Done by- Joslin Fernandes
3 rd year group 1

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Most frequently fractured bone in all ages
Most common site- Junction of middle and lateral third.
If the fracture is at the lateral end, there is a greater risk of nonunion than if the fracture is of the shaft.

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Causes- Trauma- fall directly on shoulder or with outstretched hand or direct hit to collarbone.
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In neonates- during vaginal delivery when the shoulders are broadSHOULDER
DYSTOCIA , accidents, contact sports.
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GREENSTICK FRACTURE
(incomplete)- one side broken, other side bent.

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 pain(sharp or referred) causing inability to lift arm
Swelling, bruising, tenderness over collarbone sagging of shoulder downward and forward bump at fracture site grinding sensation when raising arm brachial plexus palsy(rare)
Pneumothroax/hemothorax
Subclavian/carotid artery injury

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Upward displacement of proximal fragment by pull of sternocleidomastoid
muscle and downward displacement of distal fragment by deltoid and gravity.
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Medial pull to lateral fragment by
pectoralis major- shortening of clavicle

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Treatment-
Nonsurgical- arm support/sling, medications for pain, physical therapy to avoid stiffness
Complication- can move out of place before it heals- MALUNION, bump which may remain after fracture heals.
Surgical- severe cases, open reduction, internal fixation, plates/pins and screws
Complication-complications of surgery, problems with wound healing, lung injury, blood vessel injury, neuropraxia of posterior branches of brachial plexus.

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Head of humerus out of glenoid socket
Most common type of dislocation
Types-
Anterior(95%)- extension, abduction and external rotation of arm, arm overhead and rotated backwards.
Posterior(4-5%)- external blow to the front of the shoulder- flexion, adduction, and internal rotation, associated with seizures and electrical shock, missed on radiographs
Inferior(less than 1%)LUXATIO ERECTA present in deltoid muscle atony, arm permanently held upward/ behind head, hyper abduction of arm, highest complication of vascular, neurological, tendon and ligament injuries.

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Fracture of humeral head is also called
HILL-SACHS LESION which is the flattening of the humeral head when there is forceful impaction on the anterior inferior glenoid rim
These lesions can be seen in an AP X ray when the arm is internally rotated
BANKART LESION is the disruption of the anterior inferior labrum of glenoid rim
(either fibrous or bony) this leads to recurrent dislocations in young adults whereas elderly population has recurrent dislocations related to rotator cuff tendon ruptures
Rule out anterior dislocation if the patient can touch opposite shoulder with the hand of affected side

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Signs and symptoms- pain, unsteadiness, deformity, swelling, numbness, weakness, bruising, ligament tear, loss of normal contour
Complications-
Bankart lesion: tear of anteroinferior labrum of glenoid rim, high recurrence of dislocation in patients <30y, either fibrous/bony
Rotator cuff injuries: Elderly
Hill Sachs lesion: head of humerus impact against anteroinferior edge of glenoid causing flattening of head
Damage to axillary artery and nerve may also be present in anterior dislocations

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Diagnosis- X-ray, CT, MRI(soft tissue involvement).
Axillary radiograph best to diagnose posterior dislocations. For recurrent dislocations, the apprehension test (anterior instability) and sulcus sign (inferior instability) determine predisposition to future dislocation.
Treatment- Reduction, immobilization, surgery
Anterior dislocation, AP view
L: Lightbulb sign indicative of posterior dislocation, R: shoulder of reduction
Inferior dislocation, AP view

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3 main types with causes:
Proximal- near shoulder, break at top of the humerus, 3 rd most common in adults >65y, common in elderly, with osteoporosis, tobacco smoking
Distal- near elbow, break in lower end of humerus, caused by direct trauma(car accidents)/ falls in elderly.
Mid-shaft- middle of humerus, caused by car accidents, sports injuries, gunshot wounds, fall in elderly, metastatic breast cancer

Fractures
Proximal
Greater tubercle(Avulsion fracture, middleaged/elderly)
Lesser tubercle
Midshaft
Transverse
Spiral
Distal
Supracondylar- above the two condyles at bottom of humerus
Intercondylar- T/Yshaped structure separates the condyles
Surgical neck( most common , elderly)
Butterfly(combination of transverse and spiral)
Anatomical neck
Pathological- medical conditions

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Signs and symptoms:
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 immediate, enduring pain, exacerbated with slightest movements, swelling, bruising, crackling/ rattling sound.
When nerves affected- loss of control/sensation below fracture, when blood vessels affecteddiminished pulse at wrist.
Fractures of shaft cause deformity and shortening of length.
Distal fractures limit the ability to flex elbow.

