Lecture 8OTR_Fracture and disclocation of upper limb 2023 PDF

PHT2012 Orthopaedics Traumatology and Rheumatology Fractures & Dislocations in Upper Limb (Conservative and Surgical Management) Dr. Rufina Lau 2023 Content Overview of Fracture Shoulder fractures and dislocations Elbow and wrist fractures and dislocations Principles of physiotherapy manageme...

PHT2012 Orthopaedics Traumatology and Rheumatology Fractures & Dislocations in Upper Limb (Conservative and Surgical Management) Dr. Rufina Lau 2023 Content Overview of Fracture Shoulder fractures and dislocations Elbow and wrist fractures and dislocations Principles of physiotherapy management for fractures 2 What is fracture? Structural break in the continuity of a bone 3 Types of Fracture 4 Fracture is identified by: • Site: diaphyseal, metaphyseal, epiphyseal, intraarticular F • Extent: complete, incomplete • Configuration: transverse, oblique/ spiral, comminuted • Relationship of the fragments: undisplaced, displaces • Relationship to the environment: closed (skin intact), open (fracture penetrated through skin) • Complications: local or systemic (Magee, Ch 11, p. 351) 5 What are the signs and symptoms of a possible fracture? • What is the clinical presentation? • What would the patient tell you about their injury? • What are the risk factors associated with fracture? (who are more at risk of having a fracture?) • What would you notice when you observe (look), feel, move? 6 Fracture Healing • Primary vs secondary healing • Primary healing (clinically rare) • Regeneration • Healing by bone remodelling but no external callus formation • Secondary healing • Tissue repair • Stages: haemoatoma formation > inflammation > callus formation > consolidation > remodelling When does callus usually form? Why does it matter? 7 Adapted from JBJS 8 Principles of Fracture Fixation To restore anatomical relationship To preserve blood supply https://surgeryreference.aofoundation.org/orthopedictrauma/adult-trauma To provide absolute or relative stability To facilitate early and safe mobilization https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma 12 Type of Fracture Fixation Adatped from https://orthoinfo.aaos.org/en/treatment/internal-fixation-for-fractures/ 13 What are the types of abnormal healing? What are the possible complications of fractures? 14 Shoulder Fractures & Dislocations Functional anatomy of shoulder Common shoulder disorders • Fractures • Subluxation and dislocation • Chronic shoulder instabilities 15 Anatomy: Bones 2 1 3 4 16 Anatomy: Joints B C A D 18 Anatomy: Glenohumeral Joint • Glenoid fossa • Ratio of articular surface of the head of humerus to glenoid fossa = 4:1 • Glenoid labrum • A cuff of fibrocartilage attached to the rim of the glenoid fossa 24 Acromion Coracoid Superior labrum anterior to posterior (SLAP) lesion 25 Bankart lesion (inferior/ anterior lesion) Anatomy: Joint Capsule • Scapula attachment of capsule • Glenoid rim • Glenoid labrum • Humeral attachment of capsule • Superiorly, anteriorly and laterally to the anatomical neck of humerus • Inferiorly to the surgical neck of the humerus • The gap between the greater and lesser tubercles of the humerus is bridged by a thickening in the capsule known as the transverse ____________________ ligament 27 Anatomy: Bursas • Lies between rotator cuff muscle and surrounding muscles • e.g. subacromial, subcoracoid and subscapular bursas 29 Anatomy: Ligaments • Glenohumeral • Superior, middle and inferior • Strengthen the anterior and inferior surfaces of the joint capsule IGHL • ___________________ligament primary restraint to anterior dislocation • Coracohumeral • Coracoacromial • Acromioclavicular 30 Anatomy: Muscles • Rotator Cuff – S.I.T.S subscapularis • __________ : medial rotator of the shoulder infraspinatus • ___________: lateral rotator of the shoulder teres minor • ___________: lateral rotator of the shoulder supraspinatus • ___________: initiates abduction of the shoulder (first 20 degrees) • Surrounding musculature • Long head of biceps, deltoid, pectoralis major, serratus anterior, latissimus