Fractures & Dislocations Of The Upper Limb (2) PDF

Fractures & Dislocations Of The Upper Limb (2) By Dina Othman Shokri  Elbow dislocation Elbow dislocations constitute 10% to 25% of all injuries to the elbow. Among injuries to the upper extremity, dislocation of...

Fractures & Dislocations Of The Upper Limb (2) By Dina Othman Shokri  Elbow dislocation Elbow dislocations constitute 10% to 25% of all injuries to the elbow. Among injuries to the upper extremity, dislocation of the elbow is second only to dislocation of the shoulder in adults. Elbow dislocations can be broken up into simple and complex patterns. Simple dislocations of the elbow are those in which the injury is only ligamentous without any associated fractures. It can be classified as anterior or posterior. Posterior dislocation is by far the most common and is further subdivided by the direction of the dislocated ulna (posterior, posteromedial, posterolateral, direct lateral). X-ray of right elbow dislocated and clinical appearance  Posterior elbow dislocation (PED) Anterior elbow dislocation ,radius occurs when the radius and ulna are and ulna are driven anterior to forcefully driven posterior to the humerus. humerus Complex elbow dislocations are elbow dislocations that include associated fractures. The most common associated fractures include the radial head, coronoid process of the ulna, and the olecranon. The “terrible triad” elbow dislocation commonly mentioned is an elbow dislocation with injuries to the coronoid process, radial head, and posterior lateral dislocation of the elbow joint. It may be associated with nerveovascular injury as ulnar/median neuropraxia, possible brachial artery Injury. Sometimes elbow dislocation are accompanied by ulnar collateral ligament tear.  Mechanism of injury In children under 10 years, PEDs are the most common type of joint dislocation. Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the olecranon from the trochlea. Posterior dislocation following axial compression, valgus stress, arm abduction, and forearm supination. Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexed, it is rarely occurred.  TREATMENT Simple posterior dislocation: Closed reduction under sedation, fixation in plaster cast or posterior splint with the elbow at 90 degrees for 2-3 weeks. Active range of motion exercise should be start early as much as possible. Complex or unstable elbow dislocation, severe soft tissue injuries or bony entrapment need open reduction with or without internal fixation and usually require ulnar collateral repair.  Reduction of Posterior Elbow Dislocation Palm-palm technique: Grasp pt’s hand with palm to palm and fingers interlocked. Place examiner’s elbow in patient’s ante cubital fossa, Distract dislocation by pushing downward on patient’s distal humerus with examiner’s elbow Pull posteriorly dislocated elbow back into anatomic position.  Rehabilitation considerations Most agree that extended casting and prolonged immobilization lead to elbow post-traumatic stiffness and should be avoided. For simple elbow dislocations, early active ROM is the key to preventing post-traumatic stiffness and obtaining a favorable result. The elbow is splinted for 5 to 7 days to allow soft tissue rest. Soft tissue swelling can be controlled with compressive dressings and application of ice. Beginning at day 5 to 7, a hinged elbow brace from 30 to 90 degrees is applied and active ROM is initiated. Active ROM requires muscle activation and assists with elbow stability and compression across the joint. ROM is increased in the hinged elbow brace 10 to 15 degrees per week. Up to 2 week the following should be avoided (Passive ROM should be avoided because it increases swelling and inflammation, Valgus stress to the elbow should be avoided because it may disrupt healing of the MCL and lead to instability or recurrent dislocation, avoid abduction and external rotation). Forced terminal extension should be avoided. During this time, no strengthening or resistive exercises should be prescribed because this may place tension on the healing ligamentous structures. At 6 to 8 weeks, strengthening can begin Elbow flexion returns first, with full flexion obtained by 6 to 12 weeks. Extension returns more slowly and may continue to improve for 3 to 5 months.  