AKHTAR M KHAN Taken from an Article that was once on the Hope Hospital Website but now
sadly gone Introduction INTRODUCTION Upper limb injuries are common in the elderly as well as in children. It is very important to remember that fractures in the vicinity of joints in the upper limb quite often lead to stiffness therefore when managing fractures of the upper limb this has to be kept in mind.
These fractures commonly arise due to fall onto the shoulder or on to the outstretched hand. The most common site for fracture is the mid shaft of the clavicle in which the distal fragment of the clavicle is pulled down by the weight of the arm and the proximal fragment is displaced superiorly by the action of the sternocliedomastoid muscle. Fig 1 Fracture of the mid-shaft of clavicle
Treatment involves placing the arm in a sling and providing the patient with simple analgesia until the pain subsides which is usually about two to three weeks. The patient is reviewed in the orthopaedic outpatients and active shoulder movement is encouraged when comfortable. It is important to remember that the patient may complain of a prominent swelling around the fracture site which if often due to callus production.
DISLOCATION OF THE SHOULDER JOINT The shoulder joint is one of the most commonly dislocated joints and this is due to a number of factors which includes the shallowness of the glenoid socket, the extraordinary range of movement and underlying disorders such as ligament laxity or glenoid. Anterior dislocations account for approximately 98% of the dislocations around the shoulder joint. They may arise due to a fall on the hand were the humerus is subsequently driven forwards tearing the capsule of the joint or avulsing the glenoid labrum. Clinically the patient supports the arm with the opposite hand and the lateral outline of the shoulder may be flattened.
Fig.2 Loss of lateral curve of shoulder when dislocated and the arm is held abducted away from the trunk
Radiological examination will show the humoral head and the glenoid fossa with the head lying below and medial to the glenoid. It is important to document the integrity of the neurovascular structure especially the axillary nerve by testing the sensory perception over the lateral aspect of the upper arm. Numerous methods of reduction are described and may be carried out under sedation or anaesthesia. If attempted in the A & E department the 10mg midazolam may be used with a small amount opiate analgesia and an antiemetic. Care should be taken with these drugs due to their respiratory depressive action. Kochers method of reduction involves bending the elbow to 90 degrees. The arm is slowly rotated 75 degrees laterally then the point of the elbow is lifted forwards and finally the arm is rotated medially. Radiographs to confirm reduction are taken and the arm is then rested in a collar and cuff for two to three weeks and active movement is then encouraged except combined abduction and lateral rotation for a further three weeks. Dislocations of the shoulder may occasionally remain undiagnosed however closed reduction can be attempted up to six weeks, delays greater then this should be managed by internal reduction. Posterior dislocation are uncommon and subsequently more often missed. Most commonly seen in patients following a convulsion or electric shock.
Fig3. AP anterior dislocation glenohumeral joint
FRACTURES OF THE PROXIMAL HUMERUS These are more common in osteoporotic post-menopausal women. In the majority of cases the displacement is not marked and treatment causes few problems. However in approximately 20% there is considerable displacement of one or fragments. The mechanism of injury is usually a fall on the outstretched hand. A common classification for proximal humeral fractures is the one suggested by Neer:
Neer classification of shoulder fractures
Treatment of 1 and 2 part fractures of the humerus is conservative and the patient is provided with analgesia and the arm is rested in a broad arm sling until comfortable following which the arm is mobilised. Three and four part fractures of the humerus often need to be admitted. Further management is very much dependent on the age of the patient, elderly patients are frequently treated conservatively but in younger patients open reduction and internal fixation or hemiarthroplasty may be needed. Four part fractures are usually associated with a high incidence of avascular necrosis of the humeral head. FRACTURES OF THE SHAFT OF THE HUMERUS The mechanism of the fracture is usually a fall onto the hand which may twist the humerus and subsequently lead to a spiral fracture or alternatively a fall onto the elbow with the arm abducted may hinge the bone and produce an oblique or transverse fracture. In addition a direct blow to the arm may cause a fracture which may be transverse or comminuted. With fractures above the deltoid insertion the proximal fragment is adducted by the action of the pectoralis major and fractures below the deltoid insertion the proximal fragment is abducted by the action of the deltoid. It is important to assess the function of the radial nerve since may be damaged in fractures passing through the spiral groove in the humerus. This is assessed by the ability to extend the wrist and the metacarpophalangeal joints.
