Upper Limb Fractures & Dislocations Quiz

Upper Limb Fractures & Dislocations

• Elbow dislocations comprise 10% to 25% of elbow injuries. Among upper extremity injuries in adults, elbow dislocation ranks second only to shoulder dislocations.
• Elbow dislocations are categorized as simple or complex. Simple dislocations involve only ligamentous damage without fractures. Posterior dislocations are the most common type, further classified based on the ulna's displacement direction (posterior, posteromedial, posterolateral, direct lateral).
• Complex elbow dislocations involve associated fractures, most commonly of the radial head, coronoid process of the ulna, and the olecranon. The "terrible triad" refers to a combination of these injuries. These types of dislocations can be accompanied by nerve or vascular injuries (ulnar/median neuropraxia, possible brachial artery injury). Ulnar collateral ligament tears sometimes accompany elbow dislocations.
• In children under 10, posterior elbow dislocations (PEDs) are more common, usually due to falling onto an outstretched hand or elbow.

Mechanism of Injury

• Posterior elbow dislocation mechanisms include axial compression, valgus stress, arm abduction, and forearm supination.
• Anterior elbow dislocations arise from direct force to the posterior forearm with the elbow flexed.

Treatment

• Simple posterior dislocations are reduced under sedation and immobilized in a plaster cast or splint with the elbow at 90° for 2-3 weeks. Active range-of-motion exercises are encouraged early.
• Complex or unstable dislocations, involving severe soft tissue or bony entrapment, require open reduction with or without internal fixation, and sometimes ulnar collateral ligament repair.

Reduction of Posterior Elbow Dislocation

• The palm-palm technique is a common method to reduce posterior elbow dislocations. It involves grasping the patient's hand with the examiner's hand, placing the examiner's elbow in the patient's antecubital fossa. Pushing downward on the patient's distal humerus and pulling posteriorly helps return the dislocated elbow to its normal position.

Rehabilitation Considerations

• Extensive casting and prolonged immobilization are detrimental, so avoidance is crucial.
• Initial splinting for 5-7 days is important for soft tissue rest.
• Compressive dressings and ice help control swelling.
• At 5-7 days post-injury, a hinged brace is used (30-90 degrees). Active range of motion (ROM) begins.
• Active ROM requires muscle activation to assist with stability and compression across the joint.
• Increased ROM of 10-15 degrees per week in the brace is recommended.

Physical therapy considerations

• Avoid passive ROM, valgus stress, abduction and external rotation for 2 weeks after injury:
• Avoid strengthening exercises for 2 to 4 weeks
• Elbow flexion returning first, followed by full flexion obtained by 6-12 weeks
• Further improvements in extension can take place over 3-5 months
• Early active ROM and prevention of stiffness is key to a favorable result, so early intervention is important for simple elbow dislocations.

Radial Head Fracture

• Radial head fractures result from indirect trauma, typically a fall on an outstretched arm with minimal or moderate elbow flexion (0-80 degrees).
• A direct blow to the elbow can also cause a radial head fracture but is uncommon.
• Symptoms often include lateral elbow swelling, limited ROM, and maximal tenderness over the radial head.
• Complication: 10° to 15° limitation in ROM is common.

Treatment of Radial Head Fracture

• Type I: Immobilization in plaster cast for 3 weeks
• Type II: ORIF and immobilization in plaster cast for 2 weeks
• Type III: ORIF or excision of radial head, followed by immobilization in plaster cast for 2 weeks.
• Type IV: Radial head resection or replacement.

Forearm Bone Shaft Fracture (Monteggia and Galeazzi)

• Monteggia fracture dislocation: Fracture of the upper third of the ulna with anterior displacement of the upper ulna fragment and anterior dislocation of the radius. Requires ORIF (open reduction and internal fixation) to avoid redisplacement.
• Galeazzi fracture-dislocation: Fracture of the distal third of the radius, often associated with dislocation/subluxation of the distal radioulnar joint, caused by rotational forces. Conservative treatment may result in redisplacement.

Both Bone Forearm Fracture Rehabilitation

• Phase I (0-2 weeks): Immobilization in a splint to protect surgical incisions. Sutures/staples removed. Extremity elevation. Edema control and finger exercises.
• Phase II (2-6 weeks): Splint/brace removal, progression to Active and Active-Assisted AROM of elbow, forearm, and wrist, no repetitive forearm twisting.
• Phase III (6+ weeks): Lifting/twist limitations lifted after union has been confirmed (with treatment surgeon), focus on regaining preoperative motions, and weight lifting restrictions if needed.

Distal Radial Fractures (Colles', Smith's, Barton's, Radial styloid)

• Colle's fracture: Extra-articular fracture across the distal radius, commonly occurring in falls on an outstretched hand with extended wrist. Characterized by a dinner fork deformity.

• Smith's fracture: Similar to a Colle's fracture but results from a fall on a flexed wrist. This injury is characterized by a garden spade deformity.

• Barton's fracture: An intra-articular fracture of the distal radius with volar/palmar or dorsal displacement. Requires ORIF.

• Radial Styloid Fracture: Caused by scaphoid impaction against the styloid. Treated: Non-displaced Fractures: cast immobilization, Displaced Fractures: Surgical Fixation.

Carpal Bone Fractures (Scaphoid)

• Caused by falls on the outstretched hand, resulting in extreme wrist dorsiflexion and radial side compression. Characterized by a dull ache in the radial wrist area, often mild, aggravated by pinching/gripping. Potentially swollen/bruised wrist, possible fullness in anatomical snuffbox—indicating wrist effusion.
• The radial artery supplies blood to the scaphoid. The proximal scaphoid portion has no direct blood supply.
• Fracture of the distal scaphoid pole heals in 2-3 weeks, fracture of distal scaphoid waist or proximal scaphoid pole needs 8-12 weeks of immobilization. Avoid active movement of the thumb until the fracture is radiographically healed after 6-8 weeks.
• Complications include delayed union, avascular necrosis, and osteoarthritis.

Lunate Fracture

• Result of FOOSH mechanism, with highest incidence of avascular necrosis.

• Tenderness occurs in the lunate fossa when palpated, and worsens with wrist flexion (because the lunate moves against examiner's finger in the fossa)

• Suspect lunate fracture with tenderness in lunate fossa, whether or not confirmed by radiograph.

• Treatment for the undisplaced fracture: Immobilized in a short arm cast for 4-6 weeks. Displaced requires surgical fixation.

Metacarpal Fractures (Bennett's, Boxer's Fracture)

• Bennett's fracture: Oblique base fracture of the first metacarpal, often associated with dislocation of the carpometacarpal joint.

• Management: Stable fracture = thumb spica splint; Unstable fracture = surgical fixation with percutaneous pinning.

• Boxer's fracture: Fracture of the neck of the fourth or fifth metacarpal resulting from hitting an object with a closed fist.

• Treatment: Immobilization using buddy taping to the ring finger, cast or splint. Surgery considered for significant angulation or misalignment.

Treatment Considerations for all fractures

• Reduction: Fracture reduction is maintained during splinting or casting.
• Contracture Prevention: Proper positioning to avoid contractures is important.
• Immobilization Duration: Don't immobilize longer than 3 weeks unless specific circumstances dictate.
• Uninvolved Joint Splinting: Uninvolved joints should not be immobilized in stable fractures.
• Skin Obstructions: Casts and splints should not obstruct skin creases.
• Early Active Tendon Gliding: Early active tendon gliding should be part of the treatment protocol.