Radial Head Fracture Radial head fractures usually occur as a result of indirect trauma, with most resulting from a fall on an abducted arm with minimal or moderate flexion of the elbow joint (0-80 degrees). This results in valgus pronation stress with the radial head forcibly pushed against the capitalism of the humerus. In practice, the history is often a fall onto an outstretched arm. A direct blow to the elbow can cause a radial head fracture but is uncommon. May occur in elbow dislocation, Swelling at lateral aspect. Limited ROM, maximal tenderness over radial head. Most common complication: 10º to 15º limit to ROM. X ray for stable radius head fr FIGURE 14.12 The Mason classification of radial head fractures. Type I—minimally displaced fractures (2mm of displacement. Type III—complete articular fractures with severe comminution. Type IV—radial head fracture associated with an elbow dislocation. (Reproduced with permission from Morrey BF. The Elbow and its Disorders. Philadelphia: W.B. Saunders Company; 1993.)  Treatment 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, immobilization in plaster cast for 2 weeks Type IV: radial head resection or replacement. Physical therapy guide No passive movement should be given to the elbow or radio ulnar joint for 14 to 21 days at least to decrease liability for myositis osificans. active and active-assisted ROM exercises start early.  Forearm bone shaft fracture Monteggia fracture and Galeazzi fracture-dislocation  MoNtegia fracture dislocation It is a fracture of the upper third of the ulna with anterior displacement of the upper fragment of the ulna and anterior dislocation of the radius. In short, Monteggia’s fracture is the proximal ulnar fracture with superior radio-ulnar joint dislocation It requires ORIF or it will redisplace  Galeazzi fracture-dislocation It is a fracture of the distal 1/3rd of the radius with dislocation or subluxation of the inferior radioulnar joint. It is due to rotational force causing swelling of the lower forearm; prominent head of ulna; and ulnar nerve injury. Like Montegia fracture if treated conservatively it will redisplaye This fracture appeared in acceptable Fracture redisplaced in POP. This required position after reduction and POP ORIF Galeazzi Fracture Both bone forearm fracture rehabilitation Phase I: (weeks 0–2) Patient is placed into a splint and surgical incisions are protected Sutures or staples are removed at week two. Elevation of extremity encouraged Edema control and ROM of fingers Phase II: (weeks 2–6) Active and active-assisted ROM of elbow, forearm, and wrist No repetitive forearm twisting Phase III: (weeks 6 and beyond) Lifting and twisting restrictions lifted once union has been Achieved Work on regaining preoperative motion if not already achieved. It is crucial to communicate with the treating surgeon regarding When union has been achieved and when restrictions may be removed or surgeon preference regarding weight lifting limits despite lack of full union.  Distal Radial Fractures Colle’s fracture Smith fracture Barton’s fracture= volar and dorsal Radial Styloid Fracture (Chauffeur Fracture).  Colle’s fracture Extra-Articular: The major fracture line runs transversely across the distal radius, usually about 2 cm proximal to the radiocarpal joint. This is one of the most common of all fractures. It affects primarily older people. Women are afflicted more often than men because of the prevalence of osteoporosis, especially in older women. It results from a fall on dorsi flexed (extended) wrist, typical deformity: Dinner Fork The momentum of the body weight causes the distal fragment to displace radially and rotate in a supinatory direction with respect to the proximal bone end. The momentum that results in radial displacement may also cause a sprain of the ulnar collateral ligament and an avulsion fracture of the ulnar styloid process. Because this metaphyseal area of bone is typically osteoporotic, the compression force often results in comminution and impaction of the distal fragment.  Complications Complications of Colles fracture: Early complications of Colles fracture are Radial artery injury Carpal tunnel syndrome Extensor pollicis longus injury Late complications of Colles fracture are Malunion Joint stiffness Volkman ischemic contracture Osteoarthritis Sudeck's osteodystrophy (CRPS: Complex regional pain syndrome) Malunion: A Colles' fracture rarely heals without some residual malalignment. The radius invariably ends up foreshortened such that the radial styloid process no longer extends beyond the ulnar styloid process. The distal end of the radius also tends to be angulated and displaced dorsally. The malalignment described above will result in a permanent loss of full wrist flexion and ulnar deviation. In addition, there may be some residual mal alignment of the distal fragment toward supination, resulting in a loss of pronation. The distal fragment may also heal when displaced radially, but this would have little effect on motion.  