Upper limb fractures

UPPER LIMB FRACTURES 2
ELBOW, FOREARM, HAND
Done by: Noor Alsoub
Supervised by: DR. MOHAMMAD DAWOOD M.D.

Radial Head Fracture
•Among the most common elbow fractures.
•A fall on the outstretched hand with the elbow extended
and the forearm pronated causes impaction of the radial
head against the capitulum.
•The patient has pain on supination and pronation. local
tenderness posterolateral to the proximal radius end.
•In adults this may fracture the head of the radius; in
children, it is more likely to fracture the neck of the radius
(possibly because the head is largely cartilaginous).

Radial Head Fracture
•Treatment:
❑ Adults:
1. Non-displaced fractures: supporting the
elbow in a collar and cuff.
2. Displaced fractures: open reduction and
fixation.
3. Comminuted fractures: reconstruct the radial
head or, if it has to be excised, it should be
replaced by a metal prosthesis.
•Complications
1. Joint stiffness.
2. Recurrent instability (if MCL is injured
and radial head excised).
3. Osteoarthritis.

Radial Neck Fracture
• Treatment:
❑ Children
1. Arm is rested in a collar and cuff, and exercises are
commenced after 1 week.
2. Displacement of more than 30 degrees should be corrected:
closed reduction (with the patient’s elbow extended,
traction and varus force are applied; the surgeon then pushes
the displaced radial fragment into position with his or her
thumb).
3. If this fails, open reduction without internal fixation.
⮚ The head of the radius must never be excised in children
because this will interfere with the synchronous growth of
radius and ulna.

Fractures of The Olecranon
• Two types:
1. Comminuted fracture:
❑ It's caused a direct blow or fall on the elbow. There would be
a bruise over the elbow, elbow can be extended against
gravity.
2. Transverse fracture:
 Its caused by a traction when the patient falls onto the hand
while the triceps muscle is contracted.
 There may be a palpable gap and the patient is unable to
extend the elbow against resistance.
❑ Diagnosis: x-ray lateral view.

Fractures of The
Olecranon
• Treatment:
1. Transverse fractures:
❑ Non-displaced: immobilization, figure of eight
tension band wiring using two K – wires (converts
tensile force to compression force at fracture site
when flexing elbow).
❑ Displaced: open reduction and internal rigid
fixation.
2. Comminuted fractures: open reduction and internal
fixation (ORIF).

Fractures of both the Radius and Ulna
•If the cause was a twisting force, it produces a spiral fracture.
•A direct blow causes a transverse fracture in either or both bones at the
same level.
•Treatment:
❑ Children: closed reduction is usually successful, Rigid fixation is not
required in children because they have a higher ability to remodel.
(nails might be used).
❑ Adults: open reduction and fixation with plates and screws.
•Most fractures of the radius and ulna heal within 8–12 weeks.
•Complications:
1. Compartment syndrome resulting from increased interstitial pressure
as a