FRACTURE OF UPPER

LIMB

PREPARE- M. ALISAWE
 Upper Limb include
• Clavicle
• Scapula
• Shoulder Joint
• Humerus
• Elbow Joint
• Forearm Bones
• Wrist Joint
• Scaphoid Bone
 FRACTURE

Definition : is a structural break in the

normal continuity of a bone
• It is caused by trauma
• It may be complete or incomplete or
fissure fracture
Cont

• Dislocation is total disruption of a joint with

no intact between the articular surfaces
 Aetiology of fracture
1. Traumatic fracture :
a. Direct trauma : The bone breaks
transversely at the site of trauma
,double bone break at the same level .
b. Indirect trauma : the bone breaks
obliquely at the weakness point.
c. Avulsion fracture [muscle violence] :
due to muscle contraction
Cont
2.pathological fracture :
a. By minor trauma[ which would not
fracture normal bone]due to generalized
or localized bone disease .
 Types of fracture

1. Simple : without an external wound

2. Compound : with an external wound
 Shape of fracture
1. Transverse[ direct trauma]
2. Oblique [indirect]
3. spiral[ [indirect]
4. Comminuted [sever compression]
5. Green stick [in children]
6. Wedge [vertebral fracture]
 Clinical features and diagnosis of
fracture
1. History of trauma.
2. Loss of function [loss of movement.
3. Pain due to friction between bone ends .
4. Swelling due to fracture bone , oedema,
haematoma .
5. Deformity;described according to the
position distal fragment
6. Tenderness ; maximum over the fracture line
Cont
7.abnormal mobility .
8. x-ray :
a. At the time of fracture : for diagnosis
b. after fixation :to know good or bad
reduction
C. at the end of treatment : before removing
the plaster cast to know the type of union [
good or bad union]
 Mechanism of injury
• 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
 Fracture of clavicle
• Fracture of the middle third [shaft ] (80%)
 This is the commonest fracture in the whole body
Trauma and morbid anatomy :
• Clavicular shaft fracture is usually due to a fall on the
outstretched hand and less commonly due to direct
blow or to a fall on the point of the shoulder .
Cont
• The fracture almost always occurs in the
middle third because it is the thinnest part
of the bone which is further weakened by
the junction of the two main curves of the
shaft .
• The potential deforming forces are the
weight of the arm that lead downward and
inward displacement of the outer fragment -
Cont

• -And the pull of the sternomastoid muscle

that lead to upward displacement of the
proximal fragment
• In children the fracture is often of the
greenstick varity .
Clinical features

• The shoulder is dropped and deformity

and the pt support the elbow with the
opposite hand and bend his head to the
affected side to relax the sternomastoid
muscle .
 Diagnosis
• history of injury
• clinical features
 symptoms : pain with the motion of shoulder
joint , swelling, ecchymosis,
 sign: deformity , tenderness , bony crepitus
• x-ray
 CCC fracture of middle third of clavicle

.
Treatment

• Conservative by an broad arm sling for 3

weeks and analgesics or figure of eight
bandage.
• Internal fixation is rarely needed .
Figure of eight Bandage
 Indications of open reduction and
internal fixation

• Nonunion: the most frequent indication.

• Neurovascular involvement .
• A persistent wide separation of the
.fragments with interposition of soft tissue.
• Fracture of the distal end with torn of
coracoclavicular ligaments in an adult .

• Floating shoulder: Fractures of both the

clavicle and the surgical neck of the scapula

• A patient that cannot endure the suffer of

figure-of-eight bandage fixation .

• Redisplacement after reduction that cannot

be accepted by the patient.
Complication
1. Malunion is common (union is bad time
and position).
2. Non union is uncommon .
3. Injury of subclavian vessels and brachial
plexus.
4. Tear in muscle .
5. Stiffness of shoulder joint .
Fracture of the outer third (15%)
 Usually no displacement occurs because
both fragment are attached to the scapula
by ligament .
 When the coraco clavicular ligament is
ruptured the outer segment displaces
forward and inward .
 If no displacememt , no treatment is
required (but analgesics)
Cont

 When there is displacement , the fracture

is treated by internal fixation.

Fracture of inner third are rare

(5%).
 Fracture of the scapula
 The commonest fracture of the
scapula involve is either the neck or the
body of bone .

 Fracture of the neck of scapula:

the fracture result from direct violence
and the fracture line usually run from .
Cont
The suprascapular notch to below the
coracoids process .

Treatment : broad arm sling and early

active shoulder movement .
Fracture of the body of the scapula:

• The fracture result from direct violence .

• The fracture is stellate .
• Treatment is board arm sling and active
shoulder movement .
• Important to look for and exclude an
associated chest injury.
Fractures of the scapula
1-Neck 2-body
Dislocation of the Shoulder

• Mostly Anterior > 95 % of dislocations

• Posterior Dislocation occurs < 5 %

• True Inferior dislocation (luxatio erecta) occurs < 1%

 Anterior dislocation

 The head of the humerus usually

dislocates forward to assume one of
the following position :
1. subcoracoid (commonest).
2.Subclavicular.
3.Subglenoid.
1.subcoracoid
(commonest).

