1. Dr Abhishek Agarwal Lecturer Deptt orthopedics
Upper limb injuries
Dr Abhishek Agarwal
Lecturer
Deptt orthopedics

2. Upper Limb include Clavicle Scapula Shoulder Joint Humerus Elbow Joint
Forearm Bones
Wrist and Hand

3. Mechanism of Injuries of the Upper Limb
Mostly Indirect
Commonly described as “ a fall on outstretched hand “
Type of injury depends on position of the upper limb at the time of impact : Flexed, Extended, adducted, abducted, pronated or supinated
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

4. Fracture of the clavicle in Adults
Common especially in children and elderly
Commonest site is the middle one third
Mainly due to indirect injury
Direct injury leads to comminuted fracture
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

5. Gutierrez G. Office management of upper limb fractures
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

6. Treatment Conservative by an arm sling or figure of eight bandage
Operative fixation is indicated if there is an open fracture, neurovascular injury or nonunion
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

7. Figure of eight Bandage
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

8. Dislocation of the Shoulder
Mostly Anterior > 95 % of dislocations
Posterior Dislocation occurs < 5 %
True Inferior dislocation (luxatio erecta) occurs < 1%
Habitual Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

9. Mechanism of anterior shoulder dislocation
Usually Indirect fall on Abducted and extended shoulder
May be direct when there is a blow on the shoulder from behind
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

10. Anterior Shoulder dislocation
Usually also inferior
Bankart’s Lesion
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

11. Clinical Picture Patient is in pain
Holds the injured limb with other hand close to the trunk
The shoulder is abducted and the elbow is kept flexed
There is loss of the normal contour of the shoulder
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

12. Clinical Picture
Loss of the contour of the shoulder may appear as a step
Anterior bulge of head of humerus may be visible or palpable
A gap can be palpated above the dislocated head of the humerus
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

13. Gutierrez G. Office management of upper limb fractures
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

14. X Ray anterior Dislocation of Shoulder
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

15. Associated injuries of anterior Shoulder Dislocation
Injury to the neuro vascular bundle in axilla ( rare )
Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia )
Associated fracture
Gutierrez G. Office management of upper limb fractures. .Phys and Sports Med. 24(8):60-80, 2006

16. Axillary Nerve Injury Also called circumflex nerve
It is a branch from posterior cord of Brachial plexus
It hooks close round neck of humerus from posterior to anterior
It pierces the deep surface of deltoid and supply it and the part of skin over it

17. Axillary nerve injury

18. Management of Anterior Shoulder Dislocation
Is an Emergency
It should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerus
Following reduction the shoulder should be immobilised strapped to the trunk for 3-4 weeks and rested in a collar and cuff

19. Methods of Reduction of anterior shoulder Dislocation
Hippocrates Method ( A form of anesthesia or pain abolishing is required )
Stimpson’s technique ( some sedation and analgesia are used but No anesthesia is required )
Kocher’s technique is the method used in hospitals under general anesthesia and muscle relaxation

20. Hippocrates Method

21. Stimpson’s technique

22. Kocher’s Technique

23. Complications of anterior Shoulder Dislocation : Early
Neuro vascular injury ( rare )
Axillary nerve injury
Associated Fracture of neck of humerus or greater or lesser tuberosities

24. Complications of anterior shoulder Dislocation : Late
Avascular necrosis of the head of the Humerus (high risk with delayed reduction)
Heterotopic calcification ( used to be called Myositis Ossificans )
Recurrent dislocation

25. Fractures of The Humerus
Proximal Humerus (includes surgical and anatomical neck )
Shaft of Humerus
Distal humerus ( includes Supra Condylar fracture in children )

26. Fracture Proximal Humerus

27. Fracture Proximal Humerus : Plating or Rush Nail insertion

28. Intra-medullary K wire fixation

29. Fractures Shaft of the Humerus
Commonly Indirect injury
Indirect injury results in Spiral or Oblique fractures
Direct injuries results in transverse or comminuted fracture
May be associated with Radial Nerve injury

30. Fracture shaft of the Humerus

31. Radial Nerve Injury Results in Wrist drop
Associated with fracture humerus in up to 12% of fractures
2/3 ( 8%) of Radial injury are Neuropraxia
1/3 ( 4%) are nerve lacerations or transection

32. Management of Radial Nerve Injury
When present in open fractures ; immediate exploration and ± repair
In closed injuries treated conservatively ; initial management is doing Nerve Conduction Studies ( NCS ) and Electromyography ( EMG ) and awaiting for spontaneous recovery

33. Management of Radial Nerve injury
Recovery usually starts after few days but may take up to 9 months for full recovery
If No spontaneous recovery occurs in 12 weeks confirmed by NCS and EMG ;then exploration of the nerve should be carried out

34. Management of Fracture Shaft of the Humerus
Most of the time is Conservative
Closed Reduction in upright position followed by application of U shaped Slab of POP or Cylinder cast
Few weeks later or initially in stable fractures Functional Brace may be used

35. U Shaped slab of POP

36. Functional brace Fracture Shaft of Humerus

37. Indications for ORIF Fracture Shaft of Humerus
Failure to reduce fracture conservatively
Bilateral humeral fractures
Open fracture with radial nerve Injury
Unconscious patient
Delayed-Union, Non-Union and Mal-Union

38. Plating fracture Shaft of humerus

39. Intra- medullary K Wire Fixation

40. Supra- condylar Fracture of Humerus

41. Pediatric Supra-Condylar Humeral fracture

42. Pediatric Supra-condylar fracture

43. Reduction of supra-condylar Fracture
Absolute Emergency
Should de done under G A by experienced doctor as soon as possible
In the past the arm was held in flexed elbow position in back-slab POP after reduction
At present time Percutaneous K wire fixation is ALWAYS carried out after reduction

44. Complications Supra-Condylar Fractures
Early= Compartment syndrome
Brachial Artery injury ( Acute
Volkmann's Ischemia )
Nerve Injury : Median, Ulnar or Radial
Late= Stiffness
Volkmann's Ischemic contracture
Heterotopic Calcification
Mal-Union ( Cubitus Valgus or varus)

45. Volkmann's Ischemic Contracture

46. Supracondylar fracture.

47. Fracture dislocation

48. MONTEGGIA FRACTURE-DISLOCATION
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

49. MONTEGGIA FRACTURE-DISLOCATION
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

50. GALEAZZI FRACTURE-DISLOCATION
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

51. Distal radius fracture.
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

52. Distal radius fracture.
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

53. contd
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

54. Types of treatment
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

55. Wrist & Hand Injuries Carpal tunnel (CTS)
result from repetitive stress to tissue
64% of work injuries
Compressive neuropathy
Wrist flexion/ext and finger movements
Risk factors
exertion
repetitive stress
posture
localized contact
cold
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

56. Wrist & Hand Injuries Carpal fractures
compressive loads to hyperextended wrist
hyper flexion
rotation loading against a fixed wrist
Scaphoid
60-70%
Lunate
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

57. Wrist & Hand Injuries Thumb: essential to prehension
Sprain: skiers thumb
fall with thumb in abducted position
tensile loads on MCL
Hyperextension
Bennets fracture (fighting)
Bowler’s thumb: ulnar digital nerve trauma
tingling, sensitivity
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.

58. Wrist & Hand Injuries Metacarpal & phalangeal injuries Fractures
Boxers
Dislocations
Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992.