Upper extremity fractures

1. Upper extremity fractures By Mohammad Hassan Lecturer of Orthopedic Surgery & Traumatology Faculty of MedicineUniversity of Alexandria

2. INJURIES ABOUT THE SHOULDER

3. ANATOMICAL CONSIDERATIONSBony Anatomy

4. ANATOMICAL CONSIDERATIONSBony Anatomy

5. ANATOMICAL CONSIDERATIONSArticulations

6. ANATOMICAL CONSIDERATIONSMuscular Anatomy

7. ANATOMICAL CONSIDERATIONSMuscular Anatomy

8. ANATOMICAL CONSIDERATIONSMuscular Anatomy

9. ANATOMICAL CONSIDERATIONSNeuro-Vascular Anatomy

10. Radiologic Anatomy

11. STERNOCLAVICULARJOINT DISLOCATION • Injuries to the SC joint are rare • Types; Mechanism

12. STERNOCLAVICULARJOINT DISLOCATION • Complaints • Pain, • Deformity, • Limited range of motion, • Dyspnea • Dysphagia

13. STERNO-CLAVICULARJOINT DISLOCATION • Examination • Respiratory, Heart rates, Trachea, Stridor, Breath sounds, Pulses • Pain on Palpating the clavicle, Loss of fullness of proximal clavicle, Skin tenting • Neurological examination

14. STERNO-CLAVICULARJOINT DISLOCATION • Radiological Examination • Always be Doubtful • Plain X-ray • C.T. Scan

15. STERNO-CLAVICULARJOINT DISLOCATION • COMPLICATIONS • Anterior • SC joint Arthritis • Cosmetic appearance – Persistent Prominence • Chronic Pain

16. STERNO-CLAVICULARJOINT DISLOCATION • COMPLICATIONS • Posterior • Pneumothorax • Compression or Laceration of Trachea, Oesophagous, Vessels • Brachial Plexus injury • Thoracic Outlet Obstruction

17. STERNO-CLAVICULARJOINT DISLOCATION • Treatment: Closed Reduction • Anterior SC Dislocation • Controversial • Majority unstable following reduction • Sling immobilization for 6 weeks

18. STERNO-CLAVICULARJOINT DISLOCATION • Treatment: Closed Reduction • Posterior SC Dislocation • Closed reduction – 2- 3 days of injury • Sling or figure-of-eight • If unstable or complications, then open

19. STERNO-CLAVICULARJOINT DISLOCATION • Operative Treatment include: • Fixation of the medial clavicle to the sternum using fascia lata, tendon, or suture, • Resection of the medial clavicle. • The use of Kirschner wires or Steinmann pins is discouraged, because migration of hardware may occur.

20. FRACTURES OF THE CLAVICLE • FUNCTION • Serves as a protector of the Brachial Plexus • Acts as a strut which provides the only bony connection between upper limb and the trunk.

21. FRACTURES OF THE CLAVICLE • Fractures are common especially in children and elderly • Mechanism of injury

22. Associated Injuries • Brachial Plexus Injuries; • Rib Fractures, • Scapula Fracture, • Vascular Injury • Pneumothorax FRACTURES OF THE CLAVICLE

23. Clinical Evaluation • Deformity/abnormal motion • Thorough distal neurovascular exam • Auscultation for the possibility ofpneumothorax FRACTURES OF THE CLAVICLE

24. Radiographic Exam FRACTURES OF THE CLAVICLE

25. AllmanClassification FRACTURES OF THE CLAVICLE 80% 5% 15%

26. TREATMENT • Nonoperative Treatment • Figure-of-eight bandage fixation • Sling immobilization for usually 3-4 weeks • Despite deformity, healing usually proceeds rapidly. • Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion. FRACTURES OF THE CLAVICLE

27. TREATMENT • Operative Treatment • Fractures with neurovascular injury • Fractures with severe associated chest injuries • Open fractures • Displaced distal third fractures • Cosmetic reasons, uncontrolled deformity • Painful Nonunion • Floating Shoulder; Fractures of both the clavicle and neck of the scapula FRACTURES OF THE CLAVICLE

28. ACROMIO-CLAVICULARJOINT DISLOCATION • Horizontal stability from superior / inferior AC ligaments • Vertical stability from CC ligaments

29. ACROMIO-CLAVICULARJOINT DISLOCATION • Mechanism of Injury • Direct: The most common mechanism, fall onto the shoulder with the arm adducted. • Indirect: fall onto an outstretched hand

30. ACROMIO-CLAVICULARJOINT DISLOCATION Clinical evaluation

31. ACROMIO-CLAVICULARJOINT DISLOCATION • Radiographic Evaluation • Initial Views: • Anteroposterior view • Zanca view (15 degree cephalic tilt) • Other views: • Axillary: demonstrates AP displacement • Stress views: weight lift.

32. ACROMIO-CLAVICULARJOINT DISLOCATION Classification Type I • Sprain of AC ligament • AC joint intact • CC ligaments intact • Deltoid and trapezius muscles intact

33. ACROMIO-CLAVICULARJOINT DISLOCATION Classification Type II • AC ligaments are disrupted • < 50% Vertical displacement • Sprain of the CC ligaments • Deltoid and trapezius muscles intact

34. ACROMIO-CLAVICULARJOINT DISLOCATION Classification Type III • AC and CC ligaments are all disrupted • AC joint dislocated • CC inter space greater than the normal shoulder (25-100%) • Deltoid and trapezius muscles usually detached from the distal clavicle

35. ACROMIO-CLAVICULARJOINT DISLOCATION Classification Type IV • AC and CC ligaments disrupted • AC joint dislocated and clavicle displaced posteriorly • Deltoid and trapezius muscles detached from the distal clavicle

36. ACROMIO-CLAVICULARJOINT DISLOCATION Classification Type V • AC and CC ligaments disrupted • CC inter space greater than the normal shoulder (100-300%) • Deltoid and trapezius muscles detached from the distal clavicle

37. ACROMIO-CLAVICULARJOINT DISLOCATION Classification Type VI • AC joint dislocated and clavicle displaced inferiorly • AC and CC ligaments disrupted • Deltoid and trapezius muscles detached from the distal clavicle

38. ACROMIO-CLAVICULARJOINT DISLOCATION • Treatment Options for Types I - II • Nonoperative:ice packs, sling. Refrain from full activity until painless, full range of motion (2 weeks).

39. ACROMIO-CLAVICULARJOINT DISLOCATION • Treatment Options for Types III • For inactive, especially for the non dominant arm, nonoperative treatment is indicated: sling, early range of motion, strengthening, and acceptance of deformity. • For younger, more active patients with more severe degrees of displacement may benefit from operative stabilization.

40. ACROMIO-CLAVICULARJOINT DISLOCATION • Treatment Options for Types III injuries in highly active patients, Type IV, V, and VI injuries • Open reduction and surgical repair of the CC ligaments