Upper Extremity
Trauma
MUDr. Tomas Pavlacky
Trauma Hospital, Brno Trauma Departement, Medical Faculty,
Masaryk Univerzity, Brno
Introduction
● Traumatology
● AO Trauma
– AO Surgery reference
▪ https://www2.aofoundation.org/wps/portal/surgery
Topics
●Soft tisues
●Muscles and tendons
●Joints
●Bones
●Vessels and nerves
Topics
●Clavicle
●Scapula
●AC Joint Dislocation
●Shoulder Dislocation
●Humerus
●Elbow
●Forearm
●Distal Radius
●Hand
Clavicle Fractures
Clavicle Fractures
●Mechanism
–Fall onto shoulder (87%)
–Direct blow (7%)
–Fall onto outstretched hand (6%)
●Trimodal distribution
0
10
20
30
40
50
60
70
80
Group I
(13yrs)
Group 2
(47yrs)
Group 3
(59yrs)
Percent
Clavicle Fractures
◼Clinical Evaluation
–Inspect and palpate for deformity/abnormal motion
–Thorough distal neurovascular exam
–Auscultate the chest for the possibility of lung injury or
pneumothorax
◼Radiographic Exam
–AP chest radiographs.
–Clavicular 15-45deg A/P oblique X-rays
–Traction pictures may be used as well
Clavicle Fractures
●Type I Middle Third (80%)
●Type II Distal Third (15%)
▪Differentiate whether ligaments attached to lateral or medial fragmen
●Type III Medial Third (5%)
●Allman clasification
●Neer clasification
Clavicle Fractures
●Dislocation
Clavicle Fracture
●Closed Treatment
–Sling immobilization for usually 3-4 weeks with early ROM
encouraged
●Operative intervention
–Fractures with neurovascular injury
–Fractures with severe associated chest injuries
–Open fractures
–Group II, type II fractures and those with 100% disl., more than
2cm shortening
–Cosmetic reasons, uncontrolled deformity
–Nonunion
Clavicle Fracture
●Closed Treatment
–Sling immobilization for 3-4 weeks
with early ROM encouraged
●Operative intervention
–Fractures with neurovascular injury
–Fractures with severe associated chest injuries
–Open fractures
–Group II, type II fractures and those with 100% disl., more than
2cm shortening
–Cosmetic reasons, uncontrolled deformity
–Nonunion
●Associated Injuries
–Brachial Plexus Injuries
▪Contusions most common, penetrating (rare)
–Vascular Injury
–Rib Fractures
–Scapula Fractures
–Pneumothorax
Clavicle Fracture
●Uncommon fracture pattern associated with high energy
trauma
–2-5% associated mortality rate
▪usually pulmonary or head injury
▪associated with Increased Injury Severity Scores
●Epidemiology
–incidence
▪less than 1% of all fractures
–location
▪50% involve body and spine
●Associated injuries (in 80-90%)
Scapula Fracture
●Classification is based on the location of the fracture and
includes
▪coracoid fractures
▪acromial fractures
▪glenoid fractures (Ideberg)
▪scapular neck fractures
–look for associated AC joint separation or clavicle fracture
–known as "floating shoulder"
▪scapular body fractures
–described based on anatomic location
●scapulothoracic dissociation
Scapula Fracture
●Imaging
▪Radiographs
–recommended views
▪true AP, scapular Y and axillary lateral view
▪CT
–intra-articular fracture
–significant displacement
–three-dimensional reconstruction useful
Scapula Fracture
●Treatment
–Nonoperative
▪sling for 2 weeks, followed by early motion
▪indications
–indicated for vast majority of scapula fractures
–90% are minimally displaced and acceptably aligned
▪outcomes
–union at 6 weeks
–can expect no functional deficits
–Operative
▪open reduction internal fixation
Scapula Fracture
Scapula Fracture
AC Joint Dislocations
●Primarily in male
●25% of the dislocations of the shoulder girdle
●Number 1 injury in bicycle accidents
●Mechanism: fall or direct blow to the point of shoulder
with arm adducted
AC Joint Dislocations
AC Joint Dislocations
●Treatment
–Grade I, II
▪Immobilization in a sling
–Grade III
▪Controversy with regard to op vs
conservative tx
–Grade IV, V, VI
▪Early surgery
in young individuals
Shoulder Dislocations
●Epidemiology
–Anterior: Most common
–Posterior: Uncommon, 10%, Think Electrocutions & Seizures
–Inferior (Luxatio Erecta): Rare, hyperabduction injury
