FRACTURES AND

DISLOCATIONS
Of the Upper Extremities
By Ricardo C. Liwag,M.D.
 FRACTURES OF THE
CLAVICLE
• Anatomy

Bony strut
S-shaped
 FRACTURES OF THE
CLAVICLE
• Function
-Power and stability of the arm
-Motion of the shoulder girdle
-Muscle attachment
-Protection of NV structures
-Respiratory function
-Cosmesis
 FRACTURES OF THE
CLAVICLE
• Classification

Group I- Fractures of the middle third

GroupII- Fractures of the distal third

GroupIII- Fractures of the medial third

 FRACTURES OF THE
CLAVICLE
• Most freguent fracture in children

MOI: Fall on shoulder

Fall on outstretched hand

S/Sx: swelling/tenderness
crepitus
 FRACTURES OF THE
CLAVICLE
• Treatment
conservative
surgery- rarely
1.neurovascular involvement
2.soft tissue interposition
3.open fracture
4.multiply-injured
5.distal 3rd displaced fracture
 FRACTURES OF THE
CLAVICLE
• Healing- generally well
about 4-8 weeks
FRACTURES OF THE
CLAVICLE
FRACTURES OF THE
CLAVICLE
SHOULDER DISLOCATION
 SHOULDER DISLOCATION
• Dislocation vs. Subluxation

MOI:direct
indirect- most common
 SHOULDER DISLOCATION
• Types
1.Anterior-subcoracoid
subglenoid
subclavicular
intrathoracic
2.Posterior
• S/Sx:pain/lack of mobility
(+)lump
roundedness lost
• axillary nerve involvement
SHOULDER DISLOCATION
SHOULDER DISLOCATION

Obtaining “True”
AP X-ray
SHOULDER DISLOCATION

Obtaining “True” Shoulder Lateral or Y View

SHOULDER DISLOCATION

Obtaining Lateral Axillary View

SHOULDER DISLOCATION
SHOULDER DISLOCATION

‘True”
Lateral/Scapular or Y
View
 SHOULDER DISLOCATION
• Treatment
Immediate reduction
-Hippocratic technique
-Stimson’s technique (prone)
-Kocher’s technique
-Milch Technique
-Traction/countertraction technique
-Etc.
-Open
 SHOULDER DISLOCATION
• Treatment
Immobilization- duration ?
Recurrence- age

Protection
Rehabilitation
FRACTURES OF PROXIMAL
HUMERUS

Anatomy
 FRACTURES OF PROXIMAL
HUMERUS
• Usually in elderly patients after a minor fall
• MOI: Fall on outstretched arm
Direct fall on to shoulder
• Four Major Fragments
1. Anatomical neck
2. Greater tuberosity
3. Lesser tuberosity
4. Surgical neck
 FRACTURES OF PROXIMAL
HUMERUS
• S/Sx: tenderness
swelling, LROM,crepitations
• Classification (Neer)
1.one part fracture - no displaced fragment
2.two part fracture- 1 displaced fragment
3.three part fracture
4.four part fracture
FRACTURES OF PROXIMAL
HUMERUS
FRACTURES OF PROXIMAL
HUMERUS
FRACTURES OF PROXIMAL
HUMERUS
• Treatment: early motion-healed despite
exercises
Surgical- ORIF, hemiarthroplasty
main goal: restoration of
shoulder function
and prevention of
adhesion.

• Complcations:jt.stiffness,avascular necrosis,
malunion, m.ossif. ,etc.
FRACTURES OF PROXIMAL
HUMERUS
 HUMERAL SHAFT
FRACTURE
• Anatomy
 HUMERAL SHAFT
FRACTURE

• MOI:
1.direct violence/force
2.indirect force e.g. fall,severe and sudden
muscle contraction
- Pathologic fractures
- Fracture Patterns
HUMERAL SHAFT
FRACTURE
Location of fracture
-important to know the
fracture displacement
related to anatomy

-muscles to consider:
deltoid , pectoralis,
rotator cuff. teres
major, latissimus
dorsi, biceps, triceps
HUMERAL SHAFT
FRACTURE

Hx &
PE
 HUMERAL SHAFT
FRACTURE

Radial Nerve
Involvement-
wrist drop
HUMERAL SHAFT
FRACTURE

Imaging
 HUMERAL SHAFT
FRACTURE
• Treatment: - closed reduction and
immobilization
- Operative

• Complications: non-union (rare)

malunion
radial nerve palsy
HUMERAL SHAFT
FRACTURE

Immobilization
SUPRACONDYLAR FRACTURES OF THE
HUMERUS

• Common among children and adolescents

• Peak age 5-7y.o.
• M>F
SUPRACONDYLAR FRACTURES OF THE
HUMERUS

Anatomy
 SUPRACONDYLAR FRACTURES OF THE
HUMERUS

Mechanism of Injury
Two types
1.Extension type
2.Flexion type
 SUPRACONDYLAR FRACTURES OF THE
HUMERUS