dorsi, trapezius 32 Anatomy: Nerve & Blood Supply • Nerve supply C5-T1 • Brachial Plexus ________ Level • Blood supply to the head of humerus • Subclavian Artery • Axillary Artery • Brachial Artery 34 GHJ Stability • At rest and without active muscle contraction • Force of gravity pulling on the humeral head creating a negative intraarticular pressure in an intact capsule • Active elevation • Dynamic stabilisation of shoulder muscles • At extremes of movement end of rom • E.g. cocking phase of throwing (Sh ER & Horizontal Abd at EROM ) • Capsuloligamentous complex tightened to avoid excessive translation of the humeral head in the glenoid cavity 36 Shoulder Assessment • Methods: H.O.P.S. • History • Observation • Palpation (Movement) • Special Tests 37 • Anatomical structures • Bone • Ligament • Muscles • Nerves • Blood vessels Fractures of Shoulder Region • Clavicle # • Incidence: 4% of all fractures • Humerus # • Proximal: aging people ~ 5% of all fractures • Shaft: 3% of all fractures • Epiphyseal: children • May be associated with pathological fracture or osteoporosis in elderly 38 Clavicle Fractures • Aetiology • Mostly caused by a fall on lateral aspect of shoulder, with outstretched arm or tip of shoulder • Direct impact • Common in sports injuries • Signs and Symptoms • Symptoms & signs of fractures • Subcutaneous lump 39 40 Clavicle Fractures Elevation of proximal segment by SCM _____________________ ______________ unable to hold up humerus 41 ________________ pulls the distal fragment medially Clavicle Fractures Elevation of proximal segment by Sternocleidomastoid muscle Trapezius muscle unable to hold up humerus 42 Pectoralis major muscle pulls the distal fragment medially Clavicle Fractures • Craig’s Classification • Group I: midshaft # (76%) • Group II: lateral end # (21%) • Group III: medial # (3%) 43 Midshaft # Lateral end # Medical Management of Clavicle Fractures • Goals • Alignment & stability • Methods • Sling immobilization • Open reduction and internal fixation • Expected time of bone healing • 6 – 12 weeks 44 PT Management of Clavicle Fractures • Goals • Restore shoulder ROM • Pendulum ex • Improve muscle strength • Isometric → isotonic • Shoulder muscles • Rotator cuff muscles • Maintenance ex for elbow and hand • Weight bearing • 6 weeks, if # radiographically healed 45 Humeral Fractures - Shaft • Aetiology • Indirect trauma → Fall on to an outstretched abducted arm • Direct blow → transverse or comminuted # • Compressive force → proximal or distal # • Torsional force →spiral # e.g. a fall on hand with twisting force • Pathological # may occur with minimal trauma • Signs and Symptoms • Probable deformity • May be associated with radial nerve _________________ causing wrist drop and inability to supinate the wrist (20%) 46 AO/OTA Classification – Humerus Shaft Alphanumeric fracture classification e.g. simple fracture shaft of humerus = Type 12- A1 1 – humerus 2 – shaft A – simple fracture subgroup 1 – Subgroups further specify fracture geometry e.g. spiral fracture line AO Foundation www.aofoundation.org 48 Humeral Fractures-Proximal • Represent 5% of all fracture • Risk factors: • Osteoporosis • Advancing age • Aetiology • • • • 49 Fall on outstretched arm (> 60 y.o.) Direct blow (high energy trauma especially young patients) Pathological May be associated with shoulder dislocation Humeral Fractures-Proximal • Signs and Symptoms • • • • ~ 15-20% have significant displacement/ angulation Often mistaken for a shoulder dislocation Possible severe hemorrhaging May produce neurovascular injury • Nerve injuries: brachial plexus, axillary nerve, suprascapular, radial and musculocutaneous nerve • Vascular injuries: axillary and brachial artery 50 Neer’s Classification (Number of Displaced Fragments) 51 AO/OTA Classificati on – Proximal Humerus AO Foundation www.aofoundation.org 52 Medical Management of Humeral Fractures • Goals • To restore alignment & stability • Acceptable alignment • Anterior angulation < 20 degrees, varus angulation < 30 degrees, and shortening < 30mm • Methods • Non-operative vs operative (open, arthroscopic, suture & screw) • Expected time of bone healing • 8 – 12 weeks 53 Brace Management Brace with collar and cuff 54 Shoulder abduction pillow to protect against varus tendency Operative Management • Indications for operative management • • • • presence of associated multiple injuries open or segmental fracture associated nerve or vascular injuries failed conservative treatment (non-union, inadequate reduction) • Types of operative treatments • • • • 55 Intramedullary nail Plate fixation External fixation Hemiarthroplasty PT Management of Humeral Fractures • Goals - early remobilisation of UL! • Active assisted → active → passive when fracture is stable • For GT # with conservative Rx → passive ROM (avoid ER/Abd) after immobilization to prevent displacement • Progressive muscle strengthening • Pectorals, upper and middle trapezius and deltoid • Rotator cuff muscles • Biceps and triceps • PT Rx and splinting to maintain hand functions and prevent contractures with associated radial nerve palsy injury 56 PT Management of Humeral Fractures • Expected duration of rehab • 12-16 weeks • Weight bearing • depending on quality of bone, # fixation, size of patient, compliance and intensity of loading • 4-6 weeks when callus is visible • Progressive strenuous use and weight bearing 57 Subluxations & Dislocations • Epidemiology • Accounts for up to 50% of all dislocations • Only 1-4% are posterior, > 95% anterior • Acute vs. chronic shoulder instability • Classifications: TUBS and AMBRI 58 TUBS or “Torn Loose” ▪ ▪ ▪ ▪ Traumatic aetiology Unidirectional instability Bankart lesion is the pathology Surgery is needed AMBRI or “Born Loose” ▪ ▪ ▪ ▪ ▪ 59 Atraumatic: minor trauma Multidirectional instability Bilateral affected Rehabilitation is the treatment Inferior capsular shift procedure Squaring of shoulder Anterior Dislocation • Aetiology • direct impact on posterolateral or posterior aspect of shoulder • forced abduction and ER • Signs and Symptoms • flattened deltoid contour • humeral head in the axilla • arm carried in slight abduction & ER • Radiography • X-ray, CT, MRI 60 Hill-Sachs Lesion • A cortical depression in the posterosuperior part of the humeral head which resulted from repeated impact with the anteroinferior glenoid rim. • Specific sign of anterior dislocation The humeral head overlies the anteriorinferior glenoid rim ( the point of impaction) AP View with Sh IR 61 AP View Occurs in 35% to 40% of anterior dislocations and in up to 80 % of recurrent dislocations 62 Associated Injuries with Anterior Dislocation • Bankart lesion • Presence in >90% young patients • Anterior capsulolabral tears, in which the glenoid labrum and shoulder capsule become detached from the glenoid process • Bankart fracture • Sometimes • Avulsion fracture of the anterior inferior margin of the glenoid process • Rotator cuff disruption • 30% of patients > 40 years of age • Unrepaired – cause post-traumatic anterior shoulder instability and recurrent dislocation 63 Associated Injuries with Anterior Dislocation • Nerve injury • Most common: axillary nerve • Occasionally: radial nerve, musculocutaneous nerve, median nerve or ulnar nerve • Rarely: infra-clavicular brachial plexus palsy • Vascular injury • Axillary artery • Fracture-dislocation • Associated fracture of proximal humerus • Greater tuberosity may be sheared off during dislocation 64 Posterior Dislocation • Aetiology • Forced adduction and IR • Fall on extended and internally rotated arm • May be associated with epileptic seizures or electrocution • Signs and Symptoms • Arm held in adduction and internal rotation • Head of humerus may be seen posteriorly • Radiography • X-ray, CT, MRI 65 Radiographic Features of Posterior Dislocation • The normal overlap of the humeral head and glenoid is not present • Sclerotic lines representing fractures of the anterior humeral head caused by impaction with the posterior glenoid • Rim sign • Reverse Hill-Sachs Lesion (Trough Sign) • Light bulb sign 66 AP view Light Bulb Sign 67 Associated Injuries with Posterior Dislocation • Reverse Hill-Sachs Lesion -compression