Download UPPER LIMB INJURIES

UPPER LIMB INJURIES
Total (5) lectures
Dr.Alaa A.H.Al-Algawy
Lecture (1)
FRACTURES OF THE CLAVICLE AND SHOULDER GIRDLE
Clavicular fractures
These are common injuries in adults and children about 10% of all fractures.
The majority of cases follow a fall on the shoulder.
Most fractures involve the middle third of the bone.
Popular classification:
Group I: refers to middle third fractures.
Group II: refers to lateral third fractures, which in turn are divided into three types.
1-CC ligament is intact.
2- CC ligament torn with high riding of the fractured end of clavicle.
3- Intra articular fracture that extends into the ACJ.
Group III: refers to medial third fractures.
Dx
Clinical diagnosis is not difficult in most cases - there is tenderness with visible and
palpable deformity at the site of the fracture.
A small percentage of these patients have high-energy trauma and in these cases there is
an association with brachial plexus injuries and vascular injury.
Clinical assessment should include an assessment of the neurovascular status of the upper
limb.
Virtually all of these fractures can be diagnosed with plain radiographs.
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Treatment:
In the majority of cases, management is non-operative using a collar and cuff sling for
4-6 weeks, and analgesic medication.
Patients should be advised to avoid overhead activity for the first 6 weeks and heavy
manual work for 3 months.
In adults radiographs should be obtained at 2 weeks, 6 weeks and 3 months to ensure the
fracture progresses to union.
In children, complications are unusual; very few require any additional treatment and the
fracture heals rapidly. Full function can be expected but the child and parents will be
aware of a swelling over the fracture for several months after healing. This is due to
external callus formation, which usually remodels well.
Surgical treatment of clavicular fractures is occasionally indicated:1-Patients with a vascular injury or brachial plexus palsy will usually require plating of
the clavicle.
2-Non-union occurs in 10% of adult clavicular fractures and is more common in
midshaft fractures with more than 1 cm of displacement or with comminution. Non-union
of midshaft fractures can be successfully treated in most cases with plating.
3-In lateral third fractures, delayed union or non-union is the norm if the coracoclavicular ligaments are ruptured, which results in superior migration of the medial
fragment. They can be treated non-operatively if asymptomatic. In patients with
troublesome pain, internal fixation is indicated.
Scapular fractures
These are uncommon injuries but are associated with high-energy trauma.
They have a well recognized association with rib fractures, clavicle fractures, brachial
plexus injuries and intra-thoracic injury.
The most important aspect of management is identification of the associated injuries.
In general, most scapular fractures can be treated non-operatively in a sling for 4-6
weeks.
Although most scapular fractures can be treated non-operatively, fractures involving the
glenoid fossa with significant displacement are best treated by internal fixation.
Shoulder injuries
Fractures and dislocations involving the proximal humerus and shoulder girdle are very
common and affect all age groups. There are three common injuries:
Acromio-clavicular dislocation, glenohumeral dislocation and proximal humeral
fractures.
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Acromio-clavicular dislocations
These injuries result from a fall directly onto the shoulder.
They are common in contact sports.
The lateral aspect of the clavicle is attached to the scapula by strong coraco-clavicular
ligaments. If these are disrupted, the weaker acromio-clavicular joint ligaments can be
disrupted allowing superior displacement of the clavicle in relation to the acromion.
There are three grades of injury:
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

Grade I - The acromio-clavicular ligaments are damaged, but there is no superior
displacement of the clavicle. Patients are tender on palpation of the joint, but there
is no deformity.
Grade II - The ligaments are damaged sufficiently to allow subluxation, but not
complete dislocation of the joint.
Grade III - There is complete dislocation with superior displacement of the joint.
The coraco-clavicular and acromio-clavicular ligaments are torn. This injury is
not usually seen in the younger child, but may be seen in adolescents.
Treatment of grade I and II injuries is non-operative with a sling for comfort until early
mobilization is commenced 1-2 weeks after injury. Most grade III injuries can also be
treated non-operatively. However, occasionally the clavicle is widely displaced and
comes to lie in a subcutaneous position. These injuries are best treated surgically. The
clavicle can be repositioned using a coraco-clavicular screw.
Glenohumeral dislocation
The glenohumeral joint is the most frequently dislocated major joint.
Anterior dislocation:
The usual mechanism is a fall on the extended arm with the shoulder in extension.
The humeral head dislocates in an anterior dislocation and comes to lie medial to the
glenoid, just below the coracoid process.
Posterior dislocation also occurs, but is uncommon, and accounts for less than 5% of
shoulder dislocations. It is often associated with high-energy trauma, an epileptic fit or as
a consequence of an electric shock.
Gleno-humeral dislocation is a very unusual injury in a child.
Dx:
The diagnosis of anterior dislocation is obvious on clinical examination.
There is swelling and deformity of the shoulder and the humeral head is palpable in the
anterior subcoracoid position.
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Posterior dislocations are less obvious on physical and radiographic examination, but
one key clinical feature is that the glenohumeral joint is fixed in internal rotation.
If there is a history of unusual trauma, and the shoulder is in fixed internal rotation, it
should be assumed there is a posterior dislocation.
A plain anteroposterior (AP) radiograph shows anterior dislocations readily, but
posterior dislocations are easily missed.
Axillary or modified oblique views are better for diagnosis of posterior dislocation.
Complications:
Axillary nerve injury, brachial plexus palsy and rotator cuff tears are all well recognized
complications of glenohumeral dislocation and should be looked for clinically.
Rx:
Closed reduction of the dislocation under sedation is usually possible.
Kocher’s method:
(The elbow is bent to 90 degrees, and held close to the body, no traction is applied, the
arm is slowly rotated externally to 75 degrees, then the point of the elbow lifted forwards,
and finally the arm internally rotated.)
Occasionally general anaesthesia is required and should always be used in a child.
Posterior dislocations are often associated with an impaction fracture of the humeral
head, which becomes locked on the edge of the glenoid, rendering closed reduction
difficult. Open reduction is more frequently required.
After closed reduction of a shoulder dislocation a period of 3-4 weeks of immobilization
is recommended in younger patients to minimize the risk of recurrent dislocation.
In patients over the age of 40 years this is less of a risk and early mobilization is
encouraged.
In younger patients the main risk is recurrent dislocation and in those under 20 years of
age the risk is 80%.
In patients over the age of 40 years, rotator cuff tears and nerve injury are more frequent.
Greater tuberosity fractures or rotator cuff tears are present in 10-30% of glenohumeral
dislocations.
They are more common in older patients. Nerve injuries (most commonly the axillary
nerve) can be treated non-operatively as they recover spontaneously in 95% of cases.
They are present in 30% of patients over the age of 50 with dislocation. Rotator cuff tears
are easily missed since they are difficult to diagnose at presentation after reduction of the
dislocation due to pain and limited motion. In patients who have not regained active
abduction by 4-6 weeks after injury an urgent ultrasound or MRI scan is indicated to
diagnose a rotator cuff tear and carry out surgical repair in suitable patients
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