4. Clavicle Fractures
• Mechanism
• Fall onto shoulder (87%)
• Direct blow (7%)
• Fall onto outstretched hand (6%)
• The clavicle is the last ossification center to
complete (sternal end) at about 22-25yo.
6. Clavicle Fractures
• Clinical Evaluation
• Inspect and palpate for deformity/abnormal
motion
• Thorough distal neurovascular exam
• Auscultate the chest for the possibility of lung
injury or pneumothorax
• Radiographic Exam
• AP chest radiographs.
• Clavicular 45deg A/P oblique X-rays
7. Clavicle Fractures
• Allman Classification of Clavicle Fractures
• Type I Middle Third (80%)
• Type II Distal Third (15%)
• Differentiate whether ligaments attached to
lateral or medial fragment
• Type III Medial Third (5%)
8.
9. Clavicle Fractures
• Closed Treatment
• Sling immobilization for usually 3-4 weeks with early
• ROM encouraged
• Operative intervention
• Fractures with neurovascular injury
• Fractures with severe associated chest injuries
• Open fractures
• Group II, type II fractures
• Cosmetic reasons, uncontrolled deformity
• Nonunion
13. Proximal Humerus Fractures
• Epidemiology
• MC fracture of the humerus
• Higher incidence in the elderly, related to
osteoporosis
• Females 2:1 males
• Mechanism of Injury
• MC fall onto an outstretched arm from standing
height
• Younger patient typically present after high
energy trauma such as Motor Vehicle Accident
14. Proximal Humerus Fractures
• Clinical Evaluation
• Patients typically present with arm held close
to chest by contralateral hand.Pain and
crepitus detected on palpation
• Careful NV exam is essential, particularly with
regards to the axillary nerve. Test sensation
over the deltoid. Deltoid atony does not
necessarily confirm an axillary nerve injury
16. Proximal Humerus Fractures
• Treatment
• Minimally displaced fractures-Sling immobilization, early motion
• Two-part fractures-
• Anatomic neck fractures likely require ORIF. Surgical neck fractures
that are minimally displaced can be treated
conservatively.Displacement requires ORIF
• Three-part fractures
• Due to disruption of opposing muscle forces, these are unstable so
closed treatment is difficult. Displacement requires ORIF.
• Four-part fractures
• In general for displacement or unstable injuries ORIF in the young
and hemiarthroplasty in the elderly and those with severe
comminution.
18. Humeral Shaft Fractures
• Mechanism of Injury
• Direct trauma MC - MVA
• Indirect trauma -fall on an outstretched hand
• Fracture pattern depends on stress applied
• Compressive- proximal or distal humerus
• Bending- transverse fracture of the shaft
• Torsional- spiral fracture of the shaft
• Torsion and bending- oblique fracture usually
associated with a butterfly fragment
19. Humeral Shaft Fractures
• 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
20. Humeral Shaft Fractures
• Radiographic evaluation
• AP and lateral views of the humerus
• Traction radiographs may be indicated for
hard to classify secondary to severe
displacement or a lot of comminution
21. Humeral Shaft Fractures
• Conservative Treatment
• Goal of treatment is to establish union with
acceptable alignment
• >90% of humeral shaft fractures heal with
nonsurgical management
22. Humeral Shaft Fractures
• Treatment
• Operative Treatment
• Indications :inadequate reduction, nonunion,
associated injuries, open fractures,
segmental fractures, associated vascular or
nerve injuries
• MC treated with plates and screws but also
IM nails
23. Humeral Shaft Fractures
• Holstein-Lewis Fractures
• Distal 1/3rd fractures
• May entrap or lacerate radial nerve as the
fracture passes through the intermuscular
septum
26. Forearm Fractures
• Epidemiology
• Highest ratio of open to closed than any other
fracture except the tibia
• males > females,MC secondary to MVA,
contact sports, altercations, and falls
• Mechanism of Injury
• Commonly associated with mva, direct trauma
missile projectiles, and falls
27. Forearm Fractures
• Clinical Evaluation
• Present with gross deformity of the forearm and with
pain, swelling, and loss of function at the hand
• Careful exam with specific assessment of radial, ulnar,
and median nerves and radial and ulnar pulses
• Tense compartments, unremitting pain, and pain with
passive motion:suspicion for compartment syndrome
• Radiographic Evaluation
• AP and lateral radiographs of the forearm
• Don’t forget to examine and x-ray the elbow and wrist
28. Forearm Fractures
• Ulna Fractures
• These include Nightstick and Monteggia fractures
• Monteggia denotes a fracture of the proximal ulna with an associated
radial head dislocation
• Monteggia fractures classification- Bado
• Type I- Anterior Dislocation of the radial head with fracture of ulna
at any level- produced by forced pronation
• Type II- Posterior/posterolateral dislocation of the radial head-
produced by axial loading with the forearm flexed
• Type III- Lateral/anterolateral dislocation of the radial head with
fracture of the ulnar metaphysis- forced abduction of the elbow
• Type IV- anterior dislocation of the radial head with fracture of
radius and ulna at the same level- forced pronation with radial
shaft failure
29.