fracture of anteromedial humeral head • Fracture of humeral neck • Fracture of posterior glenoid rim • Avulsion fracture of lesser tuberosity • Isolated fractures of the lesser tuberosity should raise suspicion of an associated posterior dislocation AP view 68 Position of an acute posterior shoulder dislocation Post-reduction with large reverse Hill-Sachs lesion Osteochondral transplant and subscapularis transfer (Paul et al, 2011) 69 Medical Management of Shoulder Dislocation • Goal: reduction • Reduced by traction under sedation • Methods • Immobilisation • with arm sling/ shoulder immobiliser (2-5 weeks) • with external rotation brace (3-5 weeks): better position for healing of Bankart lesion associated with anterior dislocation? • with airplane type splint (3-6 weeks): shoulder widely abducted and externally rotated for better healing of posterior capsule in shortest position with posterior dislocation 70 Medical Management of Shoulder Dislocation • Methods (cont’d) • Surgical treatment (open vs. minimal invasive arthroscopic shoulder surgery) • Mx for 1st dislocation may influence rate of recurrence • Extremely high risk of recurrence (82-90%) of anterior dislocation for young patients (<20 y.o.) • Post-surgery recurrence of anterior dislocation ~ 5% 71 PT Management of Shoulder Dislocation • After discard of sling/brace • Regain ROM • Avoid combined abduction and lateral rotation for > 3 weeks • Strengthen muscles • Proprioceptive and plyometric exercises • After surgical procedures • ? AROM restriction at early phase • Discuss with surgeons for management plan 72 Chronic Shoulder Instabilities • Aetiology • Atraumatic, congenital, and neuromuscular • Classification • Group 1: anterior • Group 2: posterior • Group 3: global • Clinical assessment • Physical examination: instability tests • X-ray • CT / MRI : stabilizers injuries 73 Shoulder Instability Tests • Anterior instability tests • • • • Load and shift test Anterior drawer test Apprehension (Crank) test Fulcrum test • Posterior instability tests • • • • • Load and shift test Posterior drawer test Posterior apprehension test Push and pull test Jerk test • Multidirectional instability • Sulcus sign 74 Assess the magnitude of translation Management of Chronic Shoulder Instabilities • Conservative Mx • Shoulder harness • Structured rehab program for strengthening stabilizers and improving proprioception • Surgical Mx • Repair lesions • Inferior capsular shift Superior shift of inferior flap and inferior shift of the superior flap 75 Elbow and Wrist Fractures & Dislocations Functional anatomy of elbow/ wrist Common elbow/ wrist disorders • Fractures • Subluxation and dislocation 76 Anatomy: Bone & Joints • Elbow is a hinge joint • Made from articulations of 1. Humerus • Medial condyle – ulnar collateral ligament and flexor pronators • Lateral epicondyle – supinator and wrist/ fingers extensors 2. Radius • Radial head - articulates with capitellum • Connected to ulnar with annular ligament 3. Ulna • Responsible to most joint bony stability • Articulation of elbow 77 Anatomy: Bone & Joints • 3 joints enclosed in 1 joint capsule 1. Ulnohumeral (olecranon-trochlea) 2. Radiohumeral (capitellum-radial head) 3. Radioulnar • Normal alignment • 2 epicondyles and apex of olecranon for an equilateral triangle in 90° flex and straight line in extension • Carry angle ~10-15° valgus in males (more in females) What are the movement(s) allowed in each joint? 78 Anatomy: Ligaments • Annular ligament – encircles head of radius • Radial collateral – lateral epicondyle to annular ligament • Interosseous ligament – medial borders of radius & ulna • Ulnar collateral ligaments (3 bands) • Anterior – primary stabilizer from 20° – 120°degrees and controls most valgus force • Posterior – secondary stabilizer in 30°flexion • Transverse – thickening of joint capsule, minimal role for joint stability 79 Anatomy: Fibrous Capsule of Elbow • This surrounds the joint attaching • proximally • around the lower end of the humerus to both lateral and medial epicondyles • On a line above the coronoid and radial fossae