Upper Limb Injuries Lecture (PDF)

UPPER LIMB INJURIES Total / (5) Lectures Lecture /1/2023-2024 Prof.Dr.Alaa Al-Algawy Learning objectives ► 1-anatomecal review of upper limbs regions. ► 2- outline the most important injuries at ► -shoulder joint. ► -Humerus bone. ► -elbow joint. ► -forearm bones. ► -wrist & carpal bones. ► -meta...

UPPER LIMB INJURIES Total / (5) Lectures Lecture /1/2023-2024 Prof.Dr.Alaa Al-Algawy Learning objectives ► 1-anatomecal review of upper limbs regions. ► 2- outline the most important injuries at ► -shoulder joint. ► -Humerus bone. ► -elbow joint. ► -forearm bones. ► -wrist & carpal bones. ► -metacarpal bones & fingers . FRACTURES OF THE CLAVICLE AND SHOULDER GIRDLE Clavicular fractures ► Common injuries in adults and children about 10% of all fractures. ► The majority of cases follow a fall on the shoulder. ► Most fractures involve the middle third of the bone. Popular classification: *Group I: middle third fractures. *Group II: lateral third fractures, which in turn are divided into three types. 1-CC ligament is intact. 2-CC ligament torn with high riding of the fractured end of clavicle. 3- Intra articular fracture that extends into the ACJ. *Group III: medial third fractures. DX ► Clinical diagnosis is not difficult in most cases . ► All of the fractures can be diagnosed with plain XR. ► Clinically status. assess of the distal neurovascular Clinical picture Treatment: 1- majority of cases, Mx is non-operative using a collar and cuff sling for 4-6 weeks, and analgesics. 2- Pat. advised to avoid overhead activity for the first 6 wks and heavy manual work for 3 months. F/UP In adults XR should be obtained at 2 weeks, 6 weeks and 3 months to ensure the fracture progresses to union. Indication of Surgical treatment :- 1- Neuro vascular injury requires plating of the clavicle. 2- Non-union of midshaft fractures can be treated with plating. Non-union occurs in( 10% of adult clavicular fractures) and is more common in midshaft fractures with more than 1 cm of displacement or with comminution. 3-In lateral third fractures, delayed union or non-union is the norm if the coraco-clavicular ligaments are ruptured, which results in superior migration of the medial fragment. They can be treated non-operatively if asymptomatic. In patients with troublesome pain, internal fixation is indicated. Scapular fractures Uncommon injuries but are associated with highenergy trauma. ► Association with rib fractures, clavicle fractures, brachial plexus injuries and intra-thoracic injury. ► The most important aspect of management is identification of the associated injuries. ► RX ► In general, most scapular fractures can be treated non-operatively in a sling for 4-6 weeks. ► Fractures involving the glenoid fossa with significant displacement are best treated by internal fixation. ► Shoulder injuries ► Acromio-clavicular ► ► dislocation. Glenohumeral dislocation. Proximal humeral fractures Anatomy Acromio-clavicular dislocation. ► Result from a fall directly onto the shoulder. ► They are common in contact sports. ► The lateral aspect of the clavicle is attached to the scapula by: - strong coraco-clavicular ligaments. If these are disrupted, the weaker acromioclavicular joint ligaments can be disrupted allowing superior displacement of the clavicle in relation to the acromion. ► There are three grades of injury: Grade I – A-C ligaments are damaged, but there is no superior displacement of the clavicle. ► Grade II - The ligaments are damaged sufficiently to allow subluxation, but not complete dislocation of the joint. Grade III - There is complete dislocation with superior displacement of the joint. The Coraco-Clavicular and Acromio-Clavicular ligaments are torn. This injury is not usually seen in the younger child, but may be seen in adolescents ► RX ►G I & G II is non-operative with a sling ,until early mobilization is commenced 1-2 weeks after injury. ► Most G III injuries, treated nonoperatively. ► If the clavicle is widely displaced and comes to lie in a subcutaneous position, so best treated surgically. ► The clavicle can be repositioned using a coraco-clavicular screw. Glenohumeral dislocation ► ► The glenohumeral joint is the most frequently dislocated major joint. Anterior dislocation: The usual mechanism is a fall on the extended arm with the shoulder in extension. The humeral head dislocates in an anterior dislocation and comes to lie medial to the glenoid, just below the coracoid process. ► Posterior dislocation also occurs, but is uncommon, and accounts for less than 5% of shoulder dislocations. ( often associated with high-energy trauma, an epileptic fit or as a consequence of an electric shock. ) ► Gleno-humeral dislocation is a very unusual injury in a child. ► DX: The diagnosis of anterior dislocation is obvious on clinical examination. There is swelling and deformity of the shoulder and the humeral head is palpable in the anterior subcoracoid position. ► ► Posterior dislocations are less obvious on physical & radiographic examination, ► but one key clinical feature is that the glenohumeral joint is fixed in internal rotation. ► If there is a history of unusual trauma, and the shoulder is in fixed internal rotation, it should be assumed there is a posterior dislocation. ► A plain anteroposterior (AP) XR. shows anterior dislocations readily, but posterior dislocations are easily missed. ► Axillary or modified oblique views are better for diagnosis of posterior dislocation. RX: ► Closed reduction of the dislocation under sedation is usually possible. ► Occasionally general anaesthesia (GA) is required and should always be used in a child. Kocher’s method: (The elbow is bent to 90 degrees, and held close to the body, no traction is applied, the arm is slowly rotated externally to 75 degrees, then the point of the elbow lifted forwards, and finally the arm internally rotated.) ► Complications: ► Axillary nerve injury. ► brachial ► rotator plexus palsy. cuff tears . ► Posterior dislocations are often associated with an impaction fracture of the humeral head, which becomes locked on the edge of the glenoid, rendering closed reduction difficult. So, open reduction is more frequently required. ► After closed reduction of a shoulder dislocation a period of 3-4 weeks of immobilization is recommended in younger patients to minimize the risk of recurrent dislocation. ► In younger patients the main risk is recurrent dislocation and in those under 20 years of age the risk is 80%. ► In patients over the age of 40 years this is less of a risk and early mobilization is encouraged. But rotator cuff tears and nerve injury are more frequent . ► Greater tuberosity fractures or rotator cuff tears are present in 10-30% of glenohumeral dislocations. ► Nerve injuries (mostly the axillary nerve) can be treated non-operatively as they recover spontaneously in 95% of cases. ► They are present in 30% of patients over the age of 50 with dislocation. ► Rotator cuff tears are easily missed since they are difficult to diagnose at presentation after reduction of the dislocation due to pain and limited motion. ► In patients who have not regained active abduction by 4-6 weeks after injury an urgent ultrasound or MRI scan is indicated to diagnose a rotator cuff tear and carry out surgical repair in suitable patients END OF LRCTURE (1) THANK YOU