Shoulder Dislocations
●Clinical Evaluation
–Examine axillary nerve (deltoid function, not sensation over
lateral shoulder)
–Examine M/C nerve (biceps function and anterolateral forearm
sensation)
●Radiographic Evaluation
–True AP shoulder
–Axillary Lateral
–Scapular Y
–Stryker Notch View (Bony Bankart)
Shoulder Dislocations
●Anterior Dislocation Recurrence Rate
–Age 20: 80-92%
–Age 30: 60%
–> Age 40: 10-15%
●Look for Concomitant Injuries
–Bony: Bankart, Hill-Sachs Lesion, Glenoid Fracture, Greater
Tuberosity Fracture
–Soft Tissue: Subscapularis Tear, RCT (older pts with
dislocation)
–Vascular: Axillary artery injury (older pts with atherosclerosis)
–Nerve: Axillary nerve neuropraxia
●Anterior Dislocation
–Traumatic
–Atraumatic
(Congenital Laxity)
–Acquired
(Repeated Microtrauma)
Shoulder Dislocations
●Posterior Dislocation
–Adduction/Flexion/IR at time of injury
–Electrocution and Seizures cause overpull of
subscapularis and latissimus dorsi
–Look for “lightbulb sign” and “vacant
glenoid” sign
–Reduce with traction and gentle anterior
translation (Avoid ER arm → Fx)
Shoulder Dislocations
●Inferior Dislocations
● Luxatio Erecta
–Hyperabduction injury
–Arm presents in a flexed “asking a
question” posture
–High rate of nerve and vascular injury
–Reduce with in-line traction and gentle
adduction
Shoulder Dislocations
Shoulder Dislocation
●Treatment
–Nonoperative treatment
▪Closed reduction should be performed after adequate clinical evaluation and appropriate
sedation
–Reduction Techniques
▪Traction/countertraction- Generally used with a sheet wrapped around the patient and
one wrapped around the reducer.
▪Hippocratic technique- Effective for one person. One foot placed across the axillary
folds and onto the chest wall then using gentle internal and external rotation with axial
traction
▪Stimson technique- Patient placed prone with the affected extremity allowed to hang
free. Gentle traction may be used
▪Milch Technique- Arm is abducted and externally rotated with thumb pressure applied
to the humeral head
▪Scapular manipulation, Kocher technique,...
▪https://www.shoulderdoc.co.uk/article/1267
Shoulder Dislocations
●Postreduction
–Post reduction films are a must to confirm the position of the
humeral head
–Pain control
–Immobilization for 2-3 weeks then begin progressive ROM
●Operative Indications
–Irreducible shoulder (soft tissue interposition)
–Displaced greater tuberosity fractures
–Glenoid rim fractures bigger than 5 mm
–Elective repair for younger patients
Proximal Humerus Fractures
Proximal Humerus Fractures
●Epidemiology
–Most common fracture of the humerus
–Higher incidence in the elderly, thought to be related to
osteoporosis
–Females 2:1 greater incidence than males
●Mechanism of Injury
–Most commonly a fall onto an outstretched arm from standing
height
–Younger patient typically present after high energy trauma such
as MVA
Proximal Humerus Fractures
●Clinical Evaluation
–Patients typically present with arm held close to chest by
contralateral hand. Pain and crepitus detected on palpation
–Careful NV exam is essential, particularly with regards to
the axillary nerve. Test sensation over the deltoid. Deltoid
atony does not necessarily confirm an axillary nerve injury
Proximal Humerus Fractures
●Neer Classification
–Four parts
▪Greater and lesser tuberosities,
▪Humeral shaft
▪Humeral head
–A part is displaced if >1 cm
displacement or >45 degrees of
angulation is seen
Proximal Humerus Fractures
●Treatment
–Minimally displaced fractures- Sling immobilization, early
motion
–Two-part fractures▪Anatomic
neck fractures likely require ORIF. High incidence of
osteonecrosis
▪Surgical neck fractures that are minimally displaced can be treated
conservatively. Displacement usually requires ORIF
–Three-part fractures
▪Due to disruption of opposing muscle forces, these are unstable so closed
treatment is difficult. Displacement requires ORIF.
