Fractures of the Upper Limb

November 26, 2015 at 2:05 pm | Posted in Life as a Medical Student, Notes | Leave a comment
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P/s: As usual, I did not owe this note. Credit should be given to Appley and Netter’s Concise Orthopaedic and of course my lecturers 😉


1. Proximal humerus # in adult (elderly and osteoporotic)

Management depends on parts. (Neer Classification – head, GT, LT, shaft)
🔵 Undisplaced/minimally displaced: sling
🔵 2 fragments: closed reduction & splint.
🔵 3 fragments: operative
🔵 4 fragments: ORIF in young, may consider hemiarthroplasty in elderly.

Shoulder stiffness
Brachial plexus injury
AVN (Anatomical neck #)

2. Shaft #

Usually treated close (CMR + casting) as humerus heal readily. Complications following operative management higher.

ORIF (either plating/nailing) is still indicated in open #, severe comminuted #, polytrauma, unstable #.

🐛Humerus can accept more angulation due to presence of both elbow and shoulder joints.
Can accept up to <3cm shortening <20°AP angulation and <40° lateral angulation.

Distal 3rd #, radial nerve palsy, however mostly are neuropraxia. Why? Radial nerve in spiral groove, can become trapped easily. 

3. Distal Humerus #
🐞In adults, mostly intraarticular, either bicondylar or unicondylar.
Extraarticular (supracondylar) but very rare.

🐞Management, as usual:
Undisplaced, treated close.
Displaced, need anatomical reduction, hence ORIF.

1. Ulnar nerve palsy. (Ulnar is situated posterior to medial epicondyle).
2. Median nerve palsy. (enters forearm at biceps aponeurosis)
3. Elbow stiffness
4. HO

4. Supracondylar # in children
:idea:Most common, extension type (posterior displacement), Gartland classification.

:idea:X ray: Fat pad sign. Fat pad at coronoid and olecranon fossa is displaced.

Gartland 1: casting
Gartland 2 & 3: CMR and k wire.
Children has good remodelling and thick cortex. K wire itself sufficent.

Rarely need ORIF. Still indicated for unreduced #, vascular involvement.

1. Nerves injury
– Radial (between brachialis and BR @ posterior elbow)
– Median (jaggered fragments poke the median nerve/AIN)
– Ulnar
2. Vascular injury – brachial artery (same mechanism as median nerve injury)
3. Malunion – cubitus varus. Usually due to angulation.

5. Elbow dislocation
🌼Simple or Complex (with fractures of the surrounding structures). Posterior dislocation commonest.

🌼Terrible triad: Dislocation with radial head & coronoid #.

Simple – simply by closed reduction, then splint (collar and cuff for 1 week, start exercise after that, off by 3rd week)
Complex – settle the # first.

1. Nerve injury.
-Ulnar nerve (in cubital tunnel)
-Median nerve in Ligament of Struthers)
Both can become compressed
2. Vascular injury – Brachial artery
3. Elbow stiffness and instability.

➡ Recurrent dislocation very rare

6. Fractures of the Radius and Ulnar
Manage like an intraarticular #, needs anatomical reduction. Why? Presence of supinator and pronator muscle. Not easy to maintain reduction.

👉Both bone #
Paeds, closed reduction and casting. Remodelling is very good.
Adult, ORIF (plating)

👉Single bone #
Monteggia: Prox ulnar # with PRUJ disruption (radial head dislocation due to shortening force @ ulnar)
Mx: ORIF. Dislocation will reduce when # has been managed

Galleazi: Distal 1/3 radial # with DRUJ disruption
Mx: ORIF, DRUJ closed reduction.

7. Distal End Radius #
MOI: Axial force, FOOSH
Common, esp in osteoporotic pt.

✴ Colles #, dinner fork deformity ( dorsal displacement)
✴ Smith #, reverse Colles

Frykman for Colles (joint involvement)
Even number – ulnar styloid #
1&2 Extraarticular
3&4 RC joint
5&6 RU joint
7&8 Both RC and RU involved

Undisplaced: cast
Extraarticular (close reduction, check X-Ray, Rule of 11). If unstable, ORIF
Intraarticular, need ORIF.

Old and osteoporotic ➡ allow more conservative mx as use the joint less.

-median nerve injury (carpal tunnel)
-TFCC injury (important for stability)

Triangular fibrocartilage complex
-between distal ulnar and ulnar prox carpal row (triquetrium)
-Ligaments – central disc, dorsal radioulnar, palmar radioulnar.

8. Scaphoid #
Tenderness @ snuffbox region.

70% of scaphoid covered by articular cartilage, hence mx line intraarticular #.
Displace # need anatomical reduction (headless screw compression)

– AVN esp if injury at proximal part.
Blood vessel enters in a nonarticular ridge on the dorsal surface. Prox part supplied by retrograde blood flow.
– Non-union


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