Fractures of upper extremity

1
Fractures of upper extremity
2
Fracture of the clavicle
3
The clavicle

• serves as protector of brachial plexus
• acts as a strut which provides the only bony
  connection between upper limb and the thorax.

4
mechanism of injury

• indirect injury a fall on the outstretched
  hand, the most common cause
• a direct blow

5
diagnosis

• history of injury
• clinical features
• symptomspain with the motion of shoulder
  joint , swelling, ecchymosis,
• sign deformity,tenderness,bony crepitus
• x-ray

6
Treatment

7
Non Operative Treatment

• figure-of-eight bandage fixation
• it is difficult to reduce and maintain the
  reduction of clavicle fractures
• despite deformity, healing usually proceeds
  rapidly
• Even when heal in overlapped or bayonet position
  with a substantial bony prominence, this will
  largely be resorbed with time and the mass will
  decrease in size.

8
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

9

• 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

10
(No Transcript)
11
FRACTURE OF THE HUMERAL SHAFT
12
Anatomy

• The radial nerve is the nerve most frequently
  injured with fractures of the humerus
• spiral course across the back of the midshaft
  (spiral groove) of the bone
• It is relatively fixed in the distal arm as it
  penetrates the lateral intermuscular septum
  anteriorly to enter the forearm.

13
mechanism

• bending force produces transverse fracture
• torsion force will result in a spiral fracture
• combination of bending and torsion produce
  oblique fracture or a butterfly fragment
• compression forces will lead to either proximal
  or distal ends of humerus fracture

14
diagnosis

• history of injury
• clinical features swelling, subcutaneous
  ecchymosis, pain , limitation of upper extremity
  motion,deformity,tenderness,
• bony crepitus, abnormal motion
• x-ray
• rule out radial nerve palsy

15
Treatment

• Most humeral shaft fractures can be treated
  nonoperatively
• Method the hanging arm cast method or coaptation
  splint

16
Notes

• these injuries are often very painful and that
  good initial immobilization is required
• long arm splint needs to be applied from shoulder
  to wrist to fully immobilize the extremity

17
Indications for Operative Treatment

• satisfactory position and alignment cannot be
  achieved by conservative measures
• associated injuries in the extremity require
  early mobilization

18

• open humeral fractures within 8-12 hours after
  injury
• pathological fracture
• fractures that associated with major vascular
  injuries
• a fracture is segmental
• Malunion that influence the function
• Nounion of a delayed fracture

19

• a spiral fracture of the distal humerus, radial
  nerve palsy develops after manipulation or
  application of a cast or splint
• when treatment of associated injuries makes bed
  rest necessary

20
fractures associated with vascular injuries
21
a spiral fracture with radial nerve injury
22
exploration of the nerve

• function has not returned in 3to 4 months and the
  fracture has healed.
• radial nerve palsy occurs with open fractures of
  the humeral shaft
• Early exploration when evidence suggests that the
  radial nerve is impaled on a bone fragment or is
  caught between the fragments
• Early exploration if the humeral fracture is to
  be repaired early by open reduction and internal
  fixation

23
Operative method

• Fractures of the humeral shaft can be fixed
  internally by plates and screws, intramedullary
  nails, or external fixation devices.

24
Humeral shaft fracture treated by closed
intramedullary nailing
25
Humeral shaft fracture fixed with compression
plate
26
SUPRACONDYLAR FRACTURES
27
classification

• 2 types

• extension type (95)
• flexion type

28
diagnosis

• history of injury
• clinical features swelling, subcutaneous
  ecchymosis,pain , deformity,tenderness,bony
  crepitus, limitation of upper extremity motion
• x-ray
• rule out nerve and vascular injury

29

• Careful neurovascular examination of the arm is
  essential, especially in extension-type
  supracondylar fractures .
• The brachial artery may be lacerated by the
  proximal fracture fragment and a compartment
  syndrome may develop.
• All three major nerves that cross the elbow can
  be injured, but the radial and median nerves are
  those most commonly affected.

30
treatment

• similarly to humeral shaft fractures with a
  hanging arm cast or coaptation splint
• Open reduction and internal fixation are used
  only in the presence of neurovascular damage or
  when a satisfactory position of the fracture is
  not obtained by closed methods

31
FRACTURES OF SHAFT OF RADIUS AND ULNA
32
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

33
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

34
Monteggia fracture-dislocation
35
Galeazzi fracture-dislocation
36
diagnosis

• history of injury
• clinical features swelling, pain , subcutaneous
  ecchymosis, limitation of upper extremity motion,
  deformity, tenderness, bony crepitus ,
• normal postelbow triangle
• x-ray

37
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.

38
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

39
FRACTURES OF DISTAL RADIUS
40
Classification

• extension type
• Colles fracture
• flexion type
• Smith fracture

41
Colles fracture
42
Smith fracture
43
Mechanism of Colles fracture

• fractureis caused by a forced dorsiextention
  of the wrist
• occurs in gt 50 years of age who fall on out
  stretched hand

44
Diagnosis of Colles fracture

• history of injuryfall on out stretched hand
• clinical features swelling, subcutaneous
  ecchymosis,pain , limitation of wrist joint,
  tenderness, fork deformity
• x-ray

45
Treatment

• Most distal radial fractures can be
  successfully treated nonoperatively(Manual
  reduction)

46
Barton fracture

• A special type of fractures of distal radius
  which is intraarticular and is produced by
  shearing.  

47
HAND INJURY
48
The posture of the hand

• rest posture
• function posture

49
skin activility

• color and temperature of skin   
•  capillary reflux test
•  shape and size of flap
• ratio between length and width of flap
• direction of flap
• bleeding state of skin edge

50
Tendons injury

• the posture of the hand often provides clues as
  to which flexor tendons are severed
• When both flexor tendons of a finger are severed,
  the finger lies in an unnatural position of
  hyperextension, especially when compared with
  uninjured fingers.

51

• If middle finger remains extended when hand is at
  rest, its flexor tendons have been severed
• This finger becomes normally flexed after its
  profundus tendon or both this tendon and sublimis
  have been repaired

52
Distribution of major nerves innervating hand for
sensory function.