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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