1. Common Adult Fractures Upper Limb
Majdi Hashem, MD
Assistant professor of orthopedic
Consultant orthopedic and spine
Course organizer
Reproduced courtesy of Prof Mamoun Kermli

2. Objectives Identify common upper limb fractures in adults
Presentation, diagnosis, management, and important considerations
Clavicle
Humerus
Forearm
Wrist
Hand

3. Clavicle Fracture One of the commonest of all fractures
A large peak incidence occurs in males younger than 30 years due to sports injuries
Can present even in the newborn period, especially following a difficult delivery

4. Clavicle Fracture Clavicular injuries include:
Fracture of the midshaft of the clavicle (commonest)
Fracture of the outer end of the clavicle
Acromioclavicular separation
Fracture of the medial end of the clavicle
Sternoclavicular dislocation

5. Dandy, Essential Orthop & Trauma
Clavicle Fracture
Etiology
Usually indirect trauma / Fall onto outstretched hand
Less common: direct trauma 
Dandy, Essential Orthop & Trauma

6. Clavicle Fracture Clinically; Pain Swelling Tenderness
Loss of function
thehealthscience.com

7. Clavicle Fracture Associated injuries are rare but include
Ipsilateral scapular fracture
Scapulothoracic dissociation
should be considered with significantly displaced fractures
Rib fracture
Pneumothorax
Neurovascular injury

8. Clavicle Fracture Lateral, Middle, Medial thirds The most common:
Middle third (why?)

9. Dandy, Essential Orthop & Trauma
Clavicle Fracture
The most common: middle third of the clavicle
Usually displaced down and medially by:
weight of upper limb
Muscle pull (which?)
Dandy, Essential Orthop & Trauma
emedicine.medscape.com

10. Clavicle Fracture: Management
Typically conservative
Shoulder sling or a figure-of-eight brace
Now no difference which more one effective
snowboardholics.gr

11. Clavicle Fracture: Management
Surgical indications:
Severe displacement
Tenting of the skin
Comminuted fractures
with a displaced (or Z-shaped) fragment
Neurovascular compromise
(floating shoulder)
eorif.com
ww.healio.com
quoteofthedayblog.blogspot.com

12. Clavicle Fracture: Management
Surgical Treatment
ORIF by Plate and Screws (standard)
Elastic nail ?

13. Clavicle Fracture - Complications
Poorer cosmoses
Non union
Hardware prominence
Neurovascular injury
Infection
Pneumothorax

14. Case Example

15. Fracture Humerus
 Proximal end
Mid shaft
Distal end

16. Proximal end fracture The head Greater tuberosity Lesser tuberosity
Surgical neck 1 2 3 4

17. Greater Tuberosity Attachment to:
Supraspinatus, infraspinatus, Teres Minor

18. Greater Tuberosity Management: Minimally displaced: conservative
Severely displaced: internal fixation
To regain function of rotator cuff
Fixation by: screws / tension band, plate

19. Color Atlas of Anatomy, Rohen et al
Surgical Neck
Problem in osteoporotic bone
Difficult fixation
Possible injury to Axillary nerve
Color Atlas of Anatomy, Rohen et al

20. Surgical Neck The axillary nerve can be injured Motor: Deltoid
Sensory: upper lateral arm

21. Comminuted upper part Usually old age / osteoporosis
Difficult fixation
Small fragments
Osteoporotic bone
3-part / 4-part

22. Treatment Most are non-displaced or minimally displaced
Sling immobilization
Early shoulder motion (2 wks)
radiopaedia.org

23. Treatment Displaced and 3-part / 4-part
Fixation if possible! (difficult to fix)
reviews.jbjs.org

24. Treatment Displaced and 3-part / 4-part
Fixation if possible! (difficult to fix)
Replacement in elderly

25. Color Atlas of Anatomy, Rohen et al
Mid shaft fracture
The Radial nerve may be injured (why?) (signs?)
Color Atlas of Anatomy, Rohen et al

26. Evaluation Radiological AP and lateral views including the shoulder
and elbow joints on
each view

27. Management Conservative: Cast slab (U-slab) / splint / orthosis
Gravity reduces and maintains reduction

28. Management Conservative: Operative: (plate / IMN) Check radial nerve
Cast slab / splint / orthosis
Gravity reduces and maintains reduction
Then humeros brace to start ROM
Operative: (plate / IMN)
More in multiple injuries
Floating elbow
Bed-ridden
Severe dispalcement
Open fracture
NV injury (radial !!!)
Check radial nerve
Before and after surgery
Signs to check?

