UPPER LIMB INJURIES DR JASON CHOW ORTHOPAEDIC REGISTRAR DESCRIBING A FRACTURE DESCRIBING A FRACTURE • 2 orthogonal views • Age of patient • Mechanism • Open Closed • Which bone • Location on the bone • Intra or extra articular • Fracture Pattern • Displacement • Neurovascular compromise? LOCATION WITHIN BONE FRACTURE PATTERN DISPLACEMENT NEUROVASCULAR EXAMINATION !!! CLAVICLE • Indications for surgery? CLAVICLE • Indications for surgery? • OPEN FRACTURE • SKIN COMPROMISE • NEUROVASCULAR INJURY • FLOATING SHOULDER • RIB FRACTURES / FLAIL CHEST • > 2CM SHORTENING • DISPLACED FRACTURES > 100% CLAVICLE STERNOCLAVICULAR JOINT DISLOCATION • May be ANTERIOR or POSTERIOR, • Anterior dislocations are much more common than posterior dislocations • Posterior dislocations may results in VASCULAR, RESPIRATORY, OESOPHAGEAL & NEUROLOGICAL compromise. STERNOCLAVICULAR JOINT DISLOCATION • XRAYS (AP / SERENDIPITY VIEWS) • Serendipity view = 40° CEPHALIC TILT • CT (gold standard) +/- Angiography STERNOCLAVICULAR JOINT DISLOCATION DISTAL CLAVICLE FRACTURES ACROMIOCLAVICULAR DISLOCATION • ACJ injuries represent nearly half of all sports related shoulder injuries. • Typically TRAUMA related – fall on tip of the shoulder in ADDUCTION. • DISPLACEMENT is measured from the top of coracoid process to bottom of clavicle (CC INTERVAL). • 1-3 non operative • Grade 3-6 operative ACROMIOCLAVICULAR DISLOCATION PROXIMAL HUMERUS FRACTURE PROXIMAL HUMERUS FRACTURE • Third most common fracture in >65 Yrs • 2: 1 Female to male PROXIMAL HUMERUS FRACTURE • Imaging • Xrays – AP/Scapular Y • CT scan – most will require a CT scan PROXIMAL HUMERUS FRACTURE • Pseudosubluxation • Inferior head subluxation secondary to blood in capsule and deltoid atony. PROXIMAL HUMERUS FRACTURE • Management • Most can be treated non operatively in shoulder immobiliser • Minimally displaced surgical and anatomical and GT fracture <5mm • Consider • Age • Fracture type/displacement • Bone quality SHOULDER DISLOCATION • Anterior – most common • Posterior – less common (electrocution, seizure, trauma, alcohol) • History • 1st dislocation? Recurrent? • Mechanism? • Previous management/ operations • Associated conditions • Laxity/ Ehlers Danlos etc? • Imaging • AP/Lateral/ Axillary ANTERIOR DISLOCATION ANTERIOR DISLOCATION • Management • Reduction • Analgesia and muscle relaxation • GA is unsuccessful • Post reduction xray • Rule out fracture (humerus and glenoid) • Prognosis • Age <20 = 90% redislocation rate • Age 20-30 = 60% redislocation rate • Age 30-40 = 30% redislocaiton rate • Age >40 = 10% redislocation rate (higher incidence of acute rotator cuff tear) POSTERIOR DISLOCATION POSTERIOR DISLOCATION • 2% of acute dislocations • Often Missed • Imaging • Light bulb sign • Axillary xrays is diagnostic • CT is unable to get axillary xray HUMERAL SHAFT FRACTURES HUMERAL SHAFT FRACTURES • Union rates are 98% NON-OPERATIVE, 93% ORIF and 87% IMN. • ACCEPTABLE ALIGNMENT for non-operative treatment: • 30° VARUS / VALGUS • 20° ANTERIOR / POSTERIOR • < 15° ROTATION • < 3CM SHORTENING HUMERAL SHAFT FRACTURES HUMERAL SHAFT FRACTURES • INDICATIONS FOR SURGERY • Indications for surgical treatment are: • OPEN FRACTURE • MULTITRAUMA • FLOATING ELBOW (IPSILATERAL FOREARM FRACTURE) • OBESITY (LARGE BREASTS) • IMPENDING PATHOLOGICAL FRACTURE • RADIAL NERVE PALSY AFTER REDUCTION • MALALIGNMENT: • 30° VARUS / VALGUS • 20° ANTERIOR / POSTERIOR • 15° ROTATION • 3CM SHORTENING • Radial nerve palsy after the fracture is not an