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  Dislocation Of The Shoulder -Mostly anterior > 95 % of dislocations. -Posterior dislocation occurs < 5 %. -True inferior dislocation ( luxato infero ) occurs < 1%. -Multi directional dislocation due to ligament laxity and is painless. Mechanism Of Anterior Shoulder Dislocation Usually indirect fall. It may be direct when there is a blow on the shoulder from behind. It is caused by the arm being positioned in an excessive amount of abduction and external rotation (the glenohumeral joint is most susceptible to dislocation in the 90 degree abduction and 90 degree external rotation).  Complications of anterior shoulder dislocation -Bony: bony Bankart, Hill-Sachs Lesion, neck of humerus, Greater or lesser Tuberosity Fracture. -Soft Tissue: Soft tissue Bankart lesion, Subscapularis Tear, RCT (older pts with dislocation). -Vascular: Axillary artery injury, avascular necrosis of the head of the Humerus -Nerve: Axillary nerve neuropraxia. -Recurrent dislocation. -Shoulder stiffness with prolonged immobilization A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. Bony Bankart lesion shows besides the soft tissue damage also a fracture of the anteroinferior glenoid rim. Hill–Sachs fracture, is a cortical depression in the posterolateral head of the humerus. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly. Reverse Hill Sach’s Lesion, It is defect in Antero medial part aspect of humerus head in posterior dislocation of shoulder.  Tests for anterior shoulder dislocation Dugas test (inability to touch the opposite shoulder by affected hand).This test is used if an unreduced anterior shoulder dislocation is suspected. The patient is asked to place the hand on the opposite shoulder and then attempt to lower the elbow to the chest. With an anterior dislocation, this is not possible, and pain in the shoulder results. If the pain is only over the acromioclavicular joint, problems in that joint should be suspected.  Clinical picture of anterior dislocation a. Arm held in an abducted and ER position, internal rotation and adduction may be limited. b. Loss of normal contour of the deltoid and acromion prominent posteriorly and laterally c. Humeral head palpable anteriorly d. All movements limited and painful E-Palpable fullness below the coracoid process and towards the axilla A clinician can determine if an axillary artery injury is present by looking for reduced pulse pressure or a transient coolness in the hands. Peripheral nerve injuries following an anterior dislocation is common because of the proximity of the brachial plexus.  Posterior Dislocation Rare, commonly missed, more among epileptics and electrocution which cause overpull of subscapularis and latissimus dorsi and may led to posterior dislocation. It is caused by an external blow to the front of the shoulder. There is an indirect force applied to the humerus that combines flexion, adduction, and internal rotation. This is usually the result of one falling on an out stretched hand (FOOSH injury). Imaging easily missed, lateral view is essential. An axillary view is a preferred view for diagnosis. Look for “light bulb sign. Posterior shoulder dislocation  Clinical Picture of Posterior Dislocation a. Arm is adducted and internal rotation. Clinically locked in internal rotation and unable to externally rotate the shoulder b. May or may not lose deltoid contour c. May notice posterior prominence head of humerus d. Tear of subscapularis muscle (weak or cannot internally rotate)  Luxtio Erecta Also known as inferior dislocation of shoulder. Caused by severe hyper abduction of force. Arm presents in abducted position. Reduce with in-line traction and gentle adduction.  Management Of Shoulder Dislocation Is an emergency, it should be reduced in less than 24 hours or there may be avascular necrosis of head of humerus. Reduction may closed or surgical open reduction Methods Of anterior Shoulder closed Reduction -Hippocratic method -Stimson’s gravity method -Kocher’s method  Hippocratic Method By holds the patients affected arm by wrist and applies traction at a 45 angle. At the same time provides counter traction by placing foot on the patients chest wall or having an assistant wrap a sheet around the patient.  Stimpson’s Technique The patient is kept in prone position on bed. The affected shoulder is supported and the arm is left to hang over the edge of the bed. A weight is attached to the elbow or wrist. It is usual to begin with 2kg up to 10 kg may be applied. Gravity stretches the muscles and reduction occurs. Gentle internal humeral rotation may be applied. This method takes 15 to 20 minutes.  