Management of common upper limb fractures in Adults and Children. Dr Matthew Sherlock Shoulder and Elbow Orthopaedic Surgeon
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1 Management of common upper limb fractures in Adults and Children Dr Matthew Sherlock Shoulder and Elbow Orthopaedic Surgeon
2 Outline Immobilisation choices Adults Clavicle Fractures Proximal Humeral Fractures Wrist Fractures Children Elbow Fractures Forearm Fractures
3 Immobilising Upper Limb #s Immobilisation choices Slings triangular, immobiliser Collar and cuff Plaster Backslab, full cast (short arm, long arm), U- slab, hanging cast Removable splints Braces Choice is determined by forces displacement
4 Immobilising Upper Limb #s Clavicle/AC joint injuries Weight of arm displacement
5 Immobilising Upper Limb #s Clavicle/AC joint injuries Weight of arm displacement Support arm with sling +/- waist strap
6 Immobilising Upper Limb #s Proximal humerus Involving tuberosities Pull of rotator cuff displacement Prevent active movement of arm,
7 Immobilising Upper Limb #s Proximal humerus Involving tuberosities Pull of rotator cuff displacement Prevent active movement of arm, waist strap important. Immobiliser sling
8 Immobilising Upper Limb #s Proximal humerus Metaphysis Rotator cuff balanced Fracture angulation worsened Axial load Shoulder extension
9 Immobilising Upper Limb #s Proximal humerus Metaphysis Rotator cuff balanced Fracture angulation worsened Axial load Shoulder extension Collar and Cuff
10 Immobilising Upper Limb #s Humeral Shaft Muscle pull displacement Pectoralis major/ lat dorsi Deltoid
11 Immobilising Upper Limb #s Humeral Shaft Muscle pull displacement Pectoralis major/ lat dorsi Deltoid Gravity maintains alignment Arm should hang Plaster immobilisation possible
12 Immobilising Upper Limb #s Humeral Shaft Muscle pull displacement Pectoralis major/ lat dorsi Deltoid Gravity maintains alignment Arm should hang Plaster immobilisation possible U-Slab plaster
13 Immobilising Upper Limb #s Humeral Shaft U-slab Uncomfortable, heavy Temporary U-Slab plaster
14 Immobilising Upper Limb #s Humeral Shaft U-slab Uncomfortable, heavy Temporary Change to Sarmiento brace after 1-2 weeks. Functional brace
15 Immobilising Upper Limb #s Elbow Fractures Adults Ideally don t immobilise elbow for more than 3 weeks! Commonly surgery is indicated to enable stable fixation and early ROM
16 Immobilising Upper Limb #s Elbow Fractures Children Supracondylar # Stable in flexion
17 Immobilising Upper Limb #s Elbow Fractures Children Supracondylar # Stable in flexion Positioning arm in flexion is more important than the actual plaster
18 Immobilising Upper Limb #s Elbow Fractures Children Supracondylar # Stable in flexion Positioning arm in flexion is more important than the actual plaster
19 Immobilising Upper Limb #s Forearm Fractures
20 Clavicle fractures Midshaft most common Distal Medial - uncommon
21 Clavicle fractures Mechanism of injury
22 Clavicle fractures Initial treatment Very painful fracture Arm immobiliser not collar and cuff Ice Figure 8 bandage
23 Midshaft Clavicle fractures All undisplaced fractures can be treated conservatively Immobiliser sling Discontinued once pain subsides (3-5 weeks) Self administered ROM and strengthening
24 Midshaft Clavicle fractures Indications for surgery Absolute Open fracture, skin compromise Progressive neurological deficit Relative Shortening Displacement/comminution Non-union
25 Midshaft Clavicle fractures How much shortening? Ledger et al. JSES 2004 Biomechanical and anatomical CT study Patients with clavicular malunion >15mm Reduction of muscular strength of adduction, extension, and internal rotation Reduced peak abduction velocity Increased upward angulation of clavicle at SCJ and increased anterior scapular version
26 Midshaft Clavicle fractures How much shortening? Assessment Clinical measurement
27 Midshaft Clavicle fractures How much shortening? Assessment Clinical measurement Assess scapular position
28 Midshaft Clavicle fractures How much shortening? Assessment Clinical measurement Assess scapular position Radiology Xray/CT
29 Midshaft Clavicle fractures Surgical Options Plate fixation Intramedullary screw
30 Midshaft Clavicle fractures Plate fixation Comminution Soft bone/smokers Less compliant patients
31 Midshaft Clavicle fractures Intramedullary screw 2 part fractures Young patients (girls) Avoid above shoulder ROM first 6 wks
32 Distal Clavicle Fractures Beware of these fractures! High non-union rate when displaced Displacement often missed Treatment also determined by relationship to and the integrity of the CC ligs