30. Forearm Fractures
• Radial Diaphysis Fractures
• Fractures of the proximal two-thirds :truly isolated
• Galeazzi or Piedmont fractures :fracture of the radius with
disruption of the distal radial ulnar joint
• Reverse Galeazzi :fracture of the distal ulna with disruption of
radioulnar joint
• Mechanism
• Usually caused by direct or indirect trauma, such as fall onto
outstretched hand
• Galeazzi fractures :direct trauma to the wrist, typically on the
dorsolateral aspect, or fall onto outstretched hand with pronation
• Reverse Galeazzi :fall with hand in supination
32. Greenstick fracture
• incomplete fractures of long bones
• young children, MC less than 10 years of age.
• MC mid-diaphyseal, affecting the forearm and lower leg.
• distinct from torus fractures.
Pathology
Mechanism
Greenstick fractures - force applied to a bone results in bending of the bone such
that the structural integrity of the convex surface is overcome.
disintegration of the cortex results in fracture of the convex surface.
the bending force applied does not break the bone completely and the concave
surface of the bent bone remains intact.
This can occur following an angulated longitudinal force applied down the bone
(e.g. an indirect trauma following a fall on an outstretched arm), or after a force
applied perpendicular to the bone (e.g. a direct blow).
different, and much less common, than the torus fracture that results in buckling
of the cortex on the concave side of the bend and an intact convex surface.
33. Greenstick fracture
• Radiographic features
• Plain radiograph
• usually mid-diaphyseal
• occur in tandem with angulation
• incomplete fracture, with cortical breach of only one
side of the bone.
• Differential diagnosis
• torus fracture: much more common, metaphyseal, and
results in buckling of the cortex
• bowing fracture: the bone is bowed, but there is no
discernible fracture
35. Distal Radius Fractures
• Epidemiology
• MC fractures of the upper extremity
• Common in younger and older patients as a result of
direct trauma such as fall on an outstretched hand
• Increasing incidence due to aging population
• Mechanism of Injury
• MC a fall on an outstretched extremity with the wrist in
dorsiflexion
• High energy injuries- significantly displaced, highly
unstable fractures
36. Distal Radius Fractures
• Clinical Evaluation
• Patients typically present with gross deformity
of the wrist with variable displacement of the
hand in relation to the wrist.Typically swollen
with painful ROM
• Ipsilateral shoulder and elbow must be
examined
• NV exam including specifically median nerve
for acute carpal tunnel compression syndrome
37. Distal Radius Fractures
• Eponyms
• Colles Fracture
• Combination of intra and extra articular fractures of the distal radius with
dorsal angulation (apex volar), dorsal displacement, radial shift, and radial
shortening
• Most common distal radius fracture caused by fall on outstretched hand
• Smith Fracture (Reverse Colles)
• Fracture with volar angulation (apex dorsal) from a fall on a flexed
• wrist
• Barton Fracture
• Fracture with dorsal or volar rim displaced with the hand and carpus
• Radial Styloid Fracture (Chauffeur Fracture)
• Avulsion fracture with extrinsic ligaments attached to the fragment
• Mechanism of injury is compression of the scaphoid against the styloid
38.
39.
40.
41. Distal Radius Fractures
• Treatment
• Displaced fractures require an attempt at
reduction.
• Operative Management
• For the treatment of intraarticular, unstable,
malreduced fractures.
• As always, open fractures must go for OR.
48. Shoulder Dislocations
• Clinical Evaluation
• Examine axillary nerve (deltoid function, not
• sensation over lateral shoulder)
• Examine M/C nerve (biceps function and
anterolateral forearm sensation)
• Radiographic Evaluation
• True AP shoulder
• Axillary Lateral
49. • Bankart
• Detachment of the anteroinferior labrum (3-6 o'clock) with complete tearing of
the anterior scapular periosteum with or without an osseus fragment of the
glenoid.
• Reverse Bankart
• Detachment of the posteroinferior labrum (6-9 o'clock) with tearing of the
posterior scapular periosteum with or without an osseus fragment of the glenoid.
• Perthes
• Detachment of the anteroinferior labrum (3-6 o'clock) with medially stripped but
intact periosteum.