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Nerves in direct contact with humerus:
Surgical neck- Axillary
Radial groove-Radial
Distal end- Median
Medial epicondyle- Ulnar Complications:
Nonunion/ Malunion
Nerve injury- radial nerve is often damaged when the humerus is fractured and causes numbness and tingling in the back of the hand, recovers over a course of few months.
Joint stiffness- Stiffness in the shoulder or elbow is common after a proximal humerus fracture and a distal humerus fracture respectively.

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Diagnosis- Radiographic imaging Xray CT.
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Treatment- Sling/brace, pain medications, reduction and internal fixation, surgery in extreme cases to prevent malunion. Humeral hemarthrioplasty when blood supply is compromised.
Proximal
Midshaft
Distal

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Affecting head- women,
30-40y
Affecting distal end(Colles fracture)- adults >50y, women with osteoporosis, most common fracture of forearm
Distal fragment of the radius is displaced posteriorly
(“dinner fork deformity”)forced extension of hand by fall with an outstretched arm; commonly accompanied by a fracture of the ulnar styloid process

50% intra-articular,
Extend to wrists
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Signs and symptoms:
Immediate pain, tenderness, bruising, and swelling
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Numbness in case of median/ulnar nerve injuries skin wound in case of open fracture
Swelling and displacement can cause compression on the median nerve which results in acute carpal tunnel syndrome

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Diagnosis- X-ray-
Posteroanterior- check for radial inclination and length and ulnar variance
Lateral- check for carpal malignment(present with volar/ dorsal tilt), tear drop angle(less than 45-> displacement of lunate facet), AP diameter(increased during lunate facet fracture), volar/dorsal tilt.
Oblique- protonated view for radial side, supinated view for ulnar side
Fracture with dorsal tilt

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Treatment- plaster cast(6wks), sling/splint, reduction, surgery- within 8hrs for open fractures, debridement, antibiotics, external/internal fixation.
External fixator used when soft tissues around fracture are badly injured

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hand movements that compresses the median nerve within the carpal tunnel.
The tunnel becomes narrowed or when tissues surrounding the flexor tendons(synovium) swell, takes up space in tunnel, result in pressure on median nerve  pain, numbness, tingling, and weakness, hypoesthesia/ anesthesia occurs in lateral 3 and half digits.

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Risk factors: women, old age, obesity, repetitive wrist work, pregnancy, rheumatoid arthritis, hypothyroidism
Feature of form of Charcot-Marie-Tooth syndrome type 1hereditary neuropathy with susceptibility to pressure palsies.
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Signs and symptoms: commonly present at night/ morning.
Sensory loss on the palmar and dorsal aspects of the index, middle, and half of the ring fingers and palmar aspect of the thumb, and flattening of the thenar eminence (“ape hand”)
Tapping of the palmaris longus tendon produces a tingling sensation (Tinel test)
Forced flexion of the wrist reproduces symptoms, while extension of the wrist alleviates symptoms
(Phalen test)
Applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms(Durkan test)
Occasional shock-like sensations that radiate to thumb, index, middle and ring finger, pain/ tingling may travel upto shoulder
Weakness and clumsiness of hand, frequent dropping of things

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Diagnosis- Tinel test, Phalen test, check for weakness, atrophy in muscles, electrophysiological tests(nerve conduction studies and electromyogram), ultrasound,
MRI, X-rays.
Treatment- nonsurgical- bracing/ splinting,
NSAIDS, partial/ complete surgical division of flexor retinaculum- carpal tunnel release, incision made at medial side of wrist and flexor retinaculum to avoid injury to recurrent branch of median nerve,

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Inflammation of bursa that separates superior surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying (coraco-acromial ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle.

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Causes: Injury to bursa, overuse of shoulder muscle, Primary inflammation may arise from rheumatoid arthritis, gout/pseudogout, calcific loose bodies, infection.
Diagnosis of shoulder bursitis is accompanied with diagnosis of tendinitis/ shoulder impingement syndrome.
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Signs and symptoms: gradual onset.
Pain along the front&side of shoulder, weakness, stiffness, swelling, redness, shoulder sore to touch on upper third of arm
Most commonly, night time pain, which awakens the patient
Painful arc of movement – shoulder pain felt between 60 - 90° of the arm moving up and outwards
Advanced bursitis- unable to move shoulder- frozen shoulder

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Diagnosis- Physical exam to differentiate between bursitis from rotator cuff injury, ultrasound, MRI,
X-ray, in case of infection- blood test
Neer’s Sign: If pain occurs during forward elevation of the internally rotated arm above 90°. This will identify impingement of the rotator cuff but is also sensitive for subacromial bursitis
Isometric flexion contraction against resistance of the therapist
(Speed’s Test). When the therapist’s resistance is removed, a sudden jerking motion results and latent pain indicates a positive test for bursitis.
Treatment- nonoperative- NSAIDS, physical therapy, rarely surgery.