33 Distal Clavicle Fractures Displaced fractures require surgery in all but the elderly (low demand) patient.
34 Distal Clavicle Fractures Beware of inadequate imaging
35 Distal Clavicle Fractures Beware of inadequate imaging
36 Distal Clavicle Fractures Beware of inadequate imaging
37 Distal Clavicle Fractures Initial management with immobiliser sling Non-operative Rx for undisplaced fractures with intact CC ligs
38 Distal Clavicle Fractures Surgical management
39 Distal Clavicle Fractures Surgical management
40 Proximal Humerus Fractures Third most common fracture after hip fracture and Colles fractures More common in females Historically 15-20% required surgery They generally result in some long term functional disability
41 Classification Systems Neer
42 Classification Systems AO/ASIF
43 Surgical decision making Not bad enough for surgery Too bad to fix
44 Surgical decision making Not bad enough for surgery Sling/ Collar & Cuff Too bad to fix Hemi/Reverse TSA
45 Surgical decision making Not bad enough for surgery Too bad to fix Sling/ Collar & Cuff ORIF Hemi/Reverse TSA
46 Surgical decision making Not bad enough for surgery Too bad to fix Sling/ Collar & Cuff ORIF Hemi/Reverse TSA Goal is maximum shoulder function and minimal shoulder pain.
47 Surgical decision making Displacement and angulation Painful Impingement Significant ROM loss Risk of non-union Neer 1cm and or 45 degrees???
48 Surgical decision making Non-op vs ORIF vs Prosthesis Determined by risk of AVN age of patient Medical comorbidities Bone quality Functional demands
49 Surgical decision making Non-op vs ORIF vs Prosthesis Determined by risk of AVN age of patient Medical comorbidities Bone quality Functional demands
50 Greater Tuberosity Fracture Usually displaced posteriorly (by infraspinatus) and superiorly (by supraspinatus) >5mm requires reduction previously 1cm shown to have poor outcomes. Depends on fragment size and articular involvement Superior displacement impingment in abduction
51 Greater Tuberosity Fracture Undisplaced Immobiliser sling for 5-6 wks until healed Elbow ROM Watch closely for displacement
52 Greater Tuberosity Fracture Large fragment Screw fixation open/arthroscopic Tension band suturing Anchors
53 Greater Tuberosity Fracture Large fragment Screw fixation open/arthroscopic Tension band suturing Anchors
54 Greater Tuberosity Fracture Large fragment Screw fixation Tension band suturing Anchors Approach: mini deltoid split/ arthroscopic Advanced Fracture Management Course
55 Greater Tuberosity Fracture Large fragment Screw fixation open/arthroscopic Tension band suturing Anchors Small fragment Treat like a cuff tear Arthroscopic repair
56 Greater Tuberosity Fracture My Preference Large fragment good bone Screw fixation (mini-open or arthroscopic) Small fragment or large with soft bone Suture anchor fixation (Intraosseous equivalent/bridge)
57 Lesser Tuberosity Fracture Rare If large and displaced block internal rotation Open reduction and screw fixation +/- biceps tenodesis.