• ALPSA = Anterior Labral Periosteal Sleeve Avulsion.
• Medially displaced labroligamentous complex with absence of the labrum on the
glenoid rim.
• GLAD = GlenoLabral Articular Disruption.
• Represents a partial tear of anteroinferior labrum with adjacent cartilage damage.
50.
51. • Bankart lesions -injuries specifically at the anteroinferior aspect of the glenoid labral complex -
common complication of anterior shoulder dislocation-frequently seen in association with a Hill-
Sachs defect.
• Terminology
• Bankart lesion refers to an injury of the labrum and associated glenohumeral capsule/ligaments.
Injury to these reinforcing soft tissue structures - recurrent dislocation .
• Bony Bankart (contrasted with a soft Bankart /fibrous Bankart) - fracture of the adjacent
anteroinferior glenoid- commonly occurs in the setting of anterior glenohumeral dislocation- less
contributory to anterior instability.
• Pathology
• Bankart lesions occur as a direct result of anterior dislocation of the humeral head, whereby the
humerus is compressed against the labrum
• Detachment of the anteroinferior labrum from the underlying glenoid, and the labral tear may
extend further superiorly or posteriorly.
• A/W Impaction fracture of the anteroinferior glenoid margin.
• Soft Bankart lesions > bony Bankart lesions .
52. • Associations
• The same mechanism of compression can result in a
Hill-Sachs defect. Bankart and Hill-Sachs defects are
11x more likely to occur together than isolated injuries.
• Variants
• Perthes lesion of the shoulder
• Anterior labroligamentous periosteal sleeve avulsion
(ALPSA)
• Glenolabral articular disruption (GLAD)
53. • Radiographic features
• Plain radiograph
• +/- fracture of the anteroinferior aspect of the glenoid
• CT
• glenoid labrum is not commonly visualized by CT
• CT arthrography may demonstrate labral avulsion
• +/- fracture at the anteroinferior aspect of the glenoid
• MRI
• frank displacement/separation of the anterior glenoid labrum, with or without glenoid fracture
fragment
• linear high T2/PD intensity through the non-displaced anteroinferior labrum, indicating a tear
• abnormally small or absent anterior labrum
• double axillary pouch sign (coronal MR arthrogram): specific sign for an anteroinferior labral tear
• Treatment and prognosis
• Bankart lesions – heal- early surgical intervention is not required.
• In Bankart repairs, the labral fragment is sutured back to the glenoid rim using suture anchors.
54. Hill-Sachs defects
• posterolateral humeral head depression fracture, resulting from the
impaction with the anterior glenoid rim - indicative of anterior
glenohumeral dislocation- a/w Bankart lesion of the glenoid.
• Repeat dislocations lead to larger defects- result in an engaging Hill-Sachs
defect- engages the anterior glenoid when the shoulder is abducted and
externally rotated
• Pathology
• Anterior glenohumeral dislocation will lead to impaction of the
posterolateral humeral head and anterior glenoid rim.
• Repeat dislocations can lead to further bony defects in both the humeral
head and glenoid and the engaging Hill–Sachs defect is associated with
decreased glenoid bone stock, glenoid rim fracture, and chronic instability
• Bankart lesions - 11x more common in patients with a Hill-Sachs defect,
with increasing incidence with increasing size .
55. • Radiographic features
• When a Hill-Sachs defect is identified careful assessment of the anterior glenoid should be
undertaken to assess for a Bankart lesion.
• Plain radiograph
• wedge shape defect in the posterolateral aspect of the humeral head
• best appreciated on AP internal rotation view
• on abduction-internal rotation views, the physiological depression at humeral head-neck junction
should not be mistaken for Hill-Sachs defect – seen 2 cm from superior humeral head margin
• CT and MRI
• loss of the normal circular shape in the posterolateral region of the superior humeral head on axial
images
• MRI and CT - show smaller defects
• anatomic shape can be preserved but the presence of bone marrow edema in the posterolateral
humeral head indicates an acute injury
• normal flattening of the posterolateral humeral head caudal to the level of coracoid should not be
misinterpreted as a Hill-Sachs defect (pseudo-Hill-Sachs defect)
56. • Treatment and prognosis
• The bony defect itself often does not require treatment, however,
the associated glenohumeral instability and coexistent anterior
labral injuries often do require surgical repair.
• The bony defect can be treated with bone grafting or placement of
soft tissue within the defect, but this is generally reserved for large,
engaging defects . Capsulotendinosis and filling of the Hill-Sachs
defect can be performed via open (Connolly procedure) or
arthroscopic (remplissage) approaches .
