1. Common Upper Limb
Fractures
By Chris Pullen

2. Common Fractures
Clavicle
Proximal Humerus
Distal radius
Scaphoid

3. Clavicle 4% to 15% of all fractures
35% of fractures about the shoulder
middle third++
Mechanism
Direct trauma
indirect - fall onto the outstretched hand

4. Clavicle – Middle 1/3
Most are treated non-surgically with a sling for weeks
Thereafter ROM exercises

5. Clavicle – Middle 1/3 ORIF
Indications
open fractures
neurovascular injury/compromise
displaced fractures with impending skin compromise
widely displaced midclavicular fractures
shortening (20 mm) or gross displacement are risk factors for the development of nonunion

6. Clavicle – Middle 1/3

7. Clavicle – Lateral 1/3 Displaced ORIF (30% nonunion) Sling 6 weeks
secondary to a fracture medial to the coracoclavicular ligaments
ORIF (30% nonunion)
Sling 6 weeks

8. Proximal Humerus 4% to 5% of all fractures ↑ age ↑ incidence
Elderly - fall osteoporotic bone
Young – significant trauma
~ 85% are minimally displaced

9. Proximal Humerus - Imaging
Plain XR
scapular anteroposterior (AP)
lateral
axillary radiographs
+/- CT scan

10. Proximal Humerus - Classification
4 parts (anatomic fragments)
humeral head
greater tuberosity
lesser tuberosity
humeral shaft
Determination of
displacement >1 cm
angulation > 45°

11. Proximal Humerus - Nonsurgical
Minimally or non-displaced fractures
Sling or collar & cuff
Rpt XR 1 & 2 weeks
Early passive motion within 14 days
Active range of motion is started at 4 to 6 weeks
A recent report indicated that functional outcome was inferior to previously reported results

12. Proximal Humerus - Surgical
Two-part fractures of the surgical neck
most common displaced proximal humeral fracture
closed reduction - if stable
ORIF - if cannot be reduced closed

13. Proximal Humerus - Surgical
Two-part fractures of the greater tuberosity
commonly occur with a shoulder dislocation
After reduction the tuberosity may return to its anatomic position
ORIF if displaced (=/- repair of the rotator cuff tear)

14. Proximal Humerus - Surgical
Three-part fractures
ORIF
functional results better

15. Proximal Humerus - Surgical
Four-part fractures
ORIF
young patients
good bone quality
Humeral head replacement
preferred method in the elderly
better functional scores

16. Distal Radius common incidence ~ 1 in 500 people
bimodal age distribution
adolescents and young adults
high-energy injuries
postmenopausal elderly women

17. Distal Radius - Imaging
Plain XR
posteroanterior (PA)
Lateral
oblique radiographs
+/- CT scan

18. Distal radius - Nonsurgical
Minimally or non-displaced fractures
Elderly
Below elbow POP 6 weeks
Young adult
Above elbow POP 6 weeks
Rpt XR 1 & 2 weeks
ROM exercises

19. Distal Radius - Surgical
Indications
Radial shortening of < 5mm at DRUJ
Dorsal tilt >/= 15° or Volar tilt >/= 20°
Intra-articular incongruity of >/= 2mm
anatomic reduction is critical

20. Distal Radius - Surgical

21. Distal Radius - Surgical
Options
closed reduction +/- K wire fixation
external fixation
ORIF
arthroscopically-assisted reduction
bone defect filling

22. Distal Radius - Surgical

23. Distal Radius - Surgical

24. Scaphoid most common fractures of the carpus
75% of all carpal injuries
Rare elderly or children

25. Scaphoid - Imaging Plain XR
Some are XR apparent at presentation
many a fracture line is not visible until bony resorption at the fracture advances
Rpt XR at 10 days +/- bone scan used for diagnosis of occult scaphoid fractures

26. Scaphoid - Nonsurgical
Tubercle
+/- splintage for analgesia
Early ROM exercises
Nondisplaced
immobilization until clinical or radiographic healing occurs
‘Glass-holding’ POP
8 to 26 weeks

27. Scaphoid - Surgical Indications ORIF (compression screw)
> 10° of angular deviation
1 mm of displacement
Proximal pole fractures
ORIF (compression screw)

28. THE END