Fig. 4 relationship of radial nerve to fractures in the spiral groove
Fractures of the humerus heal rapidly and they do not require perfect reduction or immobilisation and usually the weight of the arm or the application of a U-slab is enough to pull the fracture into alignment. The cast if used is initially applied extending from the shoulder to the wrist with the elbow flexed to 90 degrees and the forearm section is suspended from a collar and cuff sling. This cast can then at two to three weeks be reduced to just above the elbow. If the fracture is simple then a collar and cuff may be used to support the arm whilst the fracture heals and the patient can be reviewed in the fracture clinic. If the fracture pattern is more complicated or the arm is grossly swollen or the pain cannot be managed by simple analgesia at home then the patient is admitted. If conservative treatment is not indicated then surgery may be needed to stabilise the fracture. This may involve intramedullary nailing or plating depending or the fracture pattern and the surgeon’s preference.
Fig.5 segmental humeral fracture treated with a intramedullary nail
SUPRACONDYLAR FRACTURES OF THE HUMERUS These fractures are most often seen in children and the distal fragment may be displaced posteriorly or anteriorly. Posterior displacement suggests an extension injury usually due to a fall on the outstretched hand, the distal fragment is pushed backwards and because the forearm is usually pronated at the time of injury the medial cortex of the distal fragment is rotated inwards. The jagged end of the proximal fragment may poke into the soft tissue anteriorly and thereby compromise the brachial artery or the median nerve. Extension type of supracondylar fractures are the more common then the relatively uncommon flexion type.
Fig.6 supracondylar fracture of the humerus in an adult
Radiologically the fracture is most clearly seen in the lateral view. In the posterior displaced fracture the fracture line runs obliquely downwards and forwards and the distal fragment is shifted backwards. In children these fractures are also relatively common and if there is no Displacement the fracture is treated in a sling for two to three weeks with the elbow flexed to more then 90 degrees. Displaced fractures be must be reduced as soon as possible under general anaesthesia and stabilisation may be needed using K-wires.
supracondylar fracture of the humerus in a child. The reduced fracture is stabilised with two cross K-wires. Post manipulation radiographs are done to assess the reduction and is important to assess the varus or valgus angulation and the presence of rotational deformity. This can be done by assessing the Baumanns angle and this is the angle subtended by the longitudinal axis of the humerus shaft and a line through the coronal axis of the capitular physis. This is normally less then 80 degrees. If the distal fragment is tilted in varus the increase in the angle is easily detected..
CONDYLAR FRACTURES ( T AND Y FRACTURES ) Bicondylar fractures are rare and are usually confined to adults over the age of fifty. The mechanism of injury is usually a fall on to the elbow which drives the olecranon process upwards subsequently splitting the condyles. Clinically there is marked swelling and the elbow is found to be wider then normal. Undisplaced fractures only require a backslab with the elbow flexed to 90 degrees with movements commencing after two weeks. Moderately displaced fractures almost always result in a stiff elbow of treated conservatively therefore open reduction and fixation is required. This can be done through a posterior approach with plates and/screws being used to hold the fracture. Severely comminuted fractures lead to elbow stiffness regardless whether they are treated conservatively or surgically.
Types of condylar fractures
FRACTURES OF THE HEAD OF RADIUS Radial head fractures are more common in adults and are hardly ever seen in children. The mechanism of injury is usually a fall onto the outstretched hand which forces the elbow into valgus and pushes the radial head against the capitulum. Clinically there is pain on rotation of the forearm and tenderness on the lateral side of the elbow. Treatment of undisplaced fractures involves placing the arm in a collar and cuff for three weeks with flexion and extension encouraged but allowing rotation to come back on its own. Single large fragments may be treated with reduction using an A.O screw. Comminuted fractures may be treated with excision of the radial head or prosthetic replacement
Fig.8 Masons grade B and C radial head fractures
Two types of injury are commonly seen including comminuted fractures due to a direct blow or fall on to the elbow. Alternatively there may be a clean transverse break due to fall on to the elbow whilst the triceps is contracting. The fracture enters the articular surface and therefore also damages the articular cartilage. A lateral radiograph is essential to show details of the fracture pattern. Comminuted fractures in the elderly may be treated by placing the arm in a sling with further radiographs at one week to exclude displacement. With transverse fractures the extensor mechanism should be repaired and this can be carried out by tension banding of the fracture. Fig 9 A displaced fracture of the olecranon
FRACTURES OF THE SHAFT OF RADIUS AND ULNA These fractures are common in road traffic accidents, a twisting force by a fall on the hand produces a spiral fracture with fractures at different levels in the two forearm bones. A direct trauma usually produces a transverse fracture at the same level. In children closed reduction is usually successful and fracture can be held in a full length cast extending from the axilla to the metacarpals with the elbow flexed to 90 degrees.
