UPPER LIMB INJURIES
Total (5) lectures
Dr.Alaa A.H.Al-Algawy
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Lecture (5)
Fractures of the carpal bones
Scaphoid fractures :Fractures of the scaphoid bone are the commonest carpal bone fracture and typically
affect young adult males.
The scaphoid bone links the proximal row with the distal row of the carpus and is
vulnerable to fracture as a consequence of falls on the outstretched hand, which result in
hyperextension at the carpus.
Scaphoid injuries are seen in children, but the diagnosis is not always straightforward
when the bone is not fully ossified.
In these circumstances it is reasonable to treat the injury as a suspected fracture.
The history of a fall on the wrist is common, but very few physical signs may be present.
The key clinical finding is of well localized tenderness in the anatomical snuffbox of the
wrist.
The fracture may be difficult to pick up on standard AP and lateral views and two
additional oblique 'scaphoid views' should be obtained as a routine when fracture is
suspected.
Most fractures are located in the middle third (80%), but proximal pole fractures account
for 15% and distal pole fractures for 5% of cases.
The blood supply of the scaphoid enters distally and consequently avascular necrosis is
a risk, particularly with proximal pole or displaced fractures.
Undisplaced fractures can be treated non-operatively in a cast.
The usual 'scaphoid' cast is similar to that used for a distal radial fracture, but
incorporates the thumb as far as the interphalangeal joint.
Eight weeks of immobilization is required and some authors recommend 12 weeks.
Union can be expected in 95% of undisplaced fractures.
Displaced fractures are best treated surgically.
Some scaphoid fractures are associated with lunate dislocations, radial styloid fractures or
other complex carpal fracture dislocation patterns.
All of these should also be treated surgically.
Internal fixation of the scaphoid with a small screw is the usual surgical treatment.
Non-union following non-operative treatment can also be treated by internal fixation, but
bone grafting is generally required.
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Other carpal bones fracture.
Fractures of the other carpal bones are comparatively rare. They can usually be treated
non-operatively in a cast if undisplaced.
Fractures with displacement or those associated with carpal dislocations should be
treated by internal fixation.
Diagnosis may be difficult and computed tomography (CT) scanning is helpful in
doubtful cases.
Fractures of the metacarpals and phalanges
Fractures of the small bones of the hand are very common injuries.
Many of these injuries are comparatively minor and a very satisfactory result can be
expected from non-operative treatment.
However, mismanagement can result in disabling deformity and stiffness.
A careful history is the first step, taking note of hand dominance and occupation.
The mechanism of injury may be of considerable significance, particularly with industrial
injuries, where there may be crushing or penetrating trauma that will influence
management decisions.
Radiographs are not a good guide to the extent of rotational or angular deformity.
In most injured hands the patient will hold the fingers in an extended position.
Flexion of the fingers is necessary to judge the degree of angular and rotational
deformity.
In the flexed position, the middle and distal phalanges should point towards the scaphoid
region of the wrist.
Injuries sustained as a consequence of penetrating trauma may result in tendon or nerve
injury and clinical assessment should evaluate these structures also.
Most hand fractures can be diagnosed without difficulty with radiographs.
These need to include AP, oblique and true lateral views for a full assessment of the
extent of injury and the need for treatment.
Management of metacarpal and phalangeal shaft fractures:
Most of these fractures heal reliably and quickly and non-operative treatment in some
form of splintage is the treatment of choice for the majority.
The position of immobilization is important.
In a position of extension the collateral ligaments of the metacarpophalangeal (MCP)
joints are at their shortest length. If immobilized in this position, stiffness is the usual
result, and may be very difficult to overcome.
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The correct position of immobilization is with the MCP joints flexed to 90° with the
interphalangeal joints in full extension.
In the case of the thumb, it should be immobilized in abduction and palmar opposition to
minimize stiffness due to adduction contracture.
If you keep the hand in such position is called (position of safety) or the (functional
position).
Fractures with angulation or rotation can be manipulated and reduced under anaesthesia.
A splint or short cast can then be applied.
Immobilization for 2-3 weeks is more than adequate for most stable metacarpal and
phalangeal shaft fractures.
Unstable and intra-articular fractures
Some patterns of injury are inherently unstable and the displaced intra-articular
fractures, as described elsewhere, usually require surgical treatment.
Angulation of more than 10° in any plane or rotational deformity causing overlapping of
the fingers in flexion may require operative treatment if a stable reduction cannot be
maintained by closed reduction and splintage.
The exception to this rule is a fracture of the neck of the little finger metacarpal, where
up to 45° of sagittal displacement can be accepted.
Instability is more common with comminution or complete displacement of the fracture.
Usually Kirschner wires are used for fixation, and these are often inserted
percutaneously.
This has the advantage of being minimally invasive and wires may be inserted in a
variety of directions and combinations.
Screws and plates are available for use in small bones and are most suitable for use in
intra-articular injuries. They require more invasive surgery and are technically
demanding to use.
Mini-external fixators are occasionally used in the hand. They are most useful in highenergy injuries with comminution and bone loss where standard methods of fixation may
be technically impossible.
These principles also apply to fractures and dislocations of the hand and wrist in children.
Greenstick and physeal injuries of the phalanges and metacarpals are seen in children as
well as complete fractures.
The same principles of management in the adults apply to children and these injuries heal
rapidly. It is essential that any rotational malalignment is corrected as this does not
remodel.
Plates are rarely used in the child's hand as most fixations can be achieved with wires.
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Bennett's fracture:
In the case of the thumb metacarpal, a partial articular fracture at the base of the thumb
meta-carpal is called a Bennett's fracture and is an unstable pattern of injury.
The palmar oblique ligament is attached to the small volar fragment, and the first
metacarpal when detached from this fragment is subluxed or dislocated out of the joint by
the abductor pollicis longus.
Reduction and Kirschner wire fixation is the most commonly used treatment.
FAQ (Frequently Asked Questions):1- How do you approach to a child with history of fall on a shoulder, presented with pain
and swelling in the area of left clavicle?
2-when do you think that surgical fixation is necessary for a fractured clavicle?
3-how do you manage a patient with suspected anterior shoulder dislocation? What are
the expected associated injuries that you have to look for?
4- A middle aged patient, presented with fractured proximal humerus:
A- What are the primary measures of treatment?
B- How do you classify the fracture?
C-How do you make use of the Neer’s classification in your plan of treatment?
4- What are the indications of surgical fixation in case of fractured humeral shaft?
5-what are the types of supracondylar fracture in lower end of humerus?
6- How do you treat (none operatively) a child with displaced supracondylar fracture in
lower end of humerus while you are the responsible doctor?
7-what is the commonest complication of a malunited supracondylar fracture in lower
end of humerus?
8- For a patient with a displaced fracture of olecranon, what is your primary treatment in
emergency room? What is your advice for him as a next step of a definite treatment?
9- How do you treat a dislocated elbow in the emergency room? What are the expected
immediate complications?
10-How do you define Monteggia? How many types do you know?
11- How do you make sure that the radial head is dislocated while you are reading the
lateral view of an X-ray film?
12- What is Colles' fracture? How do you treat the affected patient while you are in the
emergency room?
13-what do we mean by the following terms? Galeazzi fracture dislocation?
Smith's fracture? Barton's fracture?
14- How do you diagnose the fractured scaphoid clinically? What is the X-Ray view you
are going to request? What is the position of POP cast that is specific for that?
15- What is Bennett’s fracture? What is the position of POP cast that is you are going to
keep with?
16 What do we mean by functional position of the hand when we talk about POP cat of
the hand?