uper limb fracture

Dr Tarif Alakhras
Orthopedic surgeon
Clavicle Fracture
Clavicle injuries affect 1 in 1000 people per year.
The most common of all pediatric fractures.
10-16% of all fractures in this age group.
can present even in the newborn period,
especially following a difficult delivery.
A large peak incidence occurs in males younger
than 30 years due to sports injuries.
Clavicle Fracture
• Etiology
It may be caused by
direct or indirect
trauma. Or from fall
onto an outstretched
• Clinically
Clavicle Fracture
The most common
injury is a type 1
fracture , which affects
the middle third of the
Clavicle Fracture :Management
• typically included the use of either a
shoulder sling or a figure-of-eight
Surgical indications
• Severe displacement causing tenting
of the skin with the risk of puncture
• Fractures with 2 cm of shortening
• Comminuted fractures with a
displaced (or Z-shaped) fragment
• Neurovascular compromise or
mediastinal structures at risk[5]
• Open fractures
• (floating shoulder)
Fracture Humerus
Humerus can be divided
• Proximal end
• Mid shaft
• Distal end
the proximal end fracture
The upper end:
• The head
• Surgical neck
• Greater tuberosity
• Lesser tuberosity
The axillary nerve can be damaged
in this type of fractures.
Mid shaft fracture
• Elbow fractures are the
most common fractures in
children. An understanding
of the basic anatomy and xray landmarks of the elbow
is essential in choosing
appropriate treatment to
avoid complications.
Four important questions
• Is there a sign of Joint
• Is there a Normal
alignment between the
bone ?
• Are the Ossification
centers normal?
• Is there a Subtle fracture?
There are 6 ossification centres around
the elbow joint.
• 1. Capitellum
2. Radial Head
3. Internal epicondyle
4. Trochlea
5. Olecranon
6. Lateral Epicondyle
• 1-3-5-7-9-11 years
C-R-I-T-O- L
An elevated anterior
lucency or a visible
posterior lucency on
a true lateral
radiograph of an
elbow flexed at 90° is
described as a
positive fat pad sign
• Radiocapitellar line
• Anterior humeral line.
Supracondylar fracture
Lateral condyle fracture
Fracture radial head
Position of the medial epicondyle.
Supracondylar fracture
Supracondylar fracture
• consists of more than half of all pediatric elbow
• extension type most common (95-98%)
• Physical exam
– nerve exam
• Anterior Interosseus N neurapraxia
– unable to make “OK sign”
• Radial nerve neurapraxia
– inability to extend wrist or digits
– vascular status
• vascular insufficiency at presentation is present in 5 -17%
• defined as cold, pale, and pulseless hand
– a warm, pink, pulseless hand does not qualify as vascular
S/C frx: Management
• Nonoperative
– posterior molded splint then long arm casting at at 90° or less
• indications
– Type I (non-displaced) fractures
– Type II fractures that meet the following criteria
» anterior humeral line intersects capitellum
» minimal swelling present
» no medial comminution
• Operative
– closed reduction and percutanous pinning
• indications
- in most supracondylar fractures
-- open reduction with percutaneous pinning (If close reducion failed)
S/C complications
• Cubitus valgus
– can lead to tardy ulnar nerve palsy
• Cubitus varus (gunstock deformity)
– usually a cosmetic issue with little functional limitations
• Recurvatum
– common with non-operative treatement of Type II and
Type III fractures
• Nerve palsy
– usually resolve
• Vascular Injury and Volkmann ischemic contracture
• Postoperative Stiffness
Lateral Condyle Fracture - Pediatric
 17% of all distal humerus
fractures in the pediatric
 typically occurs in patients
aged 5-10 years o
 mechanism of injury
pull-off theory
avulsion fracture that results from the
pull of the common extensor
push-off theory
impaction of the radial head into the
lateral condyle
Lateral Condyle Fracture: treatment
• Nonoperative
– long arm casting
• indications
– only indicated if < 2 mm of displacement, which indicates the cartilaginous
hinge is most likely intact
– sub-acute presentation (>4 weeks)
• Operative
– Close reduction & Percut fixation
• indications
– some authors suggest CRPP for all lateral condylar fractures with < 2 mm of
– open reduction and fixation
• indications
– if > 2mm of displacement
– any joint incongruity
– fracture non-union
Complications: of delayed or inadequate reduction
non union:
AVN of capitellum
cubitus varus:
a more common complication than
cubitus valgus; may be due to
over-stimulation of the lateral
condylar physis.
cubitus valgus:
premature growth arrest of lateral
ulnar nerve palsy may appear as a late
Fracture head and neck of radius
• frx of the radial head
occurs primarily in adults,
whereas fractures of the
radial neck are more
common in children.
• frx of the radial head and
neck of the radius
generally results from a
hard fall on an
outstretched hand.