Reflex sympathetic dystrophy syndrome (Sudecks atrophy) Complex regional pain syndrome (CRPS) is a form of chronic pain that usually affects an arm or a leg. Complex regional pain syndrome (CRPS) typically develops after an injury, a surgery, a stroke or a heart attack. The pain is out of proportion to the severity of the initial injury. Type 1 complex regional pain syndrome (CRPS 1), formerly known as reflex sympathetic dystrophy (RSD), it is a clinical syndrome of variable course and unknown cause characterized by pain, swelling, and vasomotor dysfunction of an extremity. CRPS 1 may also develop in the absence of an identifiable precipitating event. the patho-physiology of RSDS is not well understood. It has been postulated that both peripheral and central mechanisms may lead to sympathetic dysfunction. Its clinical symptoms are intense prolonged pain, pitting edema, tenderness, change skin color with shiny discoloration, vasomotor dysfunction of the extremity and restricted movements. Treatment of the patients depends on early recognition, early intervention of physical therapy besides the anti-inflammatory agents and nerve blocks. The physical therapy for CRPS: concentrate on pain and edema control, TENS ,active exercises of upper limb, auto passive exercises to regain the normal range, weight bearing exercises, and functional activities of upper limb as well and aquatic therapy, mirror therapy ,desensitization. Mirror therapy or mirror visual feedback, mirror therapy is where both hands are placed into a box with a mirror separating the two compartments and, whilst moving both hands, the patient watches the reflection of the unaffected hand in the mirror. Desensitization consist of giving stimuli of different fabrics, different pressures (light or deep), vibration, tapping, heat or cold.  Treatment An undisplaced fracture may be treated with a cast alone. The cast is applied with the distal fragment in slight palmar flexion and ulnar deviation which called colles cast. A fracture with mild angulation and displacement may require closed reduction. Significant angulation and deformity may require an open reduction and internal fixation or external fixation.  Physical therapy guide One of the primary focuses in early rehab is to limit pain and the amount of edema present in the wrist and hand region. Emphasize motion at the shoulder, elbow, and fingers during all phases of rehab. The focus in the beginning of rehabilitation is to mobilize the wrist, which is indicated approximately 7-8 weeks post fracture. If the fracture is managed using an internal fixation device, early mobilization can begin approximately 1 week after surgery. Regain range of motion (ROM) at the wrist with passive ROM and progressing to active ROM. Active and active assisted wrist exercises as much as range as possible specially extension and radial deviation. In the next phase of rehabilitation to focus on increasing ROM and beginning strengthening exercises. For surgically treated wrist, the majority of ROM should be regained between 6 to 8 weeks post-op. During this phase, progressive stretching can begin to increase available ROM. The two most common stretches are bringing the wrist into extension or flexion. If the patient is unable to tolerate a slow, prolonged stretch, shorter stretches of 10 seconds are performed for 10 repetitions.  Smith Fracture Smith fracture also called reserved colles fracture or a Goyrand fracture. in which transverse fracture occurs at the lower end of radius 2.5 cm proximal of the articular surface with anterior displacement of distal fragment of radius (Palmar displacement). Almost the opposite of Colles’ fracture, Much less common compared to colles’.Results from a fall on palmer flexed wrist. Typical deformity: Garden Spade. Management is the same as in colles EXCEPT we concentrated on regaining of wrist flexion ROM Colle’s versus smith’s fr  Barton’s Fracture Dislocation It is Intra-Articular distal radius fracture with volar displacement which looks like smith fracture. There is dorsal type which looks like Colles’ fracture. Management is by ORIF. ORIF Volar Barton’s  Radial Styloid Fracture Radial Styloid Fracture (Chauffeur Fracture). Mechanism of injury is compression of the scaphoid against the styloid. Treated by Non-displaced: Cast immobilization Displaced: Surgical fixation  Carpal bone fractures Scapohid fractures make up 50-80% of all carpal fractures. The main cause of injury is a fall on the outstretched hand with an radially deviated wrist, which results in extreme