Download Surgical treatment

Traumatology of the upper
extremity
Object and goal of the seminar
Diseases and injuries
of the upper extremity
Introduce main patological units
Diagnosis and therapy
Shoulder joint- simple ball joint
(arthrodia)
cavitas glenoidalis scapulae – caput humeri
Articulating bones:
Humerus, scapula, clavicle
Articular surface is covered
with cartilage
Shape of the articular surface
determines: range of motion,
stability
Clinical examination - anamnesis
 Complicated joint - articulatio glenohumeralis
(acromioclavicularis, sternoclavicularis)
 Clinical history – pain and its character(direction, sharp or
dull pain, permanent or short-term, mechanism of injury,
personal clinical history
 Acute pain…bursitis subacromialis, rotator cuff rupture,
inflammation, fracture, …
 Chronic pain– degenerative disease
Examination of the injured joint
– objective status
Aspection – swelling,
hematoma, patological
shape,damaged skin surface
Palpation– sensitivity,
temperature
Examination of stabilitydislocation of the joint
Range of the motion
Physiological range of the motion
(degree) – shoulder joint
•
•
•
•
•
•
•
Flexion…90
Extension …50
Abduction…90
Adduction …25
Elevation…180
External rotation…90
Internal rotation….90
Examination of the injured joint
X-ray evaluation – AP , lateral, comparative
images
CT
MRI – soft tissue
Ultrasound – fluid in (around) the joint, RC,
tendons
Shoulder painfull syndrom
Tenosynovitis capitis longi m. bicipitis brachii
Rupture of long tendon of biceps muscle
Bursitis subacromialis
Tendinitis m. supraspinati
Rupture of rotator cuff
Impingement syndrom of shoulder
Frozen shoulder syndrom
Arthritis of shoulder joint
AC dislocations
Inflammation
Tumors
Pains transferred from another place
Transferred pain
C spine
Thoracic outlet syndrom
Heart diseases
Lung diseases
Neuralgia, herpes zoster
Stomach tumor
Acromioclavicular dislocation
 indirect violence
 classification Allman - Tossy I.-III.
 rupture of ligaments /CC, AC, CA/
Clinical status
 deformation of AC region
 pain
 antalgic position of the extremity
 limitation of motion of the limb
Examination
X-ray
• AP
• comparative view
• traction X-ray
Treatment
Conservative
I. + II. degree
• Scarf bandage, Desault
• orthesis
Treatment
Surgical - III. degree
• suture of ligaments, K-wire osteosynthesis
Rupture of long tendon of biceps
muscle
Treatment:
keep extremity immobile
analgesics
till 40 y. - surgery
more than 40 r. - conservatively
Surgery:
key hole fixation to humerus
shaft
suture to short tendon of biceps
muscle
Rupture of rotator cuff
• Pushes humeral head into cavitas glenoidalis
• Helps to abduction
Rupture of rotator
cuff
Severe pain
No abduction
Treatment:
Conservative
Surgical
• suture
• fixation to tuberculum
maius using anchor
Dislocation of humerus
• very often injury
• indirect mechanism
• anterior
• posterior
• inferior
• (superior)
Clinical status
•
•
•
•
empty cavitas glenoidalis
joint shape
antalgic position of extremity
limitation of range of motion
Treatment
Conservative
• reposition
• fixation - orthesis
Surgical … repeated dislocation
• repairing joint capsule
Reposition
• Analgesia
• General Anesthesia
• Fixation to 5 weeks
• Surgical solution
Complications
• fractures
• nerve injury
– plexus brachialis
– n. axilaris
• vessels injury
X-ray before reposition!!!
Humeral fractures
1. Proximal humerus
2. Shaft
3. Distal humerus
Proximal humeral fractures
 occurrence at any age
 4. the most common fracture (distal radius,
proximal femur, ankle)
 2. the most common fracture of upper
extremity
 4 – 5% of all fracture
 ratio of male – female till 3 : 1
 shoulder joint– greatest range of motion
Mechanism of proximal
humeral fractures
„Low energy trauma“
„High energy trauma“
 short-term and older
population
 predominace of women
 falls from standing
at floor level
 osteoporosis
 younger population
 sport, traffic, men
 falls from height
 open fracture
 polytrauma
 direct
 indirect
Anatomy
 greatest range of motion - small stability
 muscles - important role for the stability
 joint surface of head is 3-4 times
greater than joint surface of
cavitas glenoidalis
 the head forms with the shaft
an angle 130 degrees
.