indication for exploration or internal fixation DISTAL HUMERUS FRACTURES • 2 groups • Young patient with high velocity • Older patient (OP) • Most need operative intervention • NV exam is important. • Always needs a CT scan ELBOW DISLOCATION • Mechanism is FOOSH • Obtain and Maintain and concentric reduction • Pre and post xrays • Look for associated fractures • Radial head • Coranoid process • Neurovascular exam (Ulnar nerve or AIN) ELBOW DISLOCATION • Management • Pop at 90 degrees for 2/52 • 1 and 2 week check x- ray • ROM at 2/52 and check stability OLECRANON FRACTURE • Most need operative intervention unless undisplaced • Elderly can manage with functional ROM and fibrous union RADIAL HEAD FRACTURES RADIAL HEAD FRACTURES • Type 1 – Undisplaced < 2mm no mechanical block to rotation • Type 2 – Displaced >2mm but block to motion • Type 3 – Comminuted FOREARM FRACTURES • Mechanism is important? • Direct blow • Look for associated dislocations • Monteggia • Galleazzi • Associated Injuries • Ulna can be open • Compartment Syndrome ULNA – NIGHT STICK FRACTURE • Direct blow ulna fracture MONTEGGIA • Proximal 1/3 ulna with radial head dislocation GALLEAZZI • Distal 1/3 radial fracture with DRUJ disruption COMPARTMENTS SYNDROME • Circulation of tissues within a closed osteo-fascial space are compromised by increased pressure within that space • Prerequisite is volume restricting envelope • fascia & skin • POP • dressings COMPARTMENTS SYNDROME • Aetiology • 1. Increased contents • Bleeding / edema • fracture • osteotomies • crush injuries • post - ischaemic swelling • 2. Decreased size • Tight casts & dressings • Tight closure of fascial defects • Fracture reduction COMPARTMENTS SYNDROME • Increased local tissue pressure increases pressure within intracompartmental veins • local AV gradient is reduced • causes decreased local perfusion secondary to Starling Forces • Metabolic tissues demands not met • loss of tissue function & viability • distal pulses remain as ICP < SBP • digit capillary refill remains as venous return extracompartmenta COMPARTMENTS SYNDROME • P’s • Pain (most important) • Paraesthesia (often early) • Palpation (swollen and tense) • Passive stretch • Paresis (proximal nerve injury or guarding) • Pulseless (late sign) COMPARTMENTS SYNDROME • Clinical Diagnosis • Tense compartment and pain +++ • Pressure measurement • Patient is unresponsive • Uncoperative • Underlying peripheral nerve defect. COMPARTMENTS SYNDROME • Management • Prevention • Remove tight dressings • Split plasters • Early fasciotomy < 8 hours • Complications • Ischemic muscles fibrosis and contractions • Deformity and stiffness • Nerve damage and variable numbness DISTAL RADIUS FRACTURE DISTAL RADIUS FRACTURE • Normal radius angles • Volar tilt 10 degrees • Radial inclination 22 degrees • Radius is 10mm longer than ulna • Ulnar variance 2mm positive DISTAL RADIUS FRACTURE • Colles fracture • Distal radius fracture with dorsal displacement • Smiths fracture • Distal radius fracture with volar displacement DISTAL RADIUS FRACTURE • Management • Immediate reduction if displaced • NV exam pre and post reduction • ?haematoma block with elderly • Molded volar and dorsal slab DISTAL RADIUS FRACTURE • Indications for surgery • Absolute • Open fracture • CTS • Relative • Instablity • Inability to maintain adequate reduction • >2mm or radial step • Radial shortening >5mm • Sagital tilt > 15 degrees dorsal and 20 degrees volar +/- dorsal communation DISTAL RADIUS FRACTURE .