Fractures & Dislocations Of The Upper Limb PDF

Fractures & Dislocations Of The Upper Limb By Dina Othman Shokri  Fractures of the clavicle A clavicle fracture is also known as a broken collarbone. Clavicle fractures are very common injuries in adults (2–5%) and children (10–15%...

Fractures & Dislocations Of The Upper Limb By Dina Othman Shokri  Fractures of the clavicle A clavicle fracture is also known as a broken collarbone. Clavicle fractures are very common injuries in adults (2–5%) and children (10–15%) and represent the 44–66% of all shoulder fractures. It is the most common fracture of childhood. Despite the high frequency the choice of proper treatment is still debated. Both conservative and surgical management are possible, and surgeons must choose the most appropriate management modality according to the biologic age, functional demands, and type of lesion. In a clavicle fracture, the broken ends of the bone may cause tenting of the skin over the  Classification Of Clavicle Fracture Allman classified clavicular fractures into three groups on the basis of their location: Group I: Fractures of the middle third (Midshaft clavicle fractures 80%) Group II: Fractures of the distal third (Lateral-end clavicle fractures: 12–15%), A common site for non-union. Group II subtypes: Neer subclassified Group II fractures further on the basis of the location of the Coracoclavicular ligament to the fracture fragment Group III: Fractures of the proximal third (Medial-end clavicle fractures: 5–6%). The increased incidence of shaft fractures is in part due to the proximal and distal aspects of the clavicle being strongly secured by ligaments and musculature, rendering it less vulnerable to trauma; in midshaft fractures displacement and shortening occurs due to the combined forces of the sternocleidomastoid muscle pulling the medial fragment superiorly and posteriorly and the pectoralis major muscle, deltoid muscle, and gravity pulling the lateral fragment inferiorly and anteriorly  Mechanism Of Injury Clavicle fractures are often caused by a direct blow to the shoulder. This can happen during fall directly onto the lateral shoulder or a car collision, fall onto an outstretched arm can also cause a clavicle fracture. In babies, these fractures can occur during the passage through the birth canal.  Complications: -Malunion: Although common, it rarely causes any functional impairment. -Non-union: Rare. -Neurovascular involvement: Subclavian vessels and brachial plexus are at risk especially if a clavicular fracture is caused by a high velocity trauma. -Degenerative arthritis of the acromioclavicular or sternoclavicular joint. Malunion Union time in clavicle fracture: Early union occurs in 1-2 weeks in children. In adults early union occurs in 3 to 6 weeks and consolidation in 12 weeks. Callus formation can be visible and palpable. There appears to be no consensus on the optimal duration of immobilization; some have recommended two to six weeks.  ConservatiVConservative management Undisplaced fracture are treated conservatively -Immobilization in a sling (a sling is usually used and immobilization in internal rotation is usually recommended for 2-4 weeks). or figure-of-eight brace is often thought to prevent or reduce secondary fracture shortening during the time of fracture healing) until the clinical union is achieved (Clinical union defined by no pain/tenderness or movement at fracture site) in an appropriate time frame (6-8 weeks). Radiographic union if follow-up x-rays are taken.  Surgical Treatment Indication for Surgical management: displacement or shortening >2 cm, Severe displacement resulting in tenting of the skin (Open fracture requiring debridement), associated neurovascular injury requiring operative intervention, Non-union (failure of conservative treatment). Surgical management by open reduction and internal fixation by plates and screws, Intramedullary (IM) fixation. (Left) X-ray shows a displaced clavicle fracture (arrow). (Right) The pieces of bone have been realigned Radiograph showing intramedullary and held in place with plates and screws. stabilization using rockwood clavicle pins  General Guidelines For Clavicle Fracture Rehab -Physical Therapy programs typically start with gentle motion exercises as pendular exercises. -Gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks. -When pain free motion and radiographic evidence of union full activity including sports at ~ 3 month. -Watch your body mechanics: While using a sling, it's important to maintain proper bone and muscle alignment to avoid future problems. Try to focus on good shoulder position. Don't shrug, slouch, or let your shoulders round while in the sling. N.B. during forceful coughing, sneezing also patients need to take caution (as respiratory excursions may cause clavicle movement) by avoiding it as much as possible and also learning active-assisted coughing techniques if necessary.  Physical therapy rehabilitation For conservative management (First 6 weeks) -Modalities for swelling and pain (Ice-TENS) -No ROM to shoulder, elbow -AROM to wrist and hand -Start static exercises for deltoid and elbow 2nd week -Isotonic ex to wrist and hand At the end of 6th week Good callus and fracture site is stable -Removal of sling -Start gentle AROM of shoulder (abd limited to 80° and limit ext rot to avoid stress on fracture site -Full ROM elbow -Start isometric ex to rotator cuff muscle For surgical management -(+ sling for 4 weeks) -Shoulder pendulum ex inside the sling 3-5 days after surgery -The same protocol for stable # for the 1st 4 weeks At 8 weeks AROM shoulder all planes Resisted ex shoulder muscles Begin weight bearing gradually