Basics of Upper limb trauma in orthopaedics

1. BY: DR. PRATEEK GOEL (SENIOR RESIDENT ORTHO MAMC & LNH)
UPPER LIMB TRAUMA

2. Upper Limb
Anatomy
Review

3. Shoulder: (Anatomy Review)

4. Head of Humerus loses its articulation from
the Glenoid:
• Anterior dislocation >95% (Preglenoid;
Subcoracoid; Subclavicular)
• Posterior dislocation <5%
• Inferior dislocation (Luxatio erecta)
<1%(Subglenoid)

5. Anterior Dislocation
Causes: Frequently seen in younger patients after trauma such as in RTA or sports.
Posterior Dislocation
Causes: Usually the result of discoordinated rotator cuff muscle contraction seen in Electric shock,
Seizures, etc.
Examination: Humeral head is prominent, asymmetry, reduced ROM.
Assess neurovascular status. Commonly the axillary nerve is affected, check for numbness
over the regimental patch (Skin over deltoid insertion) or deltoid muscle paralysis is seen.

6. Clinical Tests
• Dugas’ test
• Hamilton ruler test
Radiographic Evaluation
• True AP shoulder: Head of humerus can be seen lying beneath coracoid
• Axillary view: Head of humerus lying anterior or posterior to glenoid

8. Pathological Changes:
• Bankart’s lesion
• Hill-Sachs lesion
• Associated fractures

9. Complications of Shoulder Dislocation
• Recurrent dislocation; common in patients <20 years of age.
• Rotator cuff injury; common in middle aged and elderly.
• Greater tuberosity fractures.
• Axillary nerve injuries; deltoid paralysis and loss of sensation over regimental badge area.
• Shoulder stiffness

10. ANTERIOR
SHOULDER
DISLOCATION

11. POSTERIOR
SHOULDER
DISLOCATION

12. Treatment
Closed Reduction and immobilisation
• Kocher’s manoeuvre
• Hippocrates manoeuvre

13. Clavicular fracture

14. Epidemiology
• Clavicle fractures are one of the most common injuries of upper limb
• Account for 5-10% of all fractures
• Easy to diagnose
• Majority unite uneventfully
• Can happen during childbirth

15. ›History›: Age is often Elderly with a H/O Trauma or Fall.
C/O: Pain, Swelling & inability to lift the upper limb.
O/E: Always compare both sides.
• Limitation of motion
• Bruising, tenderness, crepitus, deformity
• Arm usually held across the chest with the opposite limb supporting it
• Look for associated injuries such as Neurovascular deficit,
pneumothorax, etc.
Diagnosis

16. • AP Xray
- evaluate superior inferior displacement
• 45degree cephalic tilt view
- evaluate AP displacement
• CT-scan
Radiographs

17. • Pneumothorax
• Neurovascular injury (Subclavian Vessel; Brachial plexus)
• Malunion
• Nonunion
Complications

18. Treatment
In Adults - Clavicle Brace with arm sling pouch
In Children - Figure of 8 Bandage with arm sling

19. Humeral Shaft Fractures

20. • Fracture of diaphysis of the humerus
• Causes: Usual cause is direct trauma/Fall on an outstretched hand
• Fracture pattern depends on the stress applied.
• Symptoms: Pain, swelling, decreased ROM
• Examination: Assess Neurovascular status. Most commonly the radial nerve is affected
(Supplies motor innervation to the wrist extensors causing wrist drop)

22. Holstein-Lewis Fracture
• Distal 1/3 fracture of Shaft of Humerus
• May entrap or lacerate radial nerve as the
fracture passes through the intermuscular
septum

23. Clinical evaluation
• Thorough history and physical
• Patients typically present with pain, swelling,
and deformity of the upper arm
• Careful NV exam important as the radial nerve
is in close proximity to the humerus and can be
injured

24. Treatment
- Closed reduction and immobilisation
• U-Slab
• Hanging cast
• Chest arm bandage
- Open reduction and internal fixation

25. Supra- condylar Fracture of
Humerus

26. Types
It depends upon the displacement of the distal fragment.
• Extension type (80%)
• Flexion type (20%)
Presentation
• Pain, swelling, deformity and inability to move the affected elbow.
• Unusual posterior prominence of the elbow because of backward tilt of
distal fragment.
• 3 bony points relationship is maintained.

27. Pediatric Supra-condylar fracture

28. Displacements:
• Posterior or backward shift
• Posterior or backward tilt
• Proximal shift
• Medial or Lateral shift
• Medial tilt
• Internal rotation

29. • Brachial Artery Injury
• Peripheral Nerve Injury:
a) Anterior Interosseous nerve; most commonly injured
b) Median nerve; posterolateral pattern
c) Radial nerve; posteromedial pattern
d) Ulnar nerve; flexion type
• Compartment Syndrome
• Volkmann Ischemic Contracture
• Malunion; cubitus varus (Gun-stock deformity)
• Elbow stiffness/Myositis ossificans
Complications

30. Treatment
• Closed reduction and K wire fixation
• Open reduction and K wire fixation

31. Lateral Condyle Humerus Fracture
• 2nd most common fracture of the elbow in children
• Age group; 4-10 years

32. Clinical Presentation
• Pain
• Swelling
• Restriction of movement
• Skin changes or wound
• Bony crepitus
Mechanism of injury
• Fall on the extended upper extremity with
axial load transmission causing radial
head to impinge on lateral condyle (Push
off theory)
• Avulsion injury due to pull of strong wrist
extensors (Pull-off theory)