• Differential diagnosis
• hatchet sign of ankylosing spondylitis
• humeral head pseudolesion
59. Shoulder Dislocations
• Posterior Dislocation
• Adduction/Flexion/IR at time of injury
• Electrocution and Seizures cause overpull of
subscapularis and latissimus dorsi
• Look for “lightbulb sign” and “vacant glenoid”
sign
• Reduce with traction and gentle anterior
translation
60.
61. Shoulder Dislocations
• Inferior Dislocations
• Luxatio Erecta
• Hyperabduction injury
• Arm presents in a flexed “asking a question”
posture
• High rate of nerve and vascular injury
• Reduce with in-line traction and gentle
adduction
62.
63. Shoulder Dislocation
• Treatment
• Nonoperative treatment
• Closed reduction should be performed after
adequate clinical evaluation and appropriate
sedation
64. Shoulder Dislocations
• Postreduction
• Post reduction films are a must to confirm the
• position of the humeral head
• Pain control
• Immobilization for 7-10 days then begin progressive
ROM
• Operative Indications
• Irreducible shoulder (soft tissue interposition)
• Displaced greater tuberosity fractures
• Glenoid rim fractures bigger than 5 mm
• Elective repair for younger patients
65. Rotator cuff tear
• Rotator cuff tears are one of the most common
causes of shoulder pain mostly in older patients.
• Clinical presentation
• The prevalence of tears increases with age. The
most significant findings are impingement and
"arc of pain" sign (pain while lowering the
abducted arm) . Supraspinatus weakness, night
pain and weakness of external rotation (seen in
infraspinatus tear) may also be present.
67. • Location
• Rotator cuff tears can affect each one of the rotator cuff tendons and often more than one 3-5:
• subscapularis tendon tear
• supraspinatus tendon tear (most common)
• infraspinatus tendon tear (second most common)
• teres minor tendon tear
• Rotator cuff tears can occur at different locations of the tendon, and more than one location can be
involved :
• tendon insertion (footplate): often degenerative
• critical zone: degenerative or trauma-related
• myotendinous junction: often trauma-related, infraspinatus muscle most often affected
68. • Subtypes
• A modification of the original Codman classification (1930) may be used to categorize tears:
• full-thickness rotator cuff tear
• massive rotator cuff tear
• Fosbury flop tear
• partial-thickness rotator cuff tear
• intrasubstance tear: not in communication with the joint surface or with the bursal surface of
the tendon 7
• articular-sided tear
• rim rent tear: articular surface tear of the footprint
• with tendon delamination or interstitial tear; if the gap is filled with fluid then it is called
cleavage tear of the rotator cuff
• bursal-sided tear
69. • Radiographic features
• Exact features depend on the type of tear.
• Plain radiograph
• Typically, these are normal in acute tears with chronic tears
showing degenerative-type changes :
• may show a decreased acromiohumeral interval
• <7 mm on true AP shoulder radiograph in chronic tears
• <2 mm on an 'active abduction' view in acute tears
70. • may show decreased supraspinatus opacity and decreased bulk due to fatty
atrophy in chronic tears
• humeral subluxation superiorly may be seen in chronic tears
• may show features of subacromial impingement
• spur formation on the undersurface of acromioclavicular joint
• acromion with an inferolateral tilt seen on outlet view (i.e. modified 'Y' view)
• type III acromion
• secondary degenerative changes: sclerosis, subchondral cysts, osteolysis, and
notching/pitting of greater tuberosity
71. • Ultrasound
• up to 90% sensitivity and specificity.
• reveal other mimics like tendinosis, calcific tendinitis, subacromial-subdeltoid
bursitis, greater tuberosity fracture and adhesive capsulitis.
• Full-thickness tears extend from the bursal to the articular surface, while partial-
thickness tears are focal defects in the tendon that involve either the bursal or
articular surface.
• Full-thickness :ultrasound as hypoechoic/anechoic defects in the tendon.
• Due to the fluid replacing the tendon, cartilage shadow gets accentuated giving a
double cortex or cartilage interface sign.
• due to the defect, overlying peribursal fat dips down into the tendon gap, creating
a sagging peribursal fat sign .
• Direct signs :
• non-visualization of the tendon
• hypoechoic discontinuity in the tendon
72. • Indirect signs :
• double cortex sign
• sagging peribursal fat sign
• compressibility
• muscle atrophy
• Secondary associated signs :
• cortical irregularity of greater tuberosity
• shoulder joint effusion
• fluid along the biceps tendon
• fluid in the axillary pouch and posterior recess
73. • MRI
• Full-thickness tears are easier to diagnose on MRI than partial-thickness tears .