Diagnosis
- History
- PE
elbow tenderness, deformity,etc
skin condition
neurovascular
 SUPRACONDYLAR FRACTURES OF THE
HUMERUS

Imaging
- Elbow AP-Lateral view- Routine
- Oblique views
- Contralateral elbow
- Forearm xrays
SUPRACONDYLAR FRACTURES OF THE
HUMERUS

Imaging

Proper Lateral positioning

SUPRACONDYLAR FRACTURES OF THE
HUMERUS
Imaging
Jone’s View

Proper Lateral positioning

SUPRACONDYLAR FRACTURES OF THE
HUMERUS

Anterior humeral line Baumann’s angle

Imaging
SUPRACONDYLAR FRACTURES OF THE
HUMERUS
Imaging

Fat Pad Signs

-anterior
-posterior
SUPRACONDYLAR FRACTURES OF THE
HUMERUS
Gartland
Classification
Type I

Type II

Type III
SUPRACONDYLAR FRACTURES OF THE
HUMERUS

Treatment
- Initial splinting / temporary traction
- Proper assesment
- Definitive treatment- Closed reduction
Surgery- Percutaneus
pinning- gold
standard
ORIF
SUPRACONDYLAR FRACTURES OF THE
HUMERUS

• Early complications
nerve injuries, vascular injuries
Volkmann’s ischemia
• Late complications
cubitus varus/valgus
loss of elbow motion
myositis ossificans
progressive ulnar nerve palsy
SUPRACONDYLAR FRACTURES OF THE
HUMERUS
ELBOW DISLOCATION

anatomy
 ELBOW DISLOCATION
Epidemiology
-less common vs shoulder, finger
-M>F
-Adults>children
-non-dominant extremity
 ELBOW DISLOCATION

• Types-anterior-rare
posterior
medial
lateral
• MOI: extended/hyperextended
• Simple vs Complex dislocations- example
Terrible Triad Injury
 ELBOW DISLOCATION

Diagnosis
- A history of acute trauma
- PE- severe pain, deformity,loss of normal
anatomic relationship, LROM,swelling
ELBOW DISLOCATION
Imaging
 ELBOW DISLOCATION
Imaging

B
C
 ELBOW DISLOCATION
• Treatment:
immediate closed reduction
early gentle active motion

Open reduction
Prognosis- good
o Complications
FRACTURES OF THE RADIUS
AND ULNA
• Anatomy
FRACTURES OF THE RADIUS
AND ULNA
Epidemiology
- a common fracture
-M>F
-open fracture/closed ratio high

Mechanism
- direct
- indirect
FRACTURES OF THE RADIUS
AND ULNA
Classification
- open vs closed
- location
- fracture pattern
- displacement/angulation
FRACTURES OF THE RADIUS
AND ULNA
• Deforming muscle forces:pronator teres
biceps brachii
supinator brevis
pronator quad
Fracture location:
1. Proximal
2. Middle
3. Distal
FRACTURES OF THE RADIUS
AND ULNA
Diagnosis
-History- trauma
-P.E.
deformity, swelling, crepitus
LROM
neurovascular
FRACTURES OF THE RADIUS
AND ULNA Imaging
FRACTURES OF THE RADIUS
AND ULNA
• Fractures of necessity

• Monteggia’s fracture

• Galeazzi’s fracture

Mx: ORIF
FRACTURES OF THE RADIUS
AND ULNA

Monteggia’s fracture
FRACTURES OF THE RADIUS
AND ULNA

Monteggia’s fracture
FRACTURES OF THE RADIUS
AND ULNA

Galeazzi’s fracture
FRACTURES OF THE RADIUS
AND ULNA
Complications
Malunion
Non-union
Synostosis
Neurovascular
Refracture
Surgery-related complications
 DISTAL RADIAL FRACTURES
• First described by Abraham Colles in 1814
• common in elderly women
• usual MOI: fall on outstretched hand
• Classical definition
“fracture of distal 2 cm of radius and /or
ulna with dorsal angulation of distal
fragment” (vs. Smith’s fracture)
DISTAL RADIAL FRACTURES

Anatomy
DISTAL RADIAL FRACTURES
Epidemiology
- common fracture in UE
- bimodal age

Mechanism
- high energy trauma
- FOOSH
DISTAL RADIAL FRACTURES
Diagnosis
History of trauma

P.E.
swelling, deformity (Silverfork, Garden spade)
LROM
neurovascular
other UE parts
DISTAL RADIAL FRACTURES
Imaging
DISTAL RADIAL FRACTURES
Imaging
DISTAL RADIAL FRACTURES
Classification
Colles
Smith’s
Barton’s
Volar Barton’s
Chauffer’s
Die-punch
DISTAL RADIAL FRACTURES
DISTAL RADIAL FRACTURES
• Treatment
classical- closed manipulation/ cast
pins and plaster , external fixatur
ORIF
• Complications
median nerve palsy
stiffness
Sudeck’s atrophy
Volkmann’s ischemia
THANK YOU!