Presentation on theme: "Common upper limb fractures"— Presentation transcript:
1Common upper limb fractures Dr Tarif AlakhrasOrthopedic surgeonKFMC
2Clavicle FractureClavicle injuries affect 1 in 1000 people per year. The most common of all pediatric fractures % of all fractures in this age group. can present even in the newborn period, especially following a difficult delivery. A large peak incidence occurs in males younger than 30 years due to sports injuries.
3Clavicle FractureEtiologyIt may be caused by direct or indirect trauma. Or from fall onto an outstretched hand. Clinically
4Clavicle FractureThe most common injury is a type 1 fracture , which affects the middle third of the clavicle.
5Clavicle Fracture :Management typically included the use of either a shoulder sling or a figure-of-eight brace.Surgical indicationsSevere displacement causing tenting of the skin with the risk of punctureFractures with 2 cm of shorteningComminuted fractures with a displaced (or Z-shaped) fragmentNeurovascular compromise or mediastinal structures at riskOpen fractures(floating shoulder)
6Fracture Humerus Proximal end Mid shaft Distal end Humerus can be divided intoProximal endMid shaftDistal end
7the proximal end fracture The upper end:The headSurgical neckGreater tuberosityLesser tuberosity
12FRACTURE DISTAL HUMERUS Elbow fractures are the most common fractures in children. An understanding of the basic anatomy and x-ray landmarks of the elbow is essential in choosing appropriate treatment to avoid complications.
13Four important questions Is there a sign of Joint effusion?Is there a Normal alignment between the bone ?Are the Ossification centers normal?Is there a Subtle fracture?
14There are 6 ossification centres around the elbow joint. 1. Capitellum 2. Radial Head 3. Internal epicondyle Trochlea 5. Olecranon 6. Lateral EpicondyleyearsC-R-I-T-O- L
15An elevated anterior lucency or a visible posterior lucency on a true lateral radiograph of an elbow flexed at 90° is described as a positive fat pad sign
19Supracondylar fracture consists of more than half of all pediatric elbow fracturesextension type most common (95-98%)Physical examnerve examAnterior Interosseus N neurapraxia unable to make “OK sign”Radial nerve neurapraxiainability to extend wrist or digitsvascular statusvascular insufficiency at presentation is present in 5 -17%defined as cold, pale, and pulseless handa warm, pink, pulseless hand does not qualify as vascular insufficiency
20S/C frx: Management Type II fractures that meet the following criteria Nonoperativeposterior molded splint then long arm casting at at 90° or lessindications Type I (non-displaced) fractures Type II fractures that meet the following criteriaanterior humeral line intersects capitellumminimal swelling presentno medial comminutionOperativeclosed reduction and percutanous pinning indications - in most supracondylar fractures-- open reduction with percutaneous pinning (If close reducion failed)
21S/C complications Cubitus valgus Cubitus varus (gunstock deformity) can lead to tardy ulnar nerve palsyCubitus varus (gunstock deformity) usually a cosmetic issue with little functional limitations Recurvatumcommon with non-operative treatement of Type II and Type III fracturesNerve palsyusually resolveVascular Injury and Volkmann ischemic contracturePostoperative Stiffness
22Lateral Condyle Fracture - Pediatric 17% of all distal humerus fractures in the pediatric populationtypically occurs in patients aged 5-10 years omechanism of injurypull-off theoryavulsion fracture that results from the pull of the common extensorpush-off theoryimpaction of the radial head into the lateral condyle
23Lateral Condyle Fracture: treatment Nonoperativelong arm castingindicationsonly indicated if < 2 mm of displacement, which indicates the cartilaginous hinge is most likely intactsub-acute presentation (>4 weeks)OperativeClose reduction & Percut fixationsome authors suggest CRPP for all lateral condylar fractures with < 2 mm of displacementopen reduction and fixationif > 2mm of displacementany joint incongruity fracture non-union
24Complications: of delayed or inadequate reduction non union: AVN of capitellum cubitus varus: a more common complication than cubitus valgus; may be due to over-stimulation of the lateral condylar physis.cubitus valgus: premature growth arrest of lateral condyle.ulnar nerve palsy may appear as a late complication.
25Fracture head and neck of radius frx of the radial head occurs primarily in adults, whereas fractures of the radial neck are more common in children. frx of the radial head and neck of the radius generally results from a hard fall on an outstretched hand.
26Fracture head of radius pain, effusion in the elbow, & tenderness on palpation directly over radial head are typical manifestationsassociated injuries: distal radius fracture dislocation of the distal RU joint (Essex Lopresti Fracture) valgus instability (MCL rupture) rupture of the triceps tendonElbow dislocation: terrible triad:RHF + MCL + coronoid process frcture
27Fracture head and neck of radius An x-ray of the elbow will confirm the diagnosis and help determine the severity of the fracture .CT scan may also be indicated in order to choose the best treatment option.