Fig.10 fractured radius and ulna treated with plating of both bones
If check radiographs are satisfactory at two weeks the cast is retained for 6-8 weeks. In adults reduction is difficult and position is usually lost even in a cast therefore they are most often treated by plating of the fracture. Post-operativly a cast is applied with the elbow flexed to 90 degrees for six weeks. It is important to remember the potential for compartment syndrome in these fractures.
Fractures of the shaft of the radius or the ulna alone are uncommon and are usually caused by a direct blow. Ulnar fractures are rarely displaced were as in radial fractures there may be a degree of rotary displacement and subsequently the forearm needs to be supinated for fractures of the upper third of the radius, neutral for middle third fractures and pronated for lower third fractures and treated with a above elbow cast in most cases. Ulna fractures may be treated conservatively or surgically depending on the fracture pattern.
MONTEGGIA FRACTURE DISLOCATION This is a fracture of the proximal third of the ulna with dislocation of the proximal (superior) radio-ulnar joint. It usually arises due to fall on to the hand with body twisting at the point of impact leading to a pronation of the forearm leading to dislocation of the radial head.
Open reduction and fixation of Monteggia fracture-dislocation Radiographs of the forearm with the superior radio-ulnar joint is essential. Treatment involves restoring the length of the ulna which then allows reduction of the dislocation. In adults this usually requires surgery, with post operative immobilisation of the arm in above elbow cast for six weeks to prevent redislocation of the radial head.
GALEAZZI FRACTURE DISLOCATION OF THE FOREARM This fracture is caused by a fall on to the hand with a rotational force super-imposed. The radius fracture is in the lower third with dislocation of the inferior radio-ulna joint. The treatment again involves restoring the radial length to allow the dislocation to be reduced. In adults this is carried out by open reduction and plating of the radius.
Fig.12 open reduction and fixation of Galeazzi fracture -dislocation
Abraham Colles’ first described this injury in 1814 as a transverse fracture of the distal radius with dorsal displacement of the distal fragment. It is one of the commonest fractures of the elderly. The fracture occurs due to the application of a longitudinal force in the length of the radius with the wrist in extension. Radiographs show dorsal displacement, radial displacement and impaction of the distal fragment. If the fracture is undisplaced then treat with a dorsal back-slab which is converted to a complete cast when the swelling has subsided. Displaced fractures are reduced under anaesthesia. The hand is grasped and traction is applied in the length of the bone, some times extension of the wrist to disimpact the fracture may be needed. The distal fragment is then restored to its normal position by applying pressure over the dorsum of the wrist whilst applying flexion, ulna deviation and pronation to the wrist. If a reduction is not maintained then an external fixator may be applied.
Frykmans classification of distal radial fractures
In this fracture the distal fragment is displaced towards the volar aspect of the wrist as a result the fracture is often called a reversed Colles’. It is often caused by a fall on the back of the hand. Reduction of the fracture is the opposite of the Colles’ fracture and the forearm is placed in a cast with the wrist in extension.
Scaphoid injuries account for almost 70% of the carpus injuries. The mechanism of injury is a fall on the dorsi-flexed hand. There is tenderness in the anatomical snuffbox. Radiographs taken include lateral, two oblique and a A.P view of the carpus. The fracture line is usually transverse and frequently through the waist of the scaphoid. It is important to look for angulation of the distal fragment since this is often a cause of non-union.
fracture through waist of scaphoid.
Sometimes early diagnosis is not possible however if there is an index of suspicion the forearm is placed in a scaphoid plaster with check radiographs at two weeks when a sclerotic margin around the fracture may confirm the diagnosis. The scaphoid plaster extends from the upper forearm to the distal metacarpal with the wrist in dorsi- flexion, the thumb is incorporated in to the cast up to the distal phalanx whilst in a glass holding position. Displaced fractures are treated by open reduction and compression screws. Undisplaced fractures are treated conservatively. Fractures of the fifth metacarpal are common and they usually arise due to a punch. The fracture usually is at the neck or the shaft of the metacarpal and is usually spiral in pattern. Treatment is most often conservative with a wool and crepe dressing, analgesia and review in the out-patient clinic. If the fracture is angulated more then 40 degrees then manipulation of the fracture is needed.
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