58 Surgical Neck Fracture Acceptable displacement and angulation depends on: patients age activity level functional demands
59 Surgical Neck Fracture Skeletally immature Patient Age (yr) Allowable Displacement or Angulation <5 Up to 70 degrees angulation, 100% displacement 5 12 Up to degrees angulation >12 Up to 40 degrees angulation, <50% displacement Adults
60 2 Part Surgical Neck Fracture Options Closed reduction + Kwires Intramedullary nail Circlage sutures Plate fixation
61 2 Part Surgical Neck Fracture Closed reduction + Kwires
62 2 Part Surgical Neck Fracture Plate fixation
63 2 Part Surgical Neck Fracture Plate fixation
64 3 and 4 Part Fractures
65 3 and 4 Part Fractures Surgical Treatment Options Open reduction + K wires Circlage wires/sutures + Rush pins/enders rods CRKW (Resch) Intramedullary nail Locking plate (hemiarthroplasty/reverse)
66 3 and 4 Part Fractures Surgical Treatment Options Open reduction + K wires Historical Circlage wires/sutures + Rush pins/enders rods CRKW (Resch) Intramedullary nail Locking plate Technically difficult (hemiarthroplasty/reverse)
67 3 and 4 Part Fractures Approach Deltopectoral Mini-deltoid split Percutaneous plating (Extensile lateral)
68 Percutaneous Plating Beach chair Spider arm holder
69 Percutaneous Plating Beach chair Spider arm holder II opposite side
70 Percutaneous Plating Beach chair Spider arm holder II opposite side Lateral deltoid split
71 Percutaneous Plating Get control of tuberosities LT + biceps tenodesis GT
72 Percutaneous Plating Get control of tuberosities LT + biceps tenodesis GT Elevate head if impacted
73 Percutaneous Plating Get control of tuberosities LT + biceps tenodesis GT Elevate head if impacted
74 Percutaneous Plating Insert plate under deltoid/axillary nerve
75 Percutaneous Plating Lock proximally and distally
76 Percutaneous Plating Lock proximally and distally
77 Percutaneous Plating Final images AP Lateral Axillary view
78 Percutaneous Plating Final images AP Lateral Axillary view
79 Percutaneous Plating
80 Percutaneous Plating Bone grafting Elevation of valgus impacted fracture Cancellous bone defect?possible cause of late failure and collapse Injectible bone graft Ca PO4 Sets hard support head, fixation for screws
81 Deltopectoral Approach I use DP approach when: Extensive medial calcar/shaft extension Excessive rotation of head fragment Head split (access through rotator interval)
82 Deltopectoral Approach
83 Deltopectoral Approach Fracture reduction techniques Double plating method Some fractures are too comminuted to get stable fixation with 1 plate
84 Deltopectoral Approach Fracture reduction techniques Double plating method Some fractures are too comminuted to get stable fixation with 1 plate Use orthogonal plates for increased strength
85 Distal Humeral Fractures Supracondylar Extension Type COMMON!! Flexion Type (rare) Epiphyseal Epicondylar Condylar
86 Supracondylar Fractures Extension Type Grade 1 (Undisplaced) Grade 2 (Partially) Grade 3 (Completely)
87 Supracondylar Fractures Extension Type Unstable in extension Reduction is maintained with elbow held FLEXED!!! FLEXION IS MORE IMPORTANT THAN PLASTER IMMOBILISATION
88 Supracondylar Fractures This treatment is worse than nothing at all! Plaster is dead weight on fracture!!
89 Supracondylar Fractures This treatment is worse than nothing at all! Plaster is dead weight on fracture!! Apply collar and cuff in flexion. Leave on until fracture union (3-4 wks) Shirts over the top!
90 Supracondylar Fractures Mx Grade 1 Collar & Cuff in flexion for 3/52 +/- Backslab
91 Supracondylar Fractures Mx Grade 2 Closed Reduction under anaesthetic If unstable (rotationally) add K-wires Immobilize in flexion
92 Supracondylar Fractures Mx Grade 3 Usually severely swollen delay increases difficulty of reduction Vascular compromise Neurological deficit - AIN Occasionally open reduction required!
93 Supracondylar Fractures Complications Early Arterial Injury Compartment Syndrome Nerve Palsy Late Volkmann s Ischaemic Contracture Malunion
94 Complications: Cubitus Varus Residual Posteromedial displacement results in internal rotation and varus deformity of the distal fragment. This results in loss of the normal carrying angle, the so-called gunstock deformity.
95 Complications: Cubitus Varus Bauman s angle
96 Lateral Condyle Fractures 15% of elbow fractures in children Mechanism: Avulsion secondary to FOOSH with forearm supinated. Compression injury secondary to FOOSH with elbow flexed.
97 Lateral Condyle Fractures: Milch Classification Type I Type II
98 Lateral Condyle Fractures: Treatment Can be confused sometimes with a supracondylar fx - cannot make this mistake.
99 Lateral Condyle Fractures: Treatment Nondisplaced: Immobilization in simple backslab Displaced: Reduce and pin. Why reduce? Congruent joint surface Prevent nonunion Prevent growth arrest Usually Open Reduction, then 2 pins Immobilize 6 weeks, then remove pins.
100 Lateral Condyle Fracture
101 Lateral Condyle Fracture
102 Lateral Condyle Fracture
103 Elbow Dislocations Reduce Immobilise in backslab for 3 weeks
104 Elbow Dislocations Reduce Immobilise in backslab for 3 weeks Make sure radial head reduced
105 Elbow Dislocations Reduce Immobilise in backslab for 3 weeks Make sure radial head reduced and medial epicondyle is not in joint!
