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Upper Extremity Trauma NEAR EAST UNIVERSITY HOSPITAL ORTHOPAEDICS AND TRAUMATOLOGY DPT. Dr. Enes SARI  Topics Clavicle Fractures Shoulder Dislocations Humerus Fractures Elbow Fracture and Dislocations Forearm Fractures D...

Upper Extremity Trauma NEAR EAST UNIVERSITY HOSPITAL ORTHOPAEDICS AND TRAUMATOLOGY DPT. Dr. Enes SARI  Topics Clavicle Fractures Shoulder Dislocations Humerus Fractures Elbow Fracture and Dislocations Forearm Fractures Distal Radius Fractures 2 Normal Upper Extremity X-Ray 3 Clavicle Fractures 4  Clavicle Fractures Epidemiology – incidence clavicle fractures make up ~4% of all fractures – demographics often seen in young active patients trimodal distribution Pathophysiology – mechanism direct blow to lateral aspect of shoulder t lasfall he t r to on an outstretched arm or direct trauma is icle nte ) at c lav ion ce l end Th e ificAssociated at terna injuries yo. o lete (s 22-25 s s p –ut are rare but include com abo ipsilateral scapular fracture scapulothoracic dissociation should be considered with significantly displaced fractures rib fracture pneumothorax neurovascular injury 5  Clavicle Fractures Presentation – shoulder pain – tenting of skin Clinical Evaluation – inspect for deformity – palpate for abnormal motion – perform carefull 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 6 Clavicle Fractures 7  Clavicle Fracture Closed Treatment – sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks Operative Intervention – unstable Group II fractures (Type IIA, Type IIB, Type V) – open fxs – displaced fracture with skin tenting – subclavian artery or vein injury – floating shoulder (clavicle and scapula neck fx) – symptomatic nonunion – posteriorly displaced Group III fxs – displaced Group I (middle third) with >2cm shortening 8 Clavicle Fracture 9 Clavicle Fracture 10 Shoulder Dislocations 11  Shoulder Dislocations Epidemiology – Anterior: Most common – Posterior: uncommon, 10% think electrocutions & seizures – Inferior (Luxatio Erecta): rare hyperabduction injury 12  Shoulder Dislocations Clinical Evaluation – Examine axillary nerve deltoid function (not the sensation over lateral shoulder!) – Examine MC nerve biceps function and anterolateral forearm sensation Radiographic Evaluation – true AP shoulder – axillary lateral – scapular Y – stryker notch view 13 ? 14 ? 15  Shoulder Dislocations Anterior dislocation recurrence rate – Age 20: 80-92% – Age 30: 60% – > Age 40: 10-15% Look for concomitant injuries – Bony: Bankart lesion, Hill-Sachs lesion, glenoid fracture, greater tuberosity fracture – Soft Tissue: subscapularis tear, RCT (older pts with dislocation) – Vascular: axillary artery injury (older pts with atherosclerosis) – Nerve: axillary nerve neuropraxia 16  Shoulder Dislocations Anterior dislocation – Traumatic – Atraumatic (Congenital Laxity) 17  MATSEN Classification (Recurrent dislocation) TUBS AMBRI – Traumatic – Atraumatic – Unidirectional – Multidirectional – Bankart – Bilateral – Surgery – Rehab – Inferior capsular shift 18  Shoulder Dislocations Posterior dislocation – ADD+FLEX+IR at time of injury – electrocution and seizures cause overpull of subscapularis and latissimus dorsi – look for lightbulb sign – humeral head IR rim sign – anterior glenoid-medial humeral head >6mm Mouzopoulos sign – ‘M’ for greater and lesser tuberosity – reduce with traction and gentle anterior translation avoid ER arm  Fx 19  Shoulder Dislocations Inferior dislocations (Luxatio Erecta) – hyperabduction injury – arm presents in a flexed ‘asking a question’ posture – high rate of nerve and vascular injury – reduce with in-line traction and gentle adduction 20  Shoulder Dislocation Treatment – Nonoperative treatment Closed reduction should be performed after adequate clinical evaluation and appropriate sedation Reduction Techniques: – Traction/countertraction - Generally used with a sheet wrapped around the patient and one wrapped around the reducer. – Hippocratic technique - Effective for one person. One foot placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial traction – Stimson technique - Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be used – Milch technique - Arm is abducted and externally rotated with thumb pressure applied to the humeral head – Scapular manipulation 21  Shoulder Dislocation Treatment – Nonoperative treatment Reduction Techniques: – CHAIR METHOD 22 Shoulder Dislocation 23  Shoulder Dislocations Postreduction – post-reduction films are a MUST to confirm the position of the humeral head – pain control – immobilization for 7-10 days then begin progressive ROM Operative Indications – irreducible shoulder (soft tissue interposition) – displaced greater tuberosity fractures – glenoid rim fractures bigger than 5 mm – elective repair for younger patients 24 Proximal Humerus Fractures 25  Proximal Humerus Fractures Epidemiology – the most common fracture of the humerus – higher incidence in the elderly (osteoporosis) – more common in female gender (2x) Mechanism of Injury – most commonly a fall onto an outstretched arm from standing height (FOOSH injury) – younger patient typically present after high energy trauma such as MVA 26  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 clearly confirm an axillary nerve injury 27  Proximal Humerus Fractures Neer Classification – 4 parts greater and lesser tuberosities, humeral shaft humeral head – a part is displaced if >1 cm displacement or >45 degrees of angulation is seen 28  Proximal Humerus Fractures Treatment – minimally displaced fractures sling immobilization, early motion – 2-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 – 3-part fractures Due to disruption of opposing muscle forces, these are unstable – so closed treatment is difficult, displacement requires ORIF The lateral ascending branch – 4-part fractures in general for displacement or unstable of the anterior circumflex injuries humeral artery carries the most – ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution important blood supply of the – high rate of AVN (13-34%) humeral head and damage may lead to avascular necrosis 29 30 31 32 33 34 Humeral Shaft Fractures 35  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 36  Humeral Shaft Fractures Clinical evaluation – history and physical examination – patients typically present with pain, swelling, and deformity of the upper arm – careful NV exam important as the radial nerve is in close HOLSTEIN- proximity to the humerus and LEVIS can be injured FRACTURE !! 37  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 deg anterior angulation 30 deg varus