2.Subclavicular.

3.Subglenoid.
Mechanism of anterior shoulder
dislocation

1. Usually Indirect fall on Abducted and

extended and external rotation
shoulder.

2. May be direct when there is a blow on the

shoulder from behind
Anterior Shoulder dislocation
 Clinical Picture
1. Flatten of the
shoulder : Loss of
the contour of the
shoulder may appear
as a step .

2. Swelling : Anterior
bulge of head of
humerus may be
visible or palpable.
4- A gap can be palpated above the dislocated
head of the humerus.

5-Deformit y: abduction + external rotation.

6-Change in the length of the arm .

Diaganosis:

 clinical picture+ x-ray (AP views).

X Ray anterior Dislocation of
Shoulder
 Complication
1. Axillary nerve injuny.
2. Avulusion of the supraspinatus tendon is discovered by inability of the
pt to initiate abduction .
3. associated of greater tuberosity or humeral neck fracture .
4. Recurrent dislocation .
5. rupture of the inferior part of the capsule.
 Avascular necrosis of the head of the Humerus (high risk with
delayed reduction)
 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
 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.
 Methods of Reduction of
anterior shoulder Dislocation

1. Hippocrates Method ( A form of anesthesia

or pain abolishing is required).
2. Stimpson’s technique ( some sedation and
analgesia are used but No anesthesia is
required ).
3. Kocher’s technique : is the method used
in hospitals under general anesthesia and
muscle relaxation .
Hippocrates Method
Stimpson’s technique
 Kocher’s Technique
o under general anesthesia , the operator externally
rotates the arm to relax the subscapularis muscle while
pulling down on the am to disengage the head .
o The humerus is adducted and internally rotated
bringing the elbow across the chest .
o Fixation in a sling and bandage for 3 weeks .
Kocher’s Technique
 Treatment of recurrent
dislocation
1. putti-platt operation . The idea is to limit
external rotation of the shoulder by
capsulorraphy and shorten of the
subscapsularis muscle by overlapping .
2. bankart operation . The glenoidal
labrum is displayed and is repaired by
reattaching the labrum by suturing it to
the bony rim of the glenoid .
 Posterior dislocation
 Should always be suspected after an
epileptic fit or an electric shock.
 Caused by direct blow on the front of the
shoulder
 The head slide backward to the lie below
the acromion ( subacromial dis ) or
infraspinous fossa of the
scapula(subspinous dis )
 Fractures of The Humerus
1. Proximal Humerus (includes surgical
and anatomical neck ).

2. Shaft of Humerus.

3. Distal humerus ( includes Supra

Condylar fracture in children ).
 Fracture Proximal Humerus
 more common in the elderly and usually
Associated with osteoporosis.
 classification : 1- Articular surface or its
anatomical neck .
2- Greater T .
3- lesser T .
4-surgical neck.
Cont
The above classification then identify each one
according to :
 - one part # ‫ـــــــــــ‬no displacement .
 two part #‫ ـــــــــــــ‬one segment is
displaced .
 three part #‫ ـــــــــــــ‬two segment is
displaced.
Four part #‫ــــــــــــــ‬three segment
are dis.
 Mechanism of injury

 Surgical neck :- fall on out stretched hand

in abduction and external rotation.

 Anatomical neck :- fall on the shoulder

directly against the glenoid cavity.
 Clinical picture
1. pain in the shoulder and inability to
move the joint.

2. in minor impacted fracture of surgical

neck , limited movement may be
possible.

3. the diagnosis is made radiologically .

Fracture Proximal Humerus
Fracture Proximal Humerus :
Plating or Rush Nail insertion
 Treatment
 one part ( 80% of fracture are un displaced ):-
External immobilization into a sling until pain has subsided.

 two part fracture :- open reduction + internal fixation by

screw and wire then arm to neck sling for 3 weeks.

 surgical neck :- closed reduction + collar and cuff sling for

3 weeks.
Cont

 Three part # :- open reduction + internal fixation

+repair of the rotator cuff.

 four part # :- usually associated with avascular

necrosis of the humeral head ___ so replaced
by prosthetic head + repair of rotator cuff.
Intra-medullary K wire fixation
 Complication
1. shoulder stiffness.
2. axillary nerve injury.
3. Avascular necrosis of the humeral head .
4. Dislocation of the shoulder .
5. Malunion .
6. nonunion .
 Fractures Shaft of the Humerus

• Mechanism of injury:-

• Commonly Indirect injury

• Indirect injury results twisting injury of the
arm and /or fall on outstretched hand .
• Direct injuries like bit stick.
 Clinical picture
• As general principles + deformity

 Displacement:- this depends on the level

P. Fragment Distal fragment

Above the insertion of Adducted by pectoralis or Abduction by deltoid muscle.
deltoid . latisums dorsi.