Muscles around
shoulder
 Superficial level: m. deltoideus
 Deep level: muscles of RC– m. supraspinatus
m.infraspinatus
m. teres minor
m.subscapularis
Peripheral muscles:
m.pectoralis maior (crista tuberculi maioris)
m. latissimus dorsi, m. teres maior (crista tuberculi minoris)
m. corachobrachialis, m. bicipitis brachii- caput breve
(proc coracoideus)
Retroversion of the hole– 9 degrees dorsally
body of the scapula is placed 30 degrees from frontal
level
hole facing ventrolaterally
Surgical anatomy
Collum anatomicum humeri - inclination - 115-130 degrees
- retroversion of the head - 15-30 degrees
dorsally
Collum chirurgicum humeri
Morfology of proximal humeral
fractures
Anatomy – blood supplay
 a. circumflexa humeri anterior – a. arcuata (Laing artery)
 metafyseal-epifyseal supplay
(injured in dislocated fractures of surgical neck)
 Branches of ACHP – postero-inferior part of the head
 via RC in tubercles
Clinical examination
swelling
hematoma (elbow, forearm, chest wall)
damage to the skin cover, open fracture
pain
crepitation
functional deficit
vascular and neurological deficit!!!
(suspicion for vascular injury - angiography)
Examination of the whole limb – current forearm and
hand injuries
X - ray
3 standard projection
(Neer)
AP
Lateral
Axillar
(thoracal)
CT scan
 more than two fragments
 dislocation of fragments –
particullary of the humeral head
 assessment of the size of fragments
 articular fractures
 fractures of cavitas glenoidalis
 postoperative complications
Indication criteria for treatment
of proximal humeral fractures
Objective examination:
age, the internal status, the ability of active rehabilitation
Skin condition of injured extremity
Type of the fracture:
X-ray examination
Personal and technical equipment
Treatment of proximal humeral
fractures
 Conservative
 Surgical
Conservative treatment indication
75 – 80% small dislocation – conservative treatment
15 – 20% great dislocation- surgical treatment
 Individual approache
 Internal complications
Indications for surgical treatment
 Instable fractures with dislocation
 Intraarticular fractures with joint dislocations
 Failure of conservative treatment
 Neurovascular injuries
 Open fractures
 Patological fractures
 Polytrauma
Surgical or conservative?
Fracture of proximal humerus
2-frg
4-frg
2-frg
3-frg
4-frg lux.
patol.
Osteosynthesis or primary replacement?
Surgical methods
1) Conventional implants
Percutaneous stabilization - K-wires
Osteosynthesis – screw and wires
Osteosynthesis -T-plates
Conventional implants
Disadvantages:
 Problematic bone fixation in porotic bone instability
 Frequent failure of osteosynthesis
 Sometimes the need for accessory fixation (brace,
orthesis)
2) Modern surgical methods:
angle stable implants
Principle of angular stable implant
Failure prevention( osteoporotic bone, comminuted)
 Head of the screw – locked in the hole

Surgical technique-position of the patientbeach chair position
Surgical approache - deltoideopectoral
Surgical approache - transdeltoideal
Surgical technique - reduction
 K wires – joystick
 bone hook
Surgical technique – entry point
 Two X-ray projections
 Entry point
Nail insertion
Angle stable plate
Arthroplasty
CCEP
Surface replacement
TSA
Reverse replacement
Rehabilitation
 long term
 phase of the exercise
• passive
• assisted
• active and physical
exercise
Complications of surgical
treatment
General
Impaired wound healing.
