Fractures & Dislocations of the Upper Limb

Fractures & Dislocations of the Upper Limb

• Elbow dislocations constitute 10% to 25% of all elbow injuries. Dislocation of the shoulder is the most common injury to the upper extremity in adults.
• Elbow dislocations are categorized into simple and complex patterns.
• Simple dislocations involve only ligament damage without bone fractures.
• Posterior dislocations are the most common type. Subtypes are further categorized by the direction of the dislocated ulna (posterior, posteromedial, posterolateral, or lateral).
• Complex dislocations involve associated fractures, such as of the radial head, coronoid process of the ulna, or olecranon. The "terrible triad" describes an elbow dislocation with injuries to the coronoid process, radial head, and posterior lateral dislocation of the elbow joint. Nerve or blood vessel injury is a possible complication.
• In children under 10, posterior dislocations are most common (PEDs).

Mechanism of Injury

• PEDs are most commonly caused by falling on an outstretched hand or elbow.
• Axial compression, valgus stress, arm abduction, and forearm supination can result in posterior dislocations.
• Anterior dislocations result from direct force to the posterior forearm with the elbow flexed (relatively rare).

Treatment

• Simple posterior dislocations are treated with closed reduction under sedation and fixation with a plaster cast or posterior splint at a 90-degree elbow angle for 2-3 weeks. Active range-of-motion exercises should also begin promptly.
• Complex or unstable dislocations, severe soft tissue injuries, or bony entrapment require open reduction with or without internal fixation and often ulnar collateral repair.

Reduction Techniques

• Palm-palm technique: Grasp patient's hand palm-to-palm, interlocked fingers. Position examiner's elbow in the patient's antecubital fossa. Apply downward pressure on the patient's distal humerus with the examiner's elbow. Pull the posteriorly dislocated elbow back into anatomical position.

Rehabilitation Considerations

• Extended casting and prolonged immobilization should be avoided to prevent post-traumatic stiffness.
• Early active range of motion (ROM) is critical for simple dislocations.
• Splinting for 5-7 days allows for soft tissue rest, while compressive dressings and ice can manage swelling.
• A hinged elbow brace (30-90 degrees) is applied from day 5-7, followed by active ROM.
• Active ROM enhances muscle activation, stability, and compression across the joint and is gradually increased (10-15 degrees per week) within the hinged brace.

Other Considerations following Elbow Dislocation

• Avoid passive ROM, valgus stress, abduction, and external rotation for up to 2 weeks after dislocation to avoid increasing swelling and/or inflammation and disrupting MCL healing leading to instability or recurrent dislocation.
• Avoid strengthening or resistive exercises during the initial healing phase.
• Strengthening exercises can resume at 6-8 weeks.
• Elbow flexion usually returns first (6-12 weeks), followed by extension (3-5 more weeks).

Radial Head Fracture

• Most radial head fractures are caused by indirect trauma (a fall on an outstretched arm).
• A direct blow to the elbow can cause a radial head fracture but is much less common.
• Falling with the arm abducted and the elbow slightly flexed (0-80 degrees) produces a valgus pronation stress and the radial head is forcibly pushed against the capitula of the humerus Typical presentations are pain, swelling at the lateral aspect of the elbow, limited ROM, and maximal tenderness over the radial head.
• Common complications that can arise are limited ROM (10-15 degrees)
• Treatment depends on the severity of the fracture. Undisplaced fractures are treated with a cast. ORIF (Open Reduction Internal Fixation) or excision and cast for more severe fractures, and possibly radial head replacement.

Forearm Bone Shaft Fractures

• Monteggia fractures involve a fracture of the upper third of the ulna with anterior displacement of the upper ulna fragment and anterior dislocation of the radius.

• Often require ORIF.

• Galeazzi fractures involve a fracture of the distal one third of the radius with dislocation or subluxation of the distal radioulnar joint.

• Often, require ORIF.

Both Bone Forearm Fracture Rehabilitation

• Phase I (weeks 0-2): Protect surgical incisions, elevate extremity, edema control, and finger ROM exercises.
• Phase II (weeks 2-6): Active and active-assisted ROM of elbow, forearm, and wrist. Avoid repetitive forearm twisting.
• Phase III (weeks 6+): Lifting and twisting restrictions may be removed, once union has been achieved. Work on regaining pre-injury motion.

Distal Radial Fractures

• Colle's fractures are a common type of distal radius fracture. They frequently occur in older people due to falling on an outstretched hand when the wrist is dorsiflexed (extended). The result is a typical "dinner fork" deformity.
• Smith's fractures involve anterior displacement of the distal fragment and are the opposite of Colles fractures (fall on a palmar-flexed wrist). A common deformity is a "garden spade" deformity.
• Barton's fractures are intra-articular fractures of the distal radius with volar (palmar) displacement, and appear similar to Smith's fractures. ORIF management is common.
• Radial styloid fractures result from compressive forces on the scaphoid against the styloid. Non-displaced fractures are managed with cast immobilization. Displaced fractures necessitate surgical fixation.

Complications

• Early complications of Colles' fractures can include radial artery injury, carpal tunnel syndrome, and extensor pollicis longus injury.
• Late complications include malunion, joint stiffness, Volkmann ischemic contracture, osteoarthritis, and Sudeck's osteodystrophy (CRPS).

Reflex Sympathetic Dystrophy (RSD)

• CRPS is a chronic pain syndrome which typically develops after an injury or surgery. Pain, swelling, and vasomotor dysfunction are common symptoms.
• The exact cause of RSD is unknown but peripheral and central mechanisms may play a role in sympathetic dysfunction.

Treatment Summary

• Treatment of fractures and dislocations focuses on restoring anatomical alignment and providing adequate stabilization and support during recovery.
• Cast immobilization, ORIF, external fixation, or a combination of these methods may be necessary to ensure complete healing.
• Physical therapy is essential to regain range of motion, muscle strength, and functional abilities.