dorsiflexion at the wrist and compression to the radial side of the hand. The patient experience a deep, dull ache in the radial part of the wrist. The Pain in anatomical snuff box, which often is mild, is aggravated by pinching and gripping. The wrist can be lightly swollen or bruised and, possibly, fullness in the anatomic snuffbox, suggesting a wrist effusion. The major blood supply comes from the radial artery. The proximal portion has no direct blood supply, what is an explanation for the cause of scaphoid necrosis on the basis of the vascular anatomy and an important complication of scaphoid fractures. The fracture of the distal pole heals in 2 to 3 weeks, whereas the fractures of the waist and proximal pole need 8 to 12 weeks of immobilization. No active movement for the thumb until fracture appears radiographically healed from (6-8 weeks). Complication: Delayed union, avascular necrosis, osteoarthritis Treatment for Scaphoid fx: Undisplaced: Cast immobilization is the standard treatment for treating a scaphoid fracture. Minimal displaced fr: Closed reduction followed by Long arm thumb spica cast for 2-4 weeks, followed by short arm thumb if union is delayed. OR glass holding cast. Thumb spica Splint glass holding cast Displaced or unstable fractures, operative treatment is recommended. open reduction and internal fixation by special compression screw is preferable to avoid fr complication.  Important concerns Above elbow thumb spica cast for proximal pole, short arm thumb spica for mid and distal poles. The Active range of motion (AROM) and passive range of motion (PROM) to the digits, except the thumb, which is immobilized (till 12 weeks). There is no research on the use of physical agents in the specific treatment of scaphoid fractures. This, however, doesn't preclude one from using agents such as TENS, ultrasound to treat pain, or an agent such as NMES to treat attenuated muscle activity.  Lunate Fracture Occurs via FOOSH mechanism. Blood supply enters distal end - proximal fracture fragment at risk of avascular necrosis (Kienbock’s disease). Tenderness elicited by axial compression applied along 3rd metacarpal Highest incidence of avascular necrosis. Suspect when there is tenderness in lunate fossa regardless of whether or not confirmed by radiograph. Palpate just distal to the center of distal radius. Wrist flexion causes lunate to move against the examiner’s finger and increases tenderness.  Lunate fracture treatment When clinically suspected, Short arm thumb spica splint, Follow up in 7~10 days. Non-displaced: Short arm cast for 4-6 wks Displaced: Surgical fixation  Metacarpal Fractures Bennett’s fracture: Intra articular fx an oblique fracture at base of 1st metacarpal. Associated with dislocation or subluxation of the carpometacarpal joint by pull of the abductor pollicis brevis and longus. A triangular fragment of fractured bone remains in position. If the fracture is T or Y-shaped it is called Rolando's fracture. If It is stable treated by thumb spic splint, if it is unstable surgical fixation with percutaneous pinning. Bennett’s fracture Treatment of Bennett’s fx Boxer’s fracture: Fx of distal 4th or 5th metacarpal bone (metacarpal neck frx involving ring or little finger) result from, striking with closed fist. Treatment: immobilizing the joint to promote healing. Immobilization can be achieved with a variety of splints, a cast, or taping techniques. “Buddy-taping” involves taping the little finger to the ring finger. Surgery is recommended for Boxer’s fractures if large degrees of angulation or displacement occur, or if the joint surface is misaligned. An open reduction and internal fixation (ORIF) by wires and screws. All splinting programs for metacarpal or phalangeal fractures recognize the need to position the metacarpophalangeal joints in flexion to avoid extension contractures. The thumb metacarpophalangeal is not except from this rule, and many stiff thumbs result from hyperextended thumb spica immobilization. The interphalangeal joints typically are rested in full extension. In this position the important ligaments of the wrist and hand are maintained in maximal tension to prevent contractures Greer’s principles of splinting (REDUCE) should be incorporated in casting or splinting of these fractures. R: Reduction of the fracture is maintained. E: Eliminate contractures through proper positioning. D: Don’t immobilize any of these fractures for more than 3 weeks. U: Uninvolved joint should not be splinted in stable fractures. C: Creases of the skin should not be obstructed by the splint. E: Early active tendon gliding is encouraged.