106 Medial epicondyle fractures Incarcerated medial epicondyle Incarcerated
107 Medial epicondyle fractures Incarcerated medial epicondyle Open reduction internal fixation
108 Elbow dislocation Displaced radial neck fracture
109 Elbow dislocation Displaced radial neck fracture Open reduction K-wire fixation
110 Forearm Fractures Distal radius fractures most common upper limb paediatric fracture > supracondylar fractures >shaft fractures Forearm fracture most commonly associated with the trampoline! Treatment more difficult the more proximal the fracture
111 Forearm Fractures Treatment is determined by: Age of patient (remodelling potential) Displacement Angulation, translation, rotation, shortening Cosmetic appearance Aim to restore forearm rotation
112 Forearm Fractures Plastering techniques Maintenance of reduction requires 3 point moulding
113 Forearm Fractures Plastering techniques Maintenance of reduction requires 3 point moulding
114 Distal Third Fractures Buckle or Torus Injuries Minimally displaced Stable 3-4/52 in cast short arm sufficient
115 Distal Third Fractures Displaced Greenstick Fractures? Reduce If 20 Degrees of tilt or If clinically deformed
116 Distal Third Fractures Complete Fractures CR & POP +/- wires Above elbow cast Redisplacement common Careful FU Remodel well
117 Distal Third Fractures
118 Distal Third Fractures
119 Distal Third Fractures
120 Distal Third Fractures
121 Distal Third Fractures Epiphyseal Injuries Usually Salter Harris I or II Displaced reduction and short arm cast Remodel well Don t manipulate late
122 Forearm Shaft Fractures Less remodelling Accept less than 10 degrees angulation Closed reduction under GA Always above elbow moulded cast Warn parents the cast will look bent! Recheck Xray 1 week 5% redisplacement rate Plaster for upto 6 weeks
123 Forearm Shaft Fractures Isolated radius fracture
124 Forearm Shaft Fractures Isolated radius fracture
125 Forearm Shaft Fractures Both bones shaft fracture
126 Forearm Shaft Fractures Both bones shaft fracture
127 Forearm Shaft Fractures Both bones shaft fracture
128 Forearm Shaft Fractures Both bones shaft fracture
129 Monteggia Fracture Dislocation Ulna fracture mid to proximal 1/3 Radial head dislocation Line through radial shaft and head BISECTS capitellum in ANY VIEW Never accept ISOLATED ulna fracture Examine & X-ray joint above and below
130 Monteggia Fracture Dislocation Ulna fracture mid to proximal 1/3 Radial head dislocation Line through radial shaft and head BISECTS capitellum in ANY VIEW Never accept ISOLATED ulna fracture Examine & X-ray joint above and below
131 Adult Distal Radius Fractures Most common adult fracture Usually in elderly due to osteopenia/porosis Usually associated with high energy trauma in young adults
132 Adult Distal Radius Fractures Types: Colles Smiths Bartons Chauffeurs Intraarticular Generally plain Xray adequate CT scan if intraarticular involvement
133 Adult Distal Radius Fractures Surgical Indications: Loss radial length 3mm or more
134 Adult Distal Radius Fractures Surgical Indications: Loss radial length 3mm or more Decreased radial inclination
135 Adult Distal Radius Fractures Surgical Indications: Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees
136 Adult Distal Radius Fractures Surgical Indications: Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees Step in articular surface 2mm or more
137 Adult Distal Radius Fractures Surgical Indications: Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees Step in articular surface 2mm or more Other indications: open #, progressive neurological deficit. If redisplacement outside these limits can be avoided with plaster best outcomes.
138 Adult Distal Radius Fractures Factors that make failure of conservative management more likely: Dorsal comminution Osteopenia High energy injury
139 Adult Distal Radius Fractures Conservative management: Plaster for 6 week Short arm cast only Physiotherapy
140 Adult Distal Radius Fractures Locking plate fixation New locking plates have dramatically improved surgical outcomes Early therapy has improved patients return in range of motion and function
141 Adult Distal Radius Fractures Locking plate fixation New locking plates have dramatically improved surgical outcomes Early therapy has improved patients return in range of motion and function Recommended treatment for displaced unstable fractures in adults is: Locking plate fixation Early range of motion, with removable splint
142 THANK YOU
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