UPPER & LOWER EXTREMITY TRAUMA
Çağatay Uluçay
Yeditepe University Faculty of Medicine
Department of Orthopaedics & Traumatology
Topics
Clavicle
Shoulder Dislocation
Humerus
Elbow
Forearm
Distal Radius
Schaphoid
Metacarp
Phalanx
Clavicle Fractures
Clavicle Fractures
Mechanism
Fall onto shoulder (87%)
Direct blow (7%)
Fall onto outstretched hand
(6%)
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 45deg A/P oblique X-rays
 Traction pictures may be used as well
Clavicle Fracture
Closed Treatment
Sling or 8 bandage 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
Cosmetic reasons, uncontrolled deformity
Nonunion
Clavicle Fractures
Associated Injuries
Brachial Plexus Injuries
Contusions most common, penetrating (rare)
Vascular Injury
Rib Fractures
Scapula Fractures
Pneumothorax
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
 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%)
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
Traction radiographs 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 spint 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 fractures,
associated vascular or nerve
injuries
Most commonly treated with
plates and screws but also 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
Supracondylar humerus fracture
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, altercations, and
falls
Mechanism of Injury
Commonly associated with mva, direct trauma
missile projectiles, 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
Distal Radius Fractures
Distal Radius Fractures
Epidemiology
Most common fractures of the upper extremity
Common in younger and older patients. Usually a result of
direct trauma such as fall on out stretched hand
Increasing incidence due to aging population
Mechanism of Injury
Most commonly a fall on an outstretched extremity with
the wrist in dorsiflexion
High energy injuries may result in significantly displaced,
highly unstable fractures
Distal Radius Fractures
Clinical Evaluation
Patients typically present with gross deformity of
the wrist with variable displacement of the hand
in relation to the wrist. Typically swollen with
painful ROM
Ipsilateral shoulder and elbow must be examined
NV exam including specifically median nerve for
acute carpal tunnel compression syndrome
Radiographic Evaluation
3 view of the wrist including AP, Lat, and
Oblique
Normal Relationships
23 Deg
11 Deg
11 mm
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
Colles fracture
Smith fracture
Barton fracture
Galeazzi fracture
Montegia fracture
Distal Radius Fractures
Treatment
Displaced fractures require and attempt at reduction.
Hematoma block-10ccs of lidocaine or a mix of lidocaine and
marcaine in the fracture site
Hang the wrist in fingertraps with a traction weight
Reproduce the fracture mechanism and reduce the fracture
Place in sugar tong splint
Operative Management
For the treatment of intraarticular, unstable, malreduced
fractures.
As always, open fractures must go to the OR.
Schaphoid Fracture
Metacarpal Fractures
Boxers Fracture
First Metacarpal Fractures
I- Bennett’s fracture
II-Rolando’s fractures
III-IV Extra articuler
fractures
Bennett’s Fracture
Rolando Fracture
Phalanx Fractures
Mallet Finger
Hip fractures
 High energy forces
 falls
 car accidents
 pelvic (side impacts)

