociation
(comparative X-ray)
COMBINED FOREARM FRACTURES
Preoperative X-ray II: Essex-Lopresti Injury
Radial Head Fracture
COMBINED FOREARM FRACTURES
Postoperative X-ray: Essex-Lopresti Injury
UPPER EXTREMITY TRAUMA
THERE ARE SEVERAL DIFFERENT TYPES OF
CLASSIFICATIONS…
WHICH OF THEM SHOULD I LEARN FOR THE EXAM??
BASIC REQUIREMENTS for the EXAM:
Here are some hints to help…
UPPER EXTREMITY TRAUMA
BASIC REQUIREMENTS for the EXAM:
Here are some hints to help…
(at least: I – II – III)
• Principles (not details!!) of Neer-classification
• How to differentiate a posterior glenohumeral dislocation?
• Principles of AO-classification
- A: extra-articular
- B: partially articular
- C: intra-articular, comminuted fracture
• Galeazzi / Monteggia / Essex-Lopresti injuries
• Tossy-classification
UPPER EXTREMITY TRAUMA
If you are interested in, please, check the following links for
further information:
1. AO Surgery Reference & Online Education
www.aotrauma.org:
2. Wheeles‟ Textbook of Orthopaedics
www.wheelessonline.com
3. OTA Education Resources – really useful site with online lectures
http://ota.org/education/resident-resources/core-curriculum/upperextremity/
THANKS FOR YOUR
ATTENTION!