29. Fracture Distal Humerus
More common in children
Usually treated by open reduction and internal fixation by plates and screws
Need good reduction and
Early mobilization to prevent stiffness of the elbow joint

30. Fracture Distal Humerus
Types:
Extra-articular:
Supracondylar fracture
Intra-articular:
Intercondylar fracture
besttoddlertoys.eu

31. Fracture Radial Head / Neck
Fall on the outstretched hand
Radial head fractures
Occur primarily in adults
Radial neck fractures
More in children

32. Fracture Radial Head / Neck
Presentation:
Pain, effusion in the elbow, tenderness on palpation directly over radial head, loss of supination/pronation (locking joint)
Associated injuries:   
Distal radius fracture 
Dislocation of the distal RU joint
Valgus instability (MCL rupture) 

33. X-ray
A visible posterior fat pad on the lateral view of the elbow is a sign of occult intra-articular pathology

34. X-ray
A visible posterior fat pad on the lateral view of the elbow is a sign of occult intra-articular pathology

35. Fracture head / neck of radius
Conservative treatment
Minimal displacement, and minimal head involvement
Full ROM
Early motion with a functional brace is encouraged to minimize elbow stiffness
Surgery treatment:
Required if the fracture involves more than 33% of the articular surface, is too much displaced
ORIF if possible
Replacement by radial head implant if too much comminuted and inoperable
Excision if stable wrist and elbow (not preferred)

36. Fracture head / neck of radius

37. Remember in frx Head of Radius
Early elbow ROM is needed to prevent stiffness
Examine the wrist:
For disruption of the distal radio-ulnar joint

38. Remember in frx Head of Radius
The posterior interosseous nerve
May be damaged by the initial injury or by the surgery performed to treat the fracture
Therefore, document functional status preoperatively

39. Summary – part 1 Upper limb injuries are common
Clavicle: usually heals well
Humerus: Radial nerve
Elbow: Stiffness
Head of radius: fat pad sign, posterior interosseous nerve

40. ( Considered as a joint )
Forearm fractures
Goals of treatment:
Soft tissue preservation / decompression
Restore length, axial alignment and rotation
Early motion with stable fixation
( Considered as a joint )

41. Forearm Fractures Management: Undisplaced: Displaced:
Check soft tissue, pulse, nerves
Undisplaced:
Possible conservative – cast
Internal fixation provides early motion and function and is usually preferred
Displaced:
Open reduction and internal fixation
Plating

42. Forearm Fractures Indications for surgery: In adults – all fractures!
Displaced both bones
Displace one bone
Fracture/dislocation
Open fractures

43. Forearm Fractures Indications for surgery: In adults
Displaced both bones
Displace one bone
Fracture/dislocation
Open fractures

44. Forearm Fractures Indications for surgery: In adults
Displaced both bones
Displace one bone
Fracture/dislocation
Open fractures

45. Forearm Fractures Indications for surgery: In adults
Displaced both bones
Displace one bone
Fracture/dislocation
Open fractures

46. Forearm Fractures - Fixation
Plate and screws: The best fixation
A joint
Anatomical reduction
Early motion – no need for cast – prevents stiffness
Intramedullary nail (Elastic):
In children

47. Forearm Fractures - Fixation
boneandspine.com

48. Complications
Compartment Syndrome

49. Complications Compartment Syndrome Malunion More in conservative
Causes stiffness/loss of
Supination
Pronation

50. Complications Compartment Syndrome Malunion
More in conservative
Causes stiffness (Sup/Pron)
Posttraumatic radioulnar synostosis (3% to 9% )

51. Complications Compartment Syndrome Malunion
More in conservative
Causes stiffness (Sup/Pron)
Posttraumatic radioulnar synostosis (3% to 9% )
Infection
Neurovascular injury
Nonunion
Esam Dahabra

52. Fracture/Dislocations
A fracture of one bone and dislocation of the radio-ulnar joint
If one bone is fractures and displaced, something must happen to the other bone or to the joint

53. Galeazzi Fracture/Dislocation
Fracture of the radius with dislocation of the distal radio-ulnar joint
“Fracture of necessity“:
Necessitates surgery
radiopaedia.org

54. Galeazzi Fracture/Dislocation
Fracture of the radius with dislocation of the distal radio-ulnar joint
“Fracture of necessity“:
Necessitates surgery
Plating of radius
Reduction of distal
radio-ulnar joint
(? Fixation)

55. Monteggia Fracture/Dislocation
Fracture of the proximal third of the ulna with dislocation of the head of the radius
Less common than Galeazzi
Treated usually by:
Open reduction and internal fixation of ulna
Closed reduction of head of radius
the reduction depends on ulnar reduction and fixation