28Fracture head and neck of radius Nonsurgical treatment of radial head fractures is indicated if minimal displacement, minimal angulation, and minimal head involvement.Early motion with a functional brace is encouraged to minimize elbow stiffness.Surgery is required if the fracture involves more than 33% of the articular surface, is angulated more than 30°, or is displaced more than 3 mm. excision of radial head & radial head implants: For
29Four Pearls for frx Head of Radius A visible posterior fat pad on the lateral view of the elbow is a sign of occult intraarticular pathology.Early elbow ROM is needed to prevent stiffness.Examine the wrist when examining all elbow injuries; a radial head fracture may be accompanied by a tear of the interosseous membrane and disruption of the distal radioulnar joint.The posterior interosseous nerve can be damaged by a radial head injury or by the surgery performed to treat the fracture. Therefore, document functional status preoperatively.
30Galeazzi fractureis a fracture of the radius with dislocation of the distal radioulnar joint.Ricardo Galeazzi (1866–1952), an Italian surgeonIt was first described in 1842, by Cooper, 92 years before Galeazzi reported his results.
31Galeazzi fracture :Treatment It has been called the “fracture of necessity“ because it necessitates open surgical treatment in the adult. in skeletally immature patients the fracture is typically treated with closed reduction.
32Monteggia fracture : Giovanni Battista Monteggia is a fracture of the proximal third of the ulna with dislocation of the head of the radius.(hyper-pronation injury)isolated ulnar shaft fractures (most commonly seen in defense against blunt trauma) is not a Monteggia fracture. It is called a 'nightstick fracture'.
33Managementopen reduction and internal fixation of the ulnar shaft is considered the standard treatment in adults.Monteggia fractures may be managed conservatively in children with closed reduction but due to high risk of displacement causing malunion, open reduction internal fixation is typically performed.
34Distal radius fracture Colles' fracture Smith's fractureBarton's fractureChauffeur's fractureThe Universal classification Type I: extra articular, undisplacedType II: extra articular, displacedType III intra articular, undisplacedType IV: intra articular, displaced
35Colles’fracture Is an extra-articular fracture of the distal radius with dorsal and radial displacement of the wrist and hand. The fracture is sometimes referred to as a "dinner fork" or "bayonet" deformity.often seen in elderly people with osteoporosis.most commonly caused by people falling onto a hard surface with outstretched arms
36Smith's fracture reverse Colles' fracture Robert William Smith (1807–1873) is an extra-articular fracture of the distal radius. It is caused by falling onto flexed wrists, as opposed to a Colles' fracture.The distal fracture fragment is displaced volarly . There may be one or many fragments and it may or may not involve the articular surface of the wrist joint.
37Treatment Colles’ & Smith Treatment depends on severity:Undisplaced fracture may be treated with a cast aloneFractures with angulation and displacement require closed reduction and above elbow castingPosition in cast:In colles’ frx the wrist immobilized in flexionIn smith frx the immobilization should be in extension
38Barton's fractureIs an intra articular fracture of the distal radius with dislocation of the radiocarpal joint.Intra-articular component distinguishes this fracture from a Smith's or a Colles' fracture.caused by a fall on an extended and pronated wrist
39Barton's fracture :treatment is best treated by closed reduction, application of external fixation, followed by percutaneous pin insertion.tendency to redisplace may require ORIF by buttres plate
40Chauffeur's fractureAn isolated fracture of the radial styloid process. Displacement of the fragment is uncommon.There can be associated injury to the scapholunate ligament.In most cases a fracture of the radial styloid process is part of a comminuted intraarticular fracture
41Scaphoid fracture Scaphoid is the most frequently fractured carpal bone.It usually cause pain and tenderness in the snuffbox area at the base of the thumb
42Scaphoid fractureFractures of scaphoid can occur from fall on the palm on an outstretched hand. Often diagnosed by X-rays However not all fractures are apparent initially .repeat x rayComplicationsAvascular necrosis (AVN): mainly proximal 1/3Non union: occur from undiagnosed or undertreated scaphoidwrist osteoarthritis.
43Scaphoid fracture Complications Avascular necrosis (AVN): mainly proximal 1/3Non union: occur from undiagnosed or undertreated scaphoid fracturewrist osteoarthritis.
44Scaphoid fracture Treatment Non displaced or minimally displaced waist and distal fractures have a high rate of union with closed cast management. it is generally accepted to use a short arm thumb spica for non displaced fractures