• Hyperintense signal area within the tendon on T2W, fat-suppressed, intermediate-
weighted and GRE sequences, usually matches to fluid signal.
• They extend from the articular to the bursal surface.
• tendon defect filled with fluid :direct sign of rotator cuff tear.
• Tendon retraction.
• Indirect signs on MRI - subdeltoid bursal effusion, medial dislocation of biceps,
fluid along biceps tendon, and diffuse loss of peribursal fat planes
• Partial-thickness tears extend to either the bursal or articular surface, and
sometimes they are interstitial which means confined within the tendon.
• Retraction of tendinous fibers from the distal insertion into the greater tuberosity -
considered partial tear.
• Chronic tears show signs of extensive use or repetitive stress -reflected by
intramuscular cystic changes and tendinosis in the remaining tendon.
• MR arthrography - enhance the detection of rotator cuff tears, especially full-
thickness tears.
82. Normal Alignment
• Anterior humeral line- line drawn along
anterior surface of humeral cortex should pass
through the middle third of the capitellum
• Radiocapitellar line- Line drawn through the
proximal radial shaft and neck should pass
through to the articulating capitellum
83.
84.
85.
86. Elbow Dislocations
• Epidemiology
• 11-28% of injuries to the elbow
• Posterior dislocations most common
• Highest incidence in the young 10-20 years and usually
sports injuries
• Mechanism of injury
• Most commonly due to fall on outstretched hand or elbow
resulting in force to unlock the olecranon from the trochlea
• Posterior dislocation following hyperextension, valgus
stress, arm abduction, and forearm supination
• Anterior dislocation ensuing from direct force to the
posterior forearm with elbow flexed
87. Elbow Dislocations
• Clinical Evaluation
• Patients typically present guarding the injured
• extremity
• Usually has gross deformity and swelling
• Careful NV exam in important and should be done
prior to radiographs or manipulation
• Repeat after reduction
• Radiographic Evaluation
• AP and lateral elbow films should be obtained both
pre and post reduction
• Careful examination for associated fractures
88. Elbow Fracture/Dislocations
• Treatment
• Posterior Dislocation
• Closed reduction under sedation
• Open reduction for severe soft tissue injuries
or bony entrapment
• Anterior Dislocation
• Closed reduction under sedation
89. Elbow Dislocations
• Associated injuries
• Radial head fracture (5-11%)
• Treatment
• Type I- Conservative
• Type II/III- Attempt ORIF vs. radial head
replacement
93. Elbow Dislocations
• Instability Scale
• Type I
• Posterolateral rotary instability, lateral ulnar collateral
ligament disrupted
• Type II
• Perched condyles, varus instability, ant and post capsule
disrupted
• Type III
• A: posterior dislocation with valgus instability, medial
collateral ligament disruption
• B: posterior dislocation, grossly unstable, lateral, medial,
anterior, and posterior disruption
94.
95. Pulled elbow syndrome
• Pulled elbow (also known as nursemaid's elbow) :subluxation of the
radial head into the annular ligament, which usually spontaneously
or easily reduces and rarely demonstrates abnormal radiographic
features.
• If the clinical presentation is atypical, pulled elbow should be
distinguished from elbow fractures or radial head dislocations,
which is where radiographs can be helpful .
• Epidemiology
• Pulled elbows are encountered in young children (typically between
6 months and 3 years of age) , as a result of pulling on the arm
longitudinally, as occurs when pulling a child away from something
the parents would rather they not touch, or lifting the child in play
96. • Clinical presentation
• Children with a pulled elbow will hold the elbow flexed and the forearm pronated,
unwilling to supinate .
• Pathology
• The propensity of young children to develop pulled elbows -ligamentous laxity,
which also affects the annular ligament and allows the radial head to sublux into
it.
• Younger children- no ligamentous damage
• Older children -partial tears can occur- persistence of pain a number of days
following reduction .
• Radiographic features
• Plain radiograph
• Radiography is unhelpful -mostly normal . Inadvertent reduction may occur as the
radiographer supinates the elbow to obtain an AP view .
97. • Ultrasound
• Using an anterior, longitudinal view across the radiocapitellar joint,
following findings:
• interposition of the supinator muscle into the joint space
• appearing to curl over the radial head forming the "hook" or "J"
sign
• inability to visualize the annular ligament
• restoration of normal anatomy after reduction
• Treatment and prognosis
• Supination with the elbow flexed almost always results in a
reduction, and in infants almost immediate cessation of symptoms.
• Older children :many days of ongoing discomfort.
• Only rarely is closed reduction unsuccessful.
• Recurrence common.