–Four-part fractures
▪In general for displacement or unstable injuries ORIF in the young and
hemiarthroplasty in the elderly and those with severe comminution. High
rate of AVN (13-34%)
Proximal Humerus Fractures
Humeral Shaft Fractures
Humeral Shaft Fractures
●Mechanism of Injury
–Direct trauma is the most common especially MVA
–Indirect trauma such as fall on an outstretched hand
–Fracture pattern depends on stress applied
▪Compressive- proximal or distal humerus
▪Bending- transverse fracture of the shaft
▪Torsional- spiral fracture of the shaft
▪Torsion and bending- oblique fracture usually associated with a
butterfly fragment
Humeral Shaft Fractures
●Clinical evaluation
–Thorough history and physical
–Patients typically present with pain,
swelling, and deformity of the upper arm
–Careful NV exam important as the
radial nerve is in close proximity
to the humerus and can be injured
Humeral Shaft Fractures
●Radiographic evaluation
–AP and lateral views of the humerus
–Radiographs after traction reposition attempt may be
indicated for hard to classify secondary to severe
displacement or a lot of comminution
Humeral Shaft Fractures
●Conservative Treatment
–Goal of treatment is to establish union
with acceptable alignment
–>90% of humeral shaft fractures heal with
nonsurgical management
▪ 20 degrees of anterior angulation, 30 degrees of varus
angulation and up to 3 cm of shortening are acceptable
▪ Most treatment begins with application of a coaptation
splint or a hanging arm cast followed by placement of a
fracture brace
Humeral Shaft Fractures
●Treatment
–Operative Treatment
▪Indications for operative treatment include
inadequate reduction, nonunion, associated
injuries, open fractures, segmental fract.,
associated vascular or nerve injuries
▪Most commonly treated with plates and
screws or IM nails
Humeral Shaft Fractures
●Holstein-Lewis Fractures
–Distal 1/3 fractures
–May entrap or lacerate radial nerve as the fracture passes
through the intermuscular septum
Elbow Fracture/Dislocations
Elbow Dislocations
●Epidemiology
–Accounts for 11-28% of injuries to the elbow
–Posterior dislocations most common
–Highest incidence in the young 10-20 years and usually sports
injuries
●Mechanism of injury
–Most commonly due to fall on outstretched hand or elbow
resulting in force to unlock the olecranon from the trochlea
–Posterior dislocation following hyperextension, valgus stress,
arm abduction and forearm supination
–Anterior dislocation ensuing from direct force to the posterior
forearm with elbow flexed
Elbow Dislocations
●Clinical Evaluation
–Patients typically present guarding the injured extremity
–Usually has gross deformity and swelling
–Careful NV exam in important and should be done prior to
radiographs or manipulation
–Repeat after reduction
●Radiographic Evaluation
–AP and lateral elbow films should be obtained both pre and post
reduction
–Careful examination for associated fractures
Elbow Fracture/Dislocations
●Treatment
–Posterior Dislocation
▪Closed reduction under sedation
▪Reduction should be performed with the elbow flexed while
providing distal traction
▪Post reduction management includes a posterior splint with the
elbow at 90 degrees
▪Open reduciton for severe soft tissue injuries or bony entrapment
–Anterior Dislocation
▪Closed reduction under sedation
▪Distal traction to the flexed forearm followed by dorsally direct
pressure on the volar forearm with anterior pressure on the humerus
Elbow Dislocations
●Associated injuries
–Radial head fx (5-11%)
–Treatment
▪Type I- Conservative
▪Type II/III- Attempt ORIF vs.
radial head replacement
▪No role for solely excision of
radial head.