Below the insertion of deltoid .Abduction by deltoid. Adducted and pulled up ward
by the coracobrachialis .
Fracture shaft of the Humerus
(diagnosis)
 Treatment
• Closed reduction + external fixation :-
 Reduction : with gentle traction on the elbow.
 fixation : u-shaped plaster slab for 8 weeks +
collar and cuff sling .
 if it is not possible to reduction by method used
___open reduction + plate and screws fixation or
bone graft
 If the # is transverse or near the mid shaft ,
intramedullary nail is used
U Shaped slab
Plating fracture Shaft of humerus
 Complication

1. Radial nerve injury.

2. Delayed union.
3. Nonunion.
4. Joint stiffness.
 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

 Supra-condylar Fracture of Humerus

 Mechanism of trauma:- caused by

a fall onto the outstretched hands ( it’s a
frequent in children )

Types:-1-extension types 99%

2-flexion types 1%
 Clinical picture

• As general + deformity

Extension types 99% flexion types 1%

Distal fragment . Displaced backward and up Displaced forward and up

ward . ward .
 Treatment 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.
Cont

• After care : hospitalization and monitoring

of radial pulse for 48 hours.

• Open reduction + internal fixation by wires

, when closed methods failed to reduction
Supra-condylar fracture.
 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)
 Volkmann's Ischemic Contracture

• Massive infarction of the

muscles of forearm in the
case of s-p humerus
especially flexion type from
injury of brachia l artery.
Dislocation of the elbow joint
• It more common in adults.
• Mechanism of trauma:

• 1-P-dislocation : fall on the outstretch hand

while the limb is extended .

• 2-A-dislocation : fall on the tip of the elbow .

 Clinical picture

As general + 1-pain and tenderness

2-SWELLING
3-no movement at the elbow
 Treatment
• P-DISLOCATION : Reduction by
downward traction and forward push on
the upper end of the ulna, fixation is done
90 flexion for 3 weeks .

• A-DISLOCATION: reduction by posterior

push on the ulna and fixation in extenion
position in posterior slap
 FRACTURES OF
SHAFT OF RADIUS
AND ULNA
 Anatomy
• radius & ulna lie parallel to each
other when forearm is supinated
• interosseous membrane: join
radius and ulna, which is directed
obliquely downward from radius
to ulna and is relaxant at the
neutral position of forearm
 special type
• Monteggia fracture-dislocation
fractures of proximal third of ulna with
dislocation of radial head
• Galeazzi fracture-dislocation
fracture of distal third of radius with
dislocation of distal radioulnar joint
MONTEGGIA FRACTURE-DISLOCATION
Monteggia fracture-dislocation
 Monteggia fracture dislocation
• Def: fracture of the upper 1/3 ulna and
dislocation of the head of the radius from
superior radio-ulnar joint.
• Types :
a. Extension type 85% ; the ulna is broken
and angulated anteriorly, and the head of
radiaus is displaced foreword.
 treatment
• 1. close reduction and external fixation for 3
months.
• 2. open reduction and internal fixation by plate and
screws.
b. Flextion type; 15% the ulna is angulated and broken
backward and the radius is dislocated backward.
Treatment: close reduction and external fixation 2-3
months.
Galeazzi fracture-dislocation
 Gliazi fracture dislocation
• Fracture lower1/3 of the radius
+ dislocation 1/3 of the ulna
• Treatment ; open reduction and internal
fixation as it is unstable fracture by plates
and screws.
 Diagnosis
• history of injury
• clinical features: swelling, pain ,
subcutaneous ecchymosis, limitation of
upper extremity motion, deformity,
tenderness, bony crepitus ,
normal postelbow triangle
• x-ray
 Treatment
• Fractures of the forearm bones may result
in severe loss of function unless
adequately treated
• Open reduction and internal fixation for
displaced diaphyseal fractures in the adult
are generally accepted as the best method
of treatment.
 Internal fixation
• A satisfactory device for internal fixation
must hold the fracture rigidly, eliminating
as completely as possible angular as well as
rotary motions
• method: intramedullary nail or the AO
compression plate
FRACTURES OF
DISTAL RADIUS
 Classification
• extension type
Colles fracture
• flexion type
Smith fracture
 colle’s fracture
• Def : fracture of distal inch of radius which is
commonly comminuted and impacted.
Trauma: fall on the outstrech hand.
Common associated injury:
1.Styloid fracture of the ulna and radius or both.
2.Tear in the triangular fibro-cartilage between
the lower end of radius and ulna with loss os
pronation and supination.
 Diagnosis of Colles
fracture
• history of injury:fall on out
stretched hand
• clinical features: swelling,
subcutaneous ecchymosis,pain ,
limitation of wrist joint,
tenderness, fork deformity
• x-ray
 Treatment
Most distal radial fractures can
be successfully treated
nonoperatively （ Manual
reduction ）
 Complications

• Malunion
• Sundecks' atrophy
• Tear of the extensor pollicis loungus
tendon
• Stuffiness of finger & shoulder
• Loss of movement
Colles fracture
 Smith fracture

• Due to fall on the dorsum of the

hand
• The distal fragment of radius is
displaced forward
Smith fracture