Fracture head of radius
pain, effusion in the elbow, & tenderness on palpation
directly over radial head are typical manifestations
associated injuries:
• distal radius fracture
• dislocation of the distal RU joint (Essex Lopresti Fracture)
• valgus instability (MCL rupture)
• rupture of the triceps tendon
• Elbow dislocation:
terrible triad:
RHF + MCL + coronoid process frcture
Fracture head and neck of radius
• An x-ray of the elbow
will confirm the
diagnosis and help
determine the severity
of the fracture .
• CT scan may also be
indicated in order to
choose the best
treatment option.
Fracture head and neck of radius
• Nonsurgical treatment of radial head fractures is
indicated if minimal displacement, minimal
angulation, and minimal head involvement.
Early motion with a functional brace is
encouraged to minimize elbow stiffness.
• Surgery is required if the fracture involves more
than 33% of the articular surface, is angulated
more than 30°, or is displaced more than 3 mm.
• excision of radial head & radial head implants:
Four Pearls for frx Head of Radius
• A visible posterior fat pad on the lateral view of the
elbow is a sign of occult intraarticular pathology.
• Early elbow ROM is needed to prevent stiffness.
• Examine the wrist when examining all elbow injuries; a
radial head fracture may be accompanied by a tear of
the interosseous membrane and disruption of the
distal radioulnar joint.
• The posterior interosseous nerve can be damaged by a
radial head injury or by the surgery performed to treat
the fracture. Therefore, document functional status
Galeazzi fracture
• is a fracture of the radius
with dislocation of the distal
radioulnar joint.
• Ricardo Galeazzi (1866–
1952), an Italian surgeon
• It was first described in
1842, by Cooper, 92 years
before Galeazzi reported his
Galeazzi fracture :Treatment
It has been called the
“fracture of necessity“
because it necessitates
open surgical treatment
in the adult.
in skeletally immature
patients the fracture is
typically treated with
closed reduction.
Monteggia fracture : Giovanni Battista Monteggia
• is a fracture of the proximal third
of the ulna with dislocation of
the head of the radius.
• (hyper-pronation injury)
• isolated ulnar shaft fractures
(most commonly seen in defense
against blunt trauma) is not a
Monteggia fracture. It is called a
'nightstick fracture'.
• open reduction and internal fixation of the
ulnar shaft is considered the standard
treatment in adults.
• Monteggia fractures may be managed
conservatively in children with closed
reduction but due to high risk of displacement
causing malunion, open reduction internal
fixation is typically performed.
Distal radius fracture
Colles' fracture
Smith's fracture
Barton's fracture
Chauffeur's fracture
The Universal classification
• Type I: extra articular,
• Type II: extra articular,
• Type III intra articular,
• Type IV: intra articular,
• Is an extraarticular fracture of the distal
radius with dorsal and radial
displacement of the wrist and
hand. The fracture is
sometimes referred to as a
"dinner fork" or "bayonet"
• often seen in elderly people
with osteoporosis.
• most commonly caused by
people falling onto a hard
surface with outstretched
Smith's fracture
reverse Colles' fracture
Robert William Smith (1807–1873)
• is an extra-articular fracture
of the distal radius. It is
caused by falling onto flexed
wrists, as opposed to a
Colles' fracture.
• The distal fracture fragment
is displaced volarly . There
may be one or many
fragments and it may or
may not involve the
articular surface of the wrist
Colles’ & Smith
• Treatment depends on severity:
– Undisplaced fracture may be treated with a cast
– Fractures with angulation and displacement
require closed reduction and above elbow casting
• Position in cast:
– In colles’ frx the wrist immobilized in flexion
– In smith frx the immobilization should be in
Barton's fracture
• Is an intra articular fracture
of the distal radius with
dislocation of the radiocarpal
• Intra-articular component
distinguishes this fracture
from a Smith's or a Colles'
• caused by a fall on an
extended and pronated wrist
Barton's fracture :treatment
• is best treated by closed
reduction, application
of external fixation,
followed by percutaneous
pin insertion.
• tendency to redisplace may
require ORIF by buttres plate
Chauffeur's fracture
•An isolated fracture of the
radial styloid process.
Displacement of the fragment is
•There can be associated injury
to the scapholunate ligament.
•In most cases a fracture of the
radial styloid process is part of a
comminuted intraarticular
Scaphoid fracture
• Scaphoid is the most
frequently fractured
carpal bone.
• It usually cause pain
and tenderness in the
snuffbox area at the
base of the thumb
Scaphoid fracture
• Fractures of scaphoid can occur from fall on
the palm on an outstretched hand.
• Often diagnosed by X-rays However not all
fractures are apparent initially .repeat x ray
• Avascular necrosis (AVN): mainly proximal 1/3
• Non union: occur from undiagnosed or undertreated
• wrist osteoarthritis.
Scaphoid fracture
• Avascular necrosis (AVN):
mainly proximal 1/3
• Non union: occur from
undiagnosed or undertreated
scaphoid fracture
• wrist osteoarthritis.
Scaphoid fracture
Non displaced or minimally
displaced waist and distal
fractures have a high rate of
union with closed cast
it is generally accepted to
use a short arm thumb spica
for non displaced fractures
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