33. Investigations
• Plain radiograph of elbow –
AP and lateral view

34. Complications
• Nonunion, leading to Cubitus valgus deformity
• Tardy Ulnar Nerve palsy; late complication of
progressive cubitus valgus
• Malunion
• Growth Arrest
• Lateral spurring

35. Treatment
• Cast immobilisation for undisplayed fractures
• Open reduction and internal fixation for displaced fractures

36. FOREARM FRACTURES

37. • Radial shaft fracture at junction of
middle and distal thirds with
disruption of distal radio-ulnar joint.
• Fall on outstretched hand.
• Suspect if tenderness at distal radius
and distal radial ulnar joint (DRUJ)
disruption
Galeazzi’s Fracture

38. • Transverse or oblique fracture at junction
of middle and distal thirds seen on AP
view
• Widening of DRUJ on AP view
• Radial shortening >5mm
• Dislocation of radius relative to ulna on
lat view
Radiographic Evaluation
Treatment
• Open reduction and internal fixation
with anatomic reduction.

39. • Fracture of proximal 1/3rd of ulnar shaft with
dislocation of radial head
• Fall on outstretched, extended, and pronated
elbow is usual mechanism
• Radial head may be palpated in antecubital
fossa
• Posterior Interosseus nerve injury.
Monteggia’s Fracture

40. Radiology:
• Ulnar fracture
• Dislocation of radial head
Treatment:
• Open reduction and internal
fixation

41. • Most common fracture of the distal radius
(Cortico-cancellous junction)
• Results from a fall on an outstretched hand
(FOOSH)
Examination
• Dorsal swelling
• Ecchymosis
• “Silver fork” deformity of the hand and wrist
Colles’ Fracture

42. Elements Involved:
• Posterior angulation
• Posterior displacement
• Radial deviation
• Supination
• Proximal impaction
Silver fork Deformity

43. Radiographs
• AP & Lateral views
• Fracture line prominent at portico-cancellous
junction of distal radius
• Dorsal tilt is most characteristic displacement
• Typically occurs within 2cm of distal radius articular
surface

44. Treatment
• Closed reduction and plaster immobilisation
• Closed reduction with K wire fixation
• Open reduction and internal fixation using plates

45. Complications
• Malunion
• Stiffness of joints
• Posttraumatic osteoarthritis
• Tendon rupture (EPL)
• Carpal Tunnel Syndrome

46. • Less common fracture of distal radius
• Unstable fracture
• Fall on the flexed wrist with forearm fixed in supination
• Distal fragment is displaced volarly and proximally (apex
dorsal)
• Direct blow to dorsum of the wrist
• Treatment is generally done by open reduction and
internal fixation due to unstability
Smith’s Fracture

48. Scaphoid Fracture

49. Epidemiology
• The most frequent fractured bone of the wrist
• 10-15% of all hand and wrist fractures
• 60-80% of carpal fractures
• Waist 65%
• 1/3 distal 10%
• 1/3 proximal 15%

50. Mechanism
• Axial load over hyperextended and radially
deviated wrist
Examination
• Wrist pain
• Swelling
• Tenderness in the anatomic snuffbox

51. Xray
• PA view
• Lateral view
• Radial Oblique view
• Ulnar Oblique view
CT Scan
Radiology:

52. • Nonunion
• Malunion
• Avascular Necrosis of proximal
fragment
• Carpal instability
• Wrist arthritis
Complications:
Treatment:
• Cast immobilisation for undisplaced & mildly displaced fractures
• Open reduction and internal fixation by compression screws for widely displaced fractures

53. Bennett’s Fracture

54. • Intra articular fracture through the base of 1st metacarpal
• Disruption of 1st CMC Joint
Mechanism of injury
• Axial blow directed against the partially flexed metacarpal
• Commonly sustained in fistfights

55. Radiograph:
• Treatment by fixation with K-wires & immobilisation with thumb spica cast
• Generally Closed reduction is enough but sometimes Open reduction is needed

56. Rolando Fracture
• T or Y shaped intra articular fracture involving the
base of 1st metacarpal
• Does not cause diaphyseal displacement of the shaft
as seen with Bennet’s fracture
• Treatment by fixation with K-wires & immobilisation
with thumb spica cast

57. • Any material which is used to support a fracture is called a splint.
• Splints are used for immobilizing fractures either temporarily during transportation or for
definitive treatment.
• Rule of splintage is to immobilize a joint one above and one below the fracture.
SPLINTS

58. Krammer Wire Splint
• Used for temporary quick splintage of a limb for
transport.
• Two thick parallel wires with ladder like thin
wires.
• Malleable, can easily be bent to the contour of
limb.

59. Triangular sling
• Used when there are injuries to the upper limb and
for some chest injuries.
• It holds the arm in adduction & forearm across the
chest.
• Used as first aid and is a temporary measure.

60. Buddy Strapping of fingers
• Buddy strapping is used for undisplaced proximal
or middle shaft phalynx fractures or sprains.
• It refers to the practice of bandaging an injured
finger to an uninjured one.
• The uninjured digit acts as a sort of splint, and
helps to support, protect, and realign the injured
finger.

61. Above Elbow Slab
• Used for forearm fractures and
fractures around the elbow.
• Proximally; at insertion of deltoid
muscle
• Distally; proximal to metacarpo-
phalangeal joint

62. Below Elbow Slab
• Used for metacarpal and wrist fractures.
• Proximally; below the elbow joint
• Distally; proximal to metacarpo-
phalangeal joint.

63. THANK YOU