Operative Treatment Operative Indications Irreducible shoulder (soft tissue interposition). Displaced greater tuberosity fractures. Glenoid rim fractures bigger than 5 mm. Other indications for operative intervention include three or more recurrent dislocations in a year and dislocations that occur at rest or during sleep. The non operative treatment options for anterior, posterior, and multidirectional glenohumeral instability all center on the same core issues. The immediate goals are to decrease pain and edema, protect the static stabilizers, and strengthen the dynamic stabilizers. The ultimate aim is to increase overall shoulder stability, which is facilitated via exercises designed to enhance joint proprioception and address kinetic chain deficits. N.B: Strengthening of the rotator cuff muscle and scapular muscle (mainly lower trapezius and serratus anterior is the main target in any program. After either intervention the management is similar. However, if it is a surgical procedure, knowing what type of surgery was performed as well as the precautions post surgery. Typical precautions are: If subscapularis was cut, no resisted internal rotation for 4-6 weeks. External rotation usually limited to 30 degrees initially, then 45 degrees at 6 weeks. Avoid provocative positions of the shoulder that risk recurrent of anterior shoulder dislocation: External rotation Abduction Distraction Extension, which puts additional stress on anterior structures.  Rehabilitation Phase 1 (up to 6 weeks): Goal is to maintain anterior-inferior stability After reduction (closed or open), immobilization is done. It has traditionally been thought to be immobilized with internal rotation, but according to Miller, immobilization has been beneficial in external rotation because there is more contact force between the glenoid labrum and the glenoid. The rationale for placement of the arm in external rotation centers on the fact that the Bankart lesion is forced to separate from the glenoid when the arm is placed in internal rotation, which may be detrimental to healing. In contrast, the authors describe how placing the arm in external rotation approximates the lesion to its correct anatomic position, allowing for a better healing process. Immobilization After Reduction There is currently no consensus on the duration of immobilization in a sling. But, typical time periods in a sling range for 3-6 weeks if under the age of 40 and 1-2 weeks if older than the age of 40. During the immobilization period, the focus is on AROM of the elbow, wrist and hand and reduction of pain. Isometrics can be incorporated for the rotator cuff and biceps musculature. Codman Exercises (Pendulum exercises) AAROM for external rotation (0-30º) and forward elevation (0-90º) Isometric exercises Phase 2 (6-12 weeks): Goal is to restore adequate motion, specifically in external rotation AAROM to achieve full range of motion When stretching is permitted, passively stretch the posterior joint capsule through the use of joint mobilizations or self-stretching. No strengthening or repetitive exercises should start until achievement of full range of motion. Phase 3 (12-24 weeks): Successful return to sports or physical activities of daily living. Begin strengthening exercise, strengthening exercises should be impairment- based. Typically begin strengthening exercise in a pain-free motion with exercises for stability. A possible progression could begin by focusing on the rotator cuff musculature and scapular stabilizers, which include trapezius, serratus, levator scapulae, and rhomboids. Then, progress to the larger musculature such as the deltoids, latissimus dorsi, and pectorals. Start focusing on functional exercises include proprioceptive training  Elastic band exercises examples Endurance and strength exercises Posterior Dislocation Management for posterior dislocation follows the same progression as anterior protocol, except for the following guidelines: a. Posterior glide is contraindicated, Avoid posterior capsule stretch by avoiding active ER or passive IR. b. Avoid flexion with adduction and internal rotation c. Immobilized 3-6 weeks if less than 40 years of age and 2-3 weeks if greater than 40 years of age d. Strengthening will focus primarily on posterior musculature such as: infraspinatus, teres minor and posterior deltoid  Fractures Of The Humerus -Proximal Humerus (includes surgical and anatomical neck, greater and lesser tuberosity). -Shaft of Humerus. -Distal humerus (fracture of condyle, epicondyles, supra condylar fracture).  Proximal Humeral Fracture Neer system classification: -Anatomic neck. -Surgical neck. -Lesser tuberosity. -Greater tuberosity Complication -Most common: adhesive capsulitis (frozen shoulder). -Multi-part fractures: avascular necrosis of the humeral head. -Neurovascular injury. -The most common dysfunctions after humeral shaft fractures might be associated with altered scapulohumeral rhythm and radial nerve palsy.  