Hematoma
Inflammation
Specific
Restriction of motion
Head necrosis
Failure of OS
Nonunion
Fractures
Heterotopic ossification
Nerv and vessels injuries
Nail cutting
Screw cutting
Periimplants fracture
Nonunion
Fractures of scapula
 infrequent
 mostly direct mechanism
 fr. of body
 fr. of neck
 fr. of glenoid
 fr. of acromion
 fr. of coracoid process
 fr. of spine
Treatment
Conservative
• hinge
• Desault
• orthesis
Surgical
• Intraarticular fractures
Clavicle fracture
Nonunion
Humeral shaft fractures
 direct mechanism
 dislocation depend on fracture level
Humeral shaft fractures
 Humeral shaft fractures account for
approximately 1–3% of all fractures
 High and low energy trauma
 Fracture displacement is the result of muscular
forces
Fracture patterns of the humeral shaft
Examination
X - ray
• AP
• lateral view
Treatment
Non-operative:
Operative:
• Nondislocated fxt
• Compression plating
• IM nailing
Antegrade
Retrograde
• External fixation
• MIPO technique
• Hanging Arm Cast
• Velpeau
• Abduction Brace
• Functional Brace
Anterolateral approach
Be careful about traction of the nerve
External Fixation
• Open fractures with
extensive
soft tissue injuries
• Severe contamination
OS by plating
Hackethal
Nailing
Complication of humeral fractures
 Radial nerve injury from accident or
iatrogenic –distal third of humerus
 Delayed union and nonunion
 Failure of internal fixation
Distal humeral fractures
2% of all fractures
1/3 of the humeral fractures
Mostly intraarticular
Mechanism
Low energy trauma – middle aged and elderly
(ground-level falls), associated with osteoporosis
High energy trauma – younger patients (sports,
vehicle accidents), open injuries
Anatomy – triangular structure
• MEDIAL & LATERAL column and connecting arch distally
Distally – intraarticular portion
• Laterally: capitellum humeri
• Medially: medial epicondyle with trochlea (tie arch)
• Forward angulation 30-45°
• Trochlea valgus angle 4-8°
• Trochlea externally rotated 3-8°2-3cm proximally to the
olecranon fossa
– termination of the intramedullary canal
Functional anatomy
45°
Trochlea is center of the joint
Hinged joint with single axis
of rotation (trochlear axis)
Evaluation
• Physical examination
• Soft-tissue envelope
• Vascular status
– Radial and ulnar pulses
• Neurovascular status
– Radial nerve (most commonly
injured, 14cm prox. to lat.
epicondyle)
– Ulnar and Median nerves (rarely
injured)
X -ray
- AP and lateral view
- CT
Principles of treatment
- Restoration of axial alignment
- Anatomical reduction of the articular surfaces
- Stable fixation of the articular segment to the
metaphysis and diaphysis
- Goal: early range of motion of the elbow
- Prevention of posttraumatic arthritis
New implants - LCP
Posterior approache
Isolate and gently retract the ulnar nerve
Olecranon intraarticular osteotomy (if needed)
Open reduction and internal fixation
Surgical approach—skin incision
Ulnar nerve identification and
mobilization
Olecranon osteotomy
Reduction and fixation
Early rehabilitation
Elbow joint
-
Composed joint
Humeroulnar……..hinge
Humeroradial……..ball
Prox.radioulnar…..cylindrical
Range of motion in elbow
Flexion – 140-160 extension-10
Pronation 80-90 supination 80-90
SFTR: S 10-0-160 R 90-0-90
Enthesopathy
Pathological changes in the tendons, ligaments,
insertions to the bone
Causes:
• Acute or chronic overload
• Repeated small injury
• Repetitive movements
Epicondylitis radialis humeri
Syndrome of tennis elbow
• Pain when extensors are functional
• Palpation pain on the radial epicondyle
• Painfull supination of the forearm
• Handgrip pain
Epicondylitis radialis
Conservative treatment:
• Not burdening, NSAD locally and generally
• Stretching, special orthesis
• Corticoids locally
• Rehabilitation
• Immobilization
Surgical treatment:
• Op. sec. Hohman
• Op. sec. Boyd- Mc Leod
Epicondylitis ulnaris humeri
• Enthezopathy of common flexor insertion
• Pain on the ulnar epicondyle
• Pain when flexors are functional
Dislocation of the elbow
Fracture of the radial head
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•
•
•
small abruption
large abruption
comminuted fractures
fractures of the neck
Fracture of the radial head - OS
Olecranon fracture
Olecranon + proc. coronoideus
Fractures of the both forearm
bones
Galeazzi fracture
Monteggia fracture
Fractures of distal radius