Elbow Dislocations
●Associated injuries
–Coronoid process fractures
(5-10%)
Elbow Dislocations
●Associated injuries
–Medial or lateral epicondylar fx (12-34%)
Elbow Dislocations
●Instability Scale
–Type I
▪Posterolateral rotary instability, lateral ulnar collateral ligament
disrupted
–Type II
▪Perched condyles, varus instability, ant and post capsule disrupted
–Type III
▪A: posterior dislocation with valgus instability, medial collateral
ligament disruption
▪B: posterior dislocation, grossly unstable, lateral, medial, anterior,
and posterior disruption
Olecranon fractures
Olecranon fractures
●Presentation
▪Symptoms
- pain well localized to posterior elbow
▪Physical exam
- palpable defect
▪indicates displaced fracture or severe comminution
- inability to extend elbow
▪indicates discontinuity of triceps (extensor)
mechanism
●Imaging
▪AP/lateral radiographs
–true lateral essential for determination of fracture pattern
Olecranon fractures
●Treatment
▪Nonoperative - immobilization
indications
▪nondisplaced fractures
▪displaced fracture in low demand, elderly individuals
▪immobilization in 45-90 degrees of flexion initially
▪begin motion at 1 week
▪Operative
-tension band technique
▪indications: transverse fracture with no comminution
▪outcomes: excellent results with appropriate indication
- plate and screw fixation
- excision and triceps advancement
- intramedullary fixation
Olecranon fractures
●Treatment
Olecranon fractures
●Complications
▪Symptomatic hardware
- most frequent reported complication
▪Stiffness
- occurs in ~50% of patients
- usually doesn't alter functional capabilities
▪Heterotopic ossification
- more common with associated head injury
▪Posttraumatic arthritis
▪Nonunion
- rare
▪Ulnar nerve symptoms
▪Anterior interosseous nerve injury
▪Loss of extension strength
Forearm Fractures
Forearm Fractures
●Epidemiology
–Highest ratio of open to closed than any other fracture
except the tibia
–More common in males than females, most likely
secondary MVA, contact sports and falls
●Mechanism of Injury
–Commonly associated with MVA, direct trauma and falls
Forearm Fractures
●Clinical Evaluation
–Patients typically present with gross deformity of the
forearm and with pain, swelling, and loss of function at the
hand
–Careful exam is essential, with specific assessment of
radial, ulnar, and median nerves and radial and ulnar pulses
–Tense compartments, unremitting pain, and pain with passive
motion should raise suspicion for compartment syndrome
●Radiographic Evaluation
–AP and lateral radiographs of the forearm
–Don’t forget to examine and x-ray the elbow and wrist
Forearm Fractures
●Ulna Fractures
–These include nightstick and Monteggia fractures
–Monteggia denotes a fracture of the proximal ulna with an
associated radial head dislocation
▪Monteggia fractures classification- Bado
Forearm Fractures
●Radial Diaphysis Fractures
–Galeazzi or Piedmont fractures refer
to fracture of the radius with disruption
of the distal radial ulnar joint
–A reverse Galeazzi denotes a fracture
of the distal ulna with disruption of
radioulnar joint
–Essex-Lopresti
Distal Radius Fractures
Distal Radius Fractures
●Introduction
- Most common orthopaedic injury with a bimodal distribution
▪younger patients - high energy
▪older patients - low energy / falls
- 50% intra-articular
- Associated injuries
▪DRUJ injuries must be evaluated
▪radial styloid fx - indication of higher energy
▪soft tissue injuries in 70%
- TFCC injury 40%
- scapholunate ligament injury 30%
- lunotriquetral ligament injury 15%
Distal Radius Fractures
●Osteoporosis
▪high incidence of distal radius fractures in women >50
▪distal radius fractures are a predictor of subsequent
fractures
▪DEXA scan is recommended in woman with a distal
radius fracture
Distal Radius Fractures
Eponyms
▪Die-punch
▪Barton's fx
▪Chauffeur's fx
▪Colles' fx
Distal Radius Fractures
●Eponyms
–Colles Fracture
▪Combination of intra and extra articular fractures of the distal
radius with dorsal angulation (apex volar), dorsal displacement,
radial shift, and radial shortenting
▪Most common distal radius fracture caused by fall on outstretched
hand
–Smith Fracture (Reverse Colles)
▪Fracture with volar angulation (apex dorsal) from a fall on a flexed
wrist
–Barton Fracture
▪Fracture with dorsal or volar rim displaced with the hand and carpus
–Radial Styloid Fracture (Chauffeur Fracture)
▪Avulsion fracture with extrinsic ligaments attached to the fragment
▪Mechanism of injury is compression of the scaphoid against the
styloid
Radiographic Evaluation
●3 view of the wrist including AP, Lat, and Oblique
Distal Radius Fractures
●Treatment
–Displaced fractures require and attempt at reduction.
▪Hematoma block-10ccs of Mesocaine
▪Hang the wrist in fingertraps with a traction weight
▪Reproduce the fracture mechanism and reduce the fracture
▪Place in a splint
–Operative Management
▪For the treatment of intraarticular, unstable, malreduced
fractures.