anteriorly, on a line above the olecranon fossa posteriorly • Distally • to the edge of the olecranon • posteriorly, around the upper edge of the annular ligament, which surrounds the head of the radius, and to the anterior, medial and lateral edges of the coronoid process anteriorly • The capsule is made up of circular, vertical and oblique fibers 80 Anatomy: Muscles • Elbow flexors • Brachialis, biceps brachii, brachioradialis • Elbow extensors • Triceps brachii, anconeus • Wrist and finger extensors/ spinators • Attached to lateral epicondyle • Wrist and finger flexors and pronators • Attached to medial epicondyle 81 Anatomy: Nerves • • • • Median nerve (C5-T1) Radial nerve (C6-8) Musculocutaneous nerve (C5-7) Ulnar nerve (C8-11) • Ulnar nerve travel along triceps and passes through cubital tunnel under medial epicondyle next to ulnar collateral ligament • Lack of retinaculum to allow subluxation • Tensed and flattened with elbow flexion • Stretched by 5mm with every 45° of flexion 82 Fractures of Lower End of Radius • Colles’ fracture • Distal fragment displaced dorsally - “dinner fork” deformity • Usually caused by fall on outstretched hand with wrist extended • Commonly associated with fracture ulnar styloid process • Smith’s fracture (Reversed Colles’ fracture) • Distal fragment displaced volarly • Caused by a fall on the back of the hand • Barton’s fracture • Distal fragment displaced to volar aspect with intraarticular involvement 83 https://litfl.com/colles-fracture/ 84 Fractures of Lower End of Radius Common in elderly population Prevalence female > male Can involve DURJ Common management: external fixation vs POP/ dynacast (when to use?) • Possible complications • • • • • • • • • 85 Complications related to surgery and anesthesia Unstable reduction Median/ ulnar nerve stretch Compartment syndrome Late complications: malunion, non-union, rupture of extensor pollicis tendon, frozen shoulder, carpel tunnel syndrome, Sudeck’s osteodystrophy Elbow Dislocation • Most common dislocation site in children, 2nd most common in adult • Mechanism of injury Anterior or posterior? • Posterior (most common) caused by fall on extended arm (elbow hyperextension, arm abduction and forearm supination) • Anterior caused by fall on flexed elbow • Possible structures involved • Posterior dislocation of ulnohumeral joint • May associated with radial head/ coronoid process or olecranon process # • Associated soft tissue injuries of joint capsule, ligament, nerve (which ones?) and/or blood vessels ulnar , median (which one?) ischemic contracture • 50% associated with fracture 86 Adapted from https://radiopaedia.org/articles/elbow-dislocation Clinical Presentation of Elbow Dislocation • Pain and dysfunction • Physical examination • Patient supports forearm with elbow slightly flexed • Palpation: olecranon posterior to epicondyle, potential vascular and nerve injury Adapted from https://coreem.net/core/elbow-dislocation/ 88 Management of Elbow Dislocation • Usually closed reduction and immobilization at with elbow 90 F (~ 2/52) supported with collar and cuff • Rehabilitation goals • • • • Oedema control Pain control Prevent muscle atrophy Maintain ROM • Possible complications • • • • 89 Joint stiffness myositis ossificans (heterotropic ossification) Unreduced or recurrent dislocation Osteoarthritis Key References & Further Reading • Warwick, Blom, A., & Whitehouse, M. (2022). Apley & Solomon's concise system of orthopaedics and trauma (Fifth edition..). CRC Press, Taylor & Francis Group. • Kisner, & Colby, L. A. (2012). Therapeutic exercise foundations and techniques (6th ed..). F.A. Davis. Ch 11 & 12 • Donatelli. (2004). Physical therapy of the shoulder (Fourth ed..). Churchill Livingstone.Fusco A, Foglia A, Musarra F and Testa M. The shoulder in sport: management, rehabilitation and prevention. Milan; 2008.\ Online resources • Radiopaedia https://radiopaedia.org/ • AO Foundation Surgery Reference https://surgeryreference.aofoundation.org/ • IOF Fragility Fractures https://www.osteoporosis.foundation/healthprofessionals/fragility-fractures/treatment 103