Upper limb fractures. Mithun Nambiar Orthopaedic Resident Royal Melbourne Hospital

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Upper limb fractures Mithun Nambiar Orthopaedic Resident Royal Melbourne Hospital

http://janeaustensworld.files.wordpress.com/2010/10/17_skeleton.jpg

Principles of fracture management Restoration of anatomy Stable fracture fixation Preservation of blood supply Early mobilisation of limb and patient

Restoration of anatomy Length Alignment Rotation

Stable fracture fixation Allows for fracture healing Prevention of loss of anatomy Length Alignment Rotation

Preservation of blood supply Soft tissue protection Periosteum Muscle Arteries Veins http://www.ubortho.buffalo.edu/tree3.j

Early mobilisation Limb Joint stiffness Muscle atrophy Contracture formation Patient Pneumonia DVT/Pulmonary embolus Pressure sores Hospital acquired infections

Management Operative Conservative Weight bearing status Wound management Antiobiotics Anticoagulation Smoking Immunomodulators

Clavicular fractures http://en.wikipedia.org/wiki/file:gray326.png

Clavicular fractures Medial 1/3 (5%) Usually non-operative, operative if post. displacement Middle 1/3 (80%) Non-operative if <100% displacement Operative if >100% displaced Lateral 1/3 (10%) Neer classification

http://eorif.com/clavicle-fracture-classification

http://www.orthobullets.com/trauma/1011/clavicle-fractures

https://www.jaaos.org/content/19/7/392/f1.large.jpg

Clavicular fractures Non operative management Sling vs Figure of 8 NWB 6 weeks Range of movement exercises 2-4 weeks Risks Non union Lateral 1/3 (up to 50%) Fracture displacement/shortening >2cm Decreased shoulder strength

Clavicular fractures Operative management Sling 7-10 days, then active range of motion NWB 6 weeks, once union confirmed and pain free range of motion- strengthening Full activity in 3 months Benefits Faster union Improved functional outcomes Improved cosmesis Improved shoulder function strength Risks Implant removal

Clavicular fractures

Clavicular fractures

Clavicular fractures

Clavicular fractures

Scapular fractures Usually high energy mechanism Location Acromion Corocoid process Neck of scapula Body of scapula

Scapular fractures http://a248.e.akamai.net/7/248/432/20120426151227/www.msdlatinamerica.com/ebooks/chapmansorthopaedi csurgery/files/023489cd701b474692bcdaec6c52f9a8.gif

Scapular fractures Non operative management 2 weeks sling, early motion ORIF Glenohumeral instability >25% glenoid >5mm step-off Medialisation of glenoid Open fracture Scapula neck (>40 degrees, 1cm) Coracoid >1cm displacement

Humerus fractures Location Proximal Shaft Distal http://upload.wikimedia.org/wikipedia/com mons/a/ad/gray207.png

Humerus fractures- proximal Non operative management Minimally displaced surgical neck (1,2,3) Greater tuberosity <5mm displacement Consideration for age, bone quality Early range of motion in 14 days Operative management CRPP ORIF IM rod Hemi arthroplasty Total shoulder arthroplasty

http://eorif.com/shoulderarm/images/proxhmcpp3.jpg

http://www.eorif.com/shoulderarm/images/prxhmorif3.jpg

http://www.tstsan.com/resimler/urun/b_porx_humerus_web2.jp

http://www.synthes.com/sites/na/products/trauma/intramedullarynailingsystems/publishingimages/multiloc_309.j pg

http://www.eorthopod.com/images/contentimages/shoulder/shoulder_humeral_hea d_osteonecrosis/humeral_head_osteonecrosis_hemiarthroplasty.jpg

http://www.lima.it/repository/fck/image /Special%20edition%20usa%202012/ protesi-smr-america.jpg

http://www.orthop.washington.edu/orthodev/drupal/sites/default/files/portals/21/liveco ntent/8149/images/figure6.jpg

Humerus fractures- shaft Non operative management Splint then functional bracing <20 degrees anterior angulation <30 degrees varus/valgus angulation <3cm shortening ORIF or IM nail Brachial plexus injury Open fracture Pathological fracture Spiral/oblique

Humerus fractures- distal Supracondylar Single/double column fracture Non operative Non displaced single column Operative CRPP ORIF Total elbow arthroplasty Risks Heterotropic ossification Joint stiffness Degenerative joint disease Cubital valgus/varus

http://www.orthobullets.com/trauma/1017/distal-humerus-

http://images.radiopaedia.org/images/535540/fa226724fc4371512eda2a95de

http://www.tornier-us.com/upper/elbow/elbrec001/images/latitude-back.jpg

Olecranon fractures Non operative Non displaced fractures Immobilisation in 45-90 degrees of flexion, for 3 weeks, then mobilise Operative TBW IM fixation Plate and screw fixation Fragment excision and triceps advancement

http://www.orthobullets.com/trauma/1022/olecranon-fractures

http://www.orthobullets.com/trauma/1022/olecranon-fractures

Monteggia fractures http://www.orthobullets.com/trauma/1024/monteggia-fractures

Monteggia fractures Non operative- closed reduction More common in children Casting with forearm supination Operative- ORIF ulnar +/- open radial head reduction Comminuted ulna Unable to reduce radius

Galeazzi fractures http://www.orthobullets.com/trauma/1029/galeazzi-fractures

http://www.orthobullets.com/trauma/1029/galeazzi-fractures

Galeazzi fractures Operative all cases ORIF radius, stabilisation of DRUJ DRUJ If stable- cast in supination 6 weeks Percutaneous pin fixation Open reduction- ECU ORIF ulnar styloid

http://upload.orthobullets.com/topic/1029/images/galeazzi%20fracture%20orif.jpg

http://a248.e.akamai.net/7/248/432/20120426191700/www.msdlatinamerica.com/ebooks/handsurgery/files/ed13b53e950d1a4efdb3aef6853269cf.gif

Forearm fractures Non operative Distal 2/3 ulna (nightstick) <50% displacement, <10degrees angulation ORIF Proximal 1/3 ulnar All radial shaft fractures Both bone fractures

http://fprmed.com/medical/ortho/nightstick%20fx.jpg

Distal radius fractures http://img.medscape.com/pi/emed/ckb/radiology/336139-398406-7418.jpg

Distal radius fractures http://www.orthobullets.com/trauma/1027/distal-radius-fractures#4713

Distal radius fractures http://rad.desk.nl/images/thmb_477a59f6ebe6ftek-barton2x.jpg

Distal radius fractures http://www.orthobullets.com/trauma/1027/distal-radius-fractures#4713

Distal radius fractures Non operative Extraarticular <5mm shortening Dorsal angulation <5degrees** Surgical fixation Displaced/intraarticular- >2mm step Comminution Loss of volar tilt and radial length after casting >5mm shortening, >5 degrees dorsal angulation**

Summary Management plan for upper limb fractures based on AO principles: Restoration of anatomy Stable fracture fixation Preservation of blood supply Early mobilisation of limb and patient

Acknowledgements https://aotrauma.aofoundation.org Orthobullets http://www.orthobullets.com/ Wheeless Textbook of Orthopaedics http://www.wheelessonline.com/

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