 high mortality rates
Femoral neck fractures
 > 250,000
 women 3 times likely to get
fracture
Hip fractures
 Young people: high energy
impacts
 Mechanism
 direct impact
 lateral rotation of leg
 Stress fractures femur
 Dynamic models of falls
impact forces 3-10 kN
INTERTROCHANTERIC
FRACTURE
POST OPERATIVE
X-Ray
ACETABULAR
FRACTURE
CT SCAN PELVIS
Thigh injuries
 Three muscular compartments
 anterior
 medial
 posterior
Ant.
 Quadriceps contusion
 blunt trauma
 extensive hematoma
 swelling
 increase muscle weight
 loss of strength
 Myositis Ossificans
Post.
Medial
Femoral fractures
 High energy trauma
 car & motorcycle and or
pedestrian accidents (78%)
 Classified by location,
configuration and level of
comminution
 Dangerous near epiphyseal plates
FRACTURED LT. FEMUR
AP
LAT
Femoral fractures
 Gunshot fractures affected by
bullet diameter, velocity,
weight, shape, and tumbling
 Low-velocity
 splintering
 High velocity or close range
shotgun blasts
 More soft tissue damage
 Torsional loading
 young skiers
 high skill level (risk)
Hamstring
 Excessive tension applied to
the muscle
 eccentric action
 Predisposing factors:
 fatigue
 muscle imbalance
 lack of flexibility
 lack of warm up
 Biarticular muscles
 bicep femoris
 MTJ
PATELLA FRACTURE
NORMAL
QUADRACEPS TENDON INJURY
Patella tendon injury
NORMAL
ANTERIOR CRUCIATE LIGAMENT INJURY
Normal
POST OPERATIVE LIGAMENT REPAIR
POSTERIOR CRUCIATE
LIGAMENT INJURY
normal
AP TIBIA & FIBULA
(LOWER LEG)
Lower Leg Injuries
 Four muscle compartments
 Anterior
 lateral
 sup and deep posterior
 Compartment Syndrome
 fluid accumulation as a result of




acute or chronic exertion
can affect vascular and neural
function
Ischemia
Fascia adaptations
Fasciotomy
Pressure
100
80
60
40
20
0
normal
resting
exercise
Lower Leg Injuries
 Tibial stress syndrome:
Inflammatory reaction of the
deep fascia
 Mechanism
 chronic overload
 can lead to periostitis
 common in runners
 multifactor
Lower leg injuries
 Stress reaction: bone with

evidence of remodeling but
without actual fracture
Stress fracture
 50% occur on the tibia
 runners: middle and distal
third
 jumpers: proximal fractures
 dancers midshaft
Lower leg injuries
 High energy fractures
 car accidents: direct impact
 skiing: torsional and boot
fractures
 Baseball bats
Foot & Ankle injuries
 Most complex areas in the human

body due to large number of
muscle, ligaments and bones
Ligaments
 deltoid: eversion
 ATFL: restrict inversion
 CFL
 PTFL
 26 bones
 Achilles tendon
Foot & Ankle injuries
 Arches
 Longitudinal
 medial
 lateral
 Transverse
 Absorb and distribute loads
during weight bearing
 Supported by bones, muscles,
plantar ligaments and plantar
fascia
Foot & Ankle injuries
 Achilles tendon: largest and
stronger
 forces = 10 times BW
 Injuries
 peritenitis
 bursitis
 multifactorial etiology
 training
 malaligments
 trauma
 footwear
Foot & Ankle injuries
 Tendon rupture
 degeneration
 Men 30-40 years
 Blood type (O)
 Mechanism
 sudden dorsiflexion
 rapid change in direction
 excess tension on taut tendon
 taut tendon struck by object
Foot & Ankle injuries
 Plantar Fasciitis: inflammation of


the plantar fascia involving
microtears of partial rupture of the
fascia
Repetitive loading compressing the
plantar fascia (1.3- 2.9 BW)
Factors
 lack of flexibility
 lack of ankle strength
 overtraining
 poor mechanics
 leg length discrepancies
 over pronation
Foot & Ankle injuries
 Ankle sprains: most common
injuries
 Irregular talus & stability
 plantar flexion: unstable
 Involve ankle and subtalar joint
 85% inversion sprain
(supination sprains)
 ATFL-CFL-PTFL
 Sometime deltoid (taut in
plantar flexion)
Fractures through the medial
and lateral malleoli
Foot & Ankle injuries
 Eversion sprains (pronation)
less common
 Fractures malleolus
 Deltoid ligament
 Tibia and fibula separation
(high forces)
Foot & Ankle injuries
 Lisfranc
 Low energy: tripping or



bumping
High: falls, crashes, object
drop
Axial loading foot in extreme
plantar flexion or dorsiflexion
Violent twisting
 Turf toe
 damage to capsule and
ligaments of 1st MP joint
CALCANEAL
FRACTURE
PATIENT FELL OFF OF A LADDER
Metatarsal Fractures and Dislocation