56. Fractures of Distal Radius
Colle’s fracture
Smith's fracture
Barton's fracture
Chauffeur's fracture
The Universal classification 
Type I: extra articular, undisplaced
Type II: extra articular, displaced
Type III intra articular, undisplaced
Type IV: intra articular, displaced

57. Colle’s Fracture
Extra-articular fracture of the distal radius  with dorsal and radial displacement of the wrist and hand : “Dinner fork” deformity
Often seen in elderly people with osteoporosis
Commonly caused by falling on the outstretched hand
medacad.wikispaces.com

58. Colle’s Fracture
Extra-articular fracture of the distal radius  with dorsal and radial displacement of the wrist and hand : “Dinner fork” deformity
medacad.wikispaces.com

59. Smith's Fracture Reverse Colle’s
injurysupplies.com
Reverse Colle’s
Extra-articular fracture of distal radius with volar displacement
Caused by falling onto flexed wrists, as opposed to a Colles' fracture

60. Treatment – Colle’s & Smith’s
Treatment depends on severity:
Undisplaced fractures: Cast alone
Fractures with angulation and displacement require closed reduction (Sedation/UGA / ULA) and casting

61. Treatment – Colle’s & Smith’s
Position in cast:
Colle’s frx the wrist immobilized in flexion & ulnar angulation
Smith frx the wrist immobilized in extension
murtagh.fhost.com.au

62. Barton's Fracture
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

63. Barton's Fracture: Treatment
Has tendency to re- displace
Open reduction and internal fixation with special plates
Or closed reduction, application of external fixation, and percutaneous pin insertion

64. Complications Median nerve dysfunction Malunion
Tendon rupture, most commonly extensor pollicis longus
Midcarpal instability
Posttraumatic osteoarthritis
Stiffness (wrist, finger, and elbow)
Regional sympathatic dystrophy

65. Scaphoid Fracture Fall on the palm on the outstretched hand
Scaphoid is the most frequently fractured  carpal bone
Usually presents with pain and tenderness in the anatomical snuffbox at the base of the thumb
arabbones.com

66. Scaphoid Fracture Radiology:
AP and Lateral may not be enough
Need an Oblique scaphoid view
Often diagnosed by X-rays However not all fractures are apparent initially
If tenderness present:
Treat by application of thumb spica cast
Repeat x ray after one week

67. Scaphoid Fracture Complications Avascular necrosis (AVN):
Mainly proximal 1/3
Why?
Blood supply comes from distal to proximal
More common in more proximal fractures

68. Scaphoid Fracture Complications Avascular necrosis (AVN):
Mainly proximal 1/3
Non-union:
Occur from undiagnosed or undertreated scaphoid

69. Scaphoid Fracture Complications Avascular necrosis (AVN):
Mainly proximal 1/3
Non-union:
Occur from undiagnosed or undertreated scaphoid
Wrist osteoarthritis
With non-union

70. Scaphoid Fracture - Treatment
Non displaced / minimally displaced waist and distal fractures
Have a high rate of union with closed cast management
Short arm thumb spica for non displaced fractures
May extend to16 weeks depending on fracture location

71. Scaphoid Fracture - Treatment
Displaced and more proximal fractures
Internal fixation with special screw

72. Scaphoid Fracture - Treatment
Displaced and more proximal fractures
Internal fixation with special screw

73. Metacarpal Fractures Undisplaced / only one Can treat by cast / splint

74. Metacarpal Fractures Undisplaced / only one Can treat by cast / splint
Careful about rotational malalignment
Check rotation by flexing the fingers

75. Metacarpal Fractures Displaced / Rotated / Multiple
Best internal fixation (screws / plates / wires)

76. Metacarpal Fractures Displaced / Rotated / Multiple
Best internal fixation (screws / plates / wires)

77. Metacarpal Fractures Displaced / Rotated / Multiple
Best internal fixation (screws / plates / wires)
jhs.sagepub.com

78. Metacarpal Fractures Displaced / Rotated / Multiple
Best internal fixation (screws / plates / wires)

79. Mallet Finger Avulsion injury of EPL insertion Mechanism of injury
Clinical picture
Treatment

80. Summary Upper limb injuries are common Clavicle: usually heals well
Humerus: Radial nerve
Elbow: Stiffness
Head of radius: fat pad sign, posterior interosseous nerve
Forearm: a joint
Distal radius: old age
Scaphoid: AVN
Metacarpals: Rotation