▪As always, open fractures are emmergency indication for the
operation
Hand
Hand
●Introduction
▪The hand is a very vital part of the human body
▪4 requirements for a functioning hand:
- Supple, Sensate, Painfree, Coordinate
▪Account for 5-10 % of hospital ER visits.
▪Great potential for serious handicap
Hand
●Soft tissues
–Wounds older than 6-8 hours or primarily infected (bites)
should not be closed primarily because of an increased
likelihood of infections.
–If skin cover insuficient – egalization or flap
Hand
●Tendons
Hand
●Tendons
79
Tendon injury occording to zones
80
Zone 5
Zone 1
Boutonniere’s
Deformity
Zone 3
MANAGEMENT
Zone Presentation Management
I Mallet’s Deformity •Closed: splinting 6-8 weeks
•Open: suture repair for
fixation.
•Soft tissue reconstruction
III Boutonniere’s
Deformity
•Closed: splinting MCP and PIP
in hyperextension for 6 weeks
•Open: suture repair (figure of
8 suture)
V Fixed flexion of
MCP
•Closed: splinting ,45
extension at wrist and 20
flexion at MCP
•Open: suture repair.
81
82
CARPAL FRACTURES
Scaphoid fractures:
–Most common carpal fracture (15% of wrst inj)
–Results from force applied on distal end with wrist hyper
extended (fall on outstretched hand).
–Unless treated effectively it would result in mal-union and
permanent weakness and pain in the wrist.
–Blood supply retrograde so proximal fragment at risk of
AVN
–Deep tenderness in anatomical snuffbox is felt.
–Treatment:
▪Stable: Cast for 12 weeks
▪Unstable or non-union: ORIF
83
84
CARPAL FRACTURES
Triquetral fracture:
●2nd most common carpal fracture
●Direct blow to the dorsum of the hand or extreme
dorsiflexion.
●Palpation of the triquetrum is facilitated by radial
deviation of the hand.
●Point directly over the triquetrum.
85
Metacarpal Fractures
●Relatively common. 30-40% of hand fractures
●Result from direct or indirect trauma.
●Direct trauma commonly results in transverse
fracture, usually midshaft.
●Most fractures are easily reducible, stable and
managed non-operatively.
●Indications of surgical intervention:
- Intra-articular fractures,
- Displaced and angulated fractures,
- Unstable fracture patterns,
- Combined or open injuries,
- Irreducible and unstable dislocations
86
87
Thumb Fractures
●Bennett’s fracture:
–Fracture at the base of
the1st Metacarpal.
–Intra-articular fracture
subluxation
–Swelling and pain at the
thumb base
–Closed reduction and
immobilization with thumb
spica splint
–ORIF
●Rolando’s fracture:
–Comminuted (displaced)
thumb base fracture.
–Improper healing
restriction of motion around
CMJ
–Swollen, tender thumb base.
If significant varus has
developed, a clinically visible
deformity may be present.
–ORIF
88
Bennett’s Rolando’s
89
90
Phalangeal Fractures
Distal Phalanx:
–Extra-articular fractures are common, associated with
significant soft tissue injury.
–Crush injuries from a perpendicular force (injuries from a
car door or hammer)
–Intra-articular fractures are associated with extensor
tendon avulsion (Mallet’s finger), FDP tendon
avulsion (Jersey finger).
–Examination:
▪Inspection:.
▪Neurovascular status should be examined.
▪Palpation is done for tenderness.
–Closed treatment is recommended with splinting and if
necessary closed reduction
91
Phalangeal Fractures
Middle Phalanx:
–Blunt or crush force perpendicular to the long axis of the
bone.
–Angulation and rotation are two features of instability that
must be examined.
–Rotational deformities are serious injuries and are detected
clinically.
–Examination:
▪Inspection: for dislocations and sublaxations. Ask patient to fully flex
the phalanx to examine alignment of digits.
▪Palpation: swelling and tenderness
–Treatment:
▪Nondisplaced without impaction: require only dynamic splinting for 2-3
weeks.
92
Phalangeal Fractures
◼Proximal Phalanx:
–More common than middle phalanx fractures.
–May result in a great deal of disability.
–Dorsal or palmar angulation may occur with these fractures.
–Examination:
▪Inspection:
▪Neurovascular status
▪Palpation is done for tenderness.
–Treatment:
▪Nondisplaced fractures: usually stable and treated by closed reduction and
dynamic splinting.
▪Angulated or unstable fractures may require internal or external fixation.
93
94
K-Wire Fixation
Plates for ORIF