Introduction
 1/6 of all the fractures
 most cases between 6 – 10 year a 60 – 69 year
 75 % of the forearm fractures
 ratio of women and men 4 : 1 (osteoporosis)
 children: ratio of boys and girls 3 : 1 (physical activity)
History
Abraham Colles - 1814: clinical description of this fracture in
English speaking countries
- described it before discovery of X-ray (1898)
- extraarticular fracture with dorsal dislocation
- „Colles fracture“ – incorrectly used name
for all fractures of distal radius
R.W. Smith - 1847 volar dislocation of distal fragment
Anatomy
JOINTS:
 radio-carpal
 medio-karpal
 carpo-metacarpal
 distal radio-ulnar
Mechanism of injury
Dorsal angulation – wrist in extension, pronation, ulnar
duction
- 90 % of fractures (Colles type)
Volar angulation - wrist in volar flection
- 10 % of fractures (Smith type)
Clinical picture




swelling
hematoma
typical dislocation
restriction of range of
motion
 blisters, visible
fragments under skin
 vessels, nerves
Distal radius fractures
Distal radius fractures
X – ray evaluation
Normal Anatomy
1. Volar Angulation 11º (1 – 21)
2. Radial Inclination 22º(13 – 30)
3. Radial Length
11º
4. Ulnar Variance
0±2mm
(comparison with intact side)
CT
Associated Injuries
Another diagnostics method
MRI - diagnosis of post-traumatic and chronic states
- displaying of soft tissue(tendon, capsule, muscles)
- patological states(osteomyelitis, AVN)
Artroscopy – optical evaluation of articular structures
Treatment goals
Undisplaced fractures
• Non-operative
treatment
• Short arm cast
• Check X-ray at
week
Displaced fractures
• Dorsal Comminution
beyond midaxial plane of
the radius
• Intra-articular Involvement
• Associated Ulnar Fracture
• Volar
Angulation/Displacement
Closed reduction
- Anaesthesia – Haematoma/Bier’s block, GA
- X - ray control
- Manipulation technique
- Longitudinal traction
- Pronation or neutral position of hand
- Ulnar tilt
- No big wrist flexion
- Plaster cast
Percutaneous K-wiring
Unstable extra-articular
Supplementary fixation with
exfix
•
•
•
•
•
1.6mm K-wires
X - ray control
Additional cast immobilisation
Removal in 5-6 weeks
Poor wire fixation in
osteoporotic bone
Bridging external fixation
Non-bridging external fixator
• Comminuted extra-articular
• Limited indications
• Allows early mobilisation
Surgical treatment – transfixation with K wires
Surgical treatment – external fixation
Surgical treatment – plate and screws
Locked volar plate
Surgical procedure
Surgical treatment– nailing
Surgical treatment– combination of
methods
Volar approache
Dorsal approache
Complications
 Malunion
 DRUJ problems
 CRPS – overdistraction
 Tendon rupture
 Carpal Tunnel syndrome
 Arthritis
 Failure of osteosynthesis
Scaphoid fractures
 swelling
 pain - (fossa tabatiére)
 limitation of motion
Diagnostics
• X-ray
• CT
- AP
- lateral view
- ulnar duction
Treatment
Conservative
• reduction, plaster cast
(12-16 weeks!)
Surgical
• osteosynthesis (Herbert screw),
• tranfixation
Herbert screw
Complications
 nonunion – bone grafting
 carpal instability
 necrosis
Luxatio perilunatis
Hand
Open or closed fracture
 skin damage and fracture in the same place of limb
 a wide range of local findings
o
!!! Decision affects treatment!!!
Clinical status
 skin damage, swelling of soft tissue,
hematoma
 bleeding (artery, vein, capillary)
 pathological movement, crepitations, changed
shape
 prominence of bone fragments from the wound
 oppression skin with impending perforation
 contamination of the wound
 neurovascular lesion
General Principles
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•
•
•
Protecting open wounds
Positioning the limb
Immobilizing the injury
Checking neurovascular function
• Pulse
• Palpate
• Utilize pulse oximetry
• Motor
• Sensation
Treatment at operating room







mechanical cleaning of the wound with steril brush
removing dirt, foreign bodies, devitalized tissue
repeated washings with disinfectans
cultivation
debridement
osteosynthesis
antibiotics
External fixation
Advantages
• No foreign body in
the wound
• Fracture site
vascularity not
compromised
• Applied distant to
injury
• Overbridging joints
Disadvantages
• Pin tract infections
• Fracture malalignment
• Patient tolerence
• Adjacent joint stiffness
• Transfixation of muscles
• Interfere with flap
design and vascular
acces