Treatment Stable and minimally displaced fractures- Sling immobilization, early motion. Discontinue sling and start pendulum exercise early to prevent stiffness. Displacement or unstable injuries ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution. Bony healing occurs usually within 6 to 8 weeks in adults fracture :intra-medullary k wire fixation Plating Rush Nail Insertion  Physical Therapy Proximal Humeral Fracture Important Concern Extension and Internal Rotation not performed until 6 weeks Return to normal function and motion may require 3 to 4 months. Prolonged immobilization is a key factor to avoid because it leads to stiffness and decreased ROM. The goals of treatment include: preventing disuse atrophy, maintaining range of motion without displacing the proximal humerus fracture, avoiding exercises that reproduce the mechanism of injury, and early intervention to begin a successful recovery. Early passive ROM, followed by active ROM and progressive resistance, and finishing with an advanced stretching and strengthening program. Shaft fracture A spiral fracture of lower 3rd of humerus is k/a holstein lewis fracture may be associated with radial nerve injury which can lead to drop wrist.  Management Of Fracture Shaft Of The Humerus Preferably conservative: Closed Reduction in upright position followed by application of U shaped Slap of POP or cylinder cast (Coaptation splint). few weeks later or initially in stable fractures functional brace may be used. Functional Brace Fracture Shaft Of Humerus U shaped slap of POP (Coaptation splint).  Operative Treatment Indications for operative treatment include inadequate reduction, nonunion, open fractures, segmental fractures, associated vascular or nerve injuries Most commonly treated with plates and screws but also Intermedullary nails. Intra- Medullary K Wire Plating Fracture Fixation Shaft Of Humerus Rehabilitation Phase I (0 to 6 Weeks) Encourage ROM of neck, shoulder, elbow, wrist, and hand. Pendulum exercises Exercises should be performed 3 to 5 times per day for 30-minute sessions. Begin passive self-assist exercises. Phase II (6 to 12 Weeks) Can begin early active, resistive, and stretching exercises Therabands can be used for progressive strengthening of internal rotators, external rotators, flexion, extension, and abduction (3 sets of 10 to 15 reps for each).  Begin flexibility and stretching exercises to progressively increase ROM in all directions. Phase III (>12 Weeks) Initiate isotonic exercises using rubber tubing and progressing to weights for strengthening. Concentrate on rotator cuff and scapular strengthening. Weights can start at 1 lb and move forward in 1-lb increments with a limit of 5 lbs. If any pain persists after exercises with weights then discontinue the weights with the exercises. Progress to overhead exercises. Advance ROM to maximum.  Supra- condylar fracture of humerus Supracondylar fractures of the humerus are the most frequent fractures in children with a peak incidence at the ages of five to eight years. FOOSH is the most mechanism of injury of Supracondylar fracture of the humerus. They usually by falling off the monkeybars. Types: Extension type supracondylar:(98%) there is posterior displacement of the distal fragment. In displaced extension-type fractures, the so-called ‘S-deformity’ is usually present. Flexion type (2%) there is anterior displacement of the distal fragment fracture.  Complications Supra-Condylar Fractures -Brachial Artery injury (Volkmann's Ischemia) -Nerve Injury : Median, Ulnar or Radial, The Neurovascular assessment is must pre and post-operatively. -Stiffness -Heterotopic Calcification (Myositis Ossificans) -Mal-Union (Cubitus varus or Valgus)  A Volkmann's contracture A Volkmann's contracture is a deformity of the hand, fingers, and wrist as a result of a trauma such as: fractures, crush injuries, burns and arterial injuries, It occurs mainly due to injury of brachial artery after supracondylar fracture. Following this trauma, there is a deficit in the arterio-venous circulation in the forearm which causes a decreased blood flow and the hypoxia can lead to the damage of muscles, nerves and vascular endothelium. This results in a shortening (contracture) of the muscles in the forearm. The muscles who are usually involved are the flexors of the wrist. Yet there is also a contracture occur in the extensors of the wrist, but this is less common. Muscles typically involved: Superficial flexors: Pronator teres,flexor carpi radialis ,flexor carpi ulnaris, flexor digitorum superfiscialis,palmaris longus.and Deep flexors: Flexor pollicis longus, Pronator quadratus ,Flexor digitorum profundus. All of these muscles supplied by median nerve except flexor carpi ulnaris (ulnar nerve innervation). The clinical presentation of Volkmann`s contracture includes what is commonly referred to as the 5 P s. These are pain, pallor, pulselessness, paresthesias, and paralysis. Pain is the earliest sign Treatment Prevention is the best management in this condition. Often times, the management require the surgical and physical therapy intervention for a better outcome The majority of Volkmann’s contractures are caused by a supracondylar fracture, and It must be ensured that this fracture heals. when there is a intra-compartment pressure of >30 mmHg, an urgent fasciotomy is recommended to avoid further complications, Raised ICP threatens the viability of the limb and CS (compartment syndrome) represents a true medical emergency. Thus, the need for decompression by removal of all dressing down to skin, followed by fasciotomy- Surgical opening of the fascia around the muscles to make more place for the structures inside. This is done to prevent the onset of Volkmann’s contractures. Physical therapy: Progressive Splinting, passive stretching and tendon gliding, as well as massage could be use in mild to moderate cases of Volkmann's contracture. In moderate Volkmann's contracture, tendon slide and neurolysis surgery should be performed (median and ulnar) along with extensor transfer procedures. After the surgery, it is important to ensure that the mobility is recovered by passive stretching techniques, range of motion exercises to enhance soft tissue elasticity. An other part in the therapy is activating and strengthening the weak agonist to ensure equilibrium in agonist and antagonist pull during joint movement. Finally, in severe cases of Volkmann's contracture, debridement of injured muscle may be performed with releases of scar tissue and salvaging procedures. Range of motion and function after injury are improved by physical and occupational therapy  Post Traumatic Ossification It is usually as a result of impact which causes damage to the sheath that surrounds a bone (periostium) as well as to the muscle. Bone will grow within the muscle (called calcification) which is painful. It occurs by formation of haematoma about the joint and instead of being absorbed the haematoma is invaded by osteoblastes and becomes ossified and lead to restriction of movement. Pain in the muscle when you use it, a hard lump in the muscle, an X-ray can show bone growth. The goal of therapy for MO is the restoration of strength and ROM. Therapy has been largely based on the RICE principle of rest, ice, compression and elevation and non-painful, passive stretching and strengthening routine. Pulsed ultra sound and phonophoresis, iontophoresis with 2 % acetic acid solution. Extra corporeal shock wave therapy.  Mal-union Supra- Condylar Fracture Most commonly results in Cubitus Varus, Less common is Cubitus Valgus or Cubitus Recurvatum. Management is by Corrective Supra-Condylar Osteotomy.  Treatment for supracondylar fracture Non-displaced fracture: Immobilization with a long-arm cast or splint. With elbow flexion up to 80° to 90° and mid pronation-supination are well toleratable for ~3weeks in case of posterior displacement, flexion of the elbow within the cast should not pass 90° because it can increase forearm pressures and impede distal vascular flow. And immobilized in elbow extension in case of anterior displacement for 2-3 weeks. Radiographic check at 1 and 2 weeks Displaced fracture without neurovascular involvement: Closed reduction with percutaneous pinning is the recommended -Sever displaced or failed closed reduction, open reduction and internal fixation may be used  Physiotherapy Guide -Active ROM for un involved joint as finger at first. -Pendulum exercises for the shoulder avoid internal and external rotation because it stress the fracture site. -Gentle active elbow flexion and extension for stable fracture treated by open reduction and internal fixation. -Isometric exercises for the forearm muscle -No pronation and supination -Grip exercises by ball or putty. -At 8 to 12 weeks resistive exercises for elbow flexion and extension may be used. If used percutaneous K wire, active elbow ROM started from 4 to 6 weeks. Passive ROM exercises for elbow may be used at 6-12 weeks as the risk of myositis ossificans related to passive motion of elbow has decreased. N.B: Active exercise is recommended in pediatric elbow fracture rather than passive treatment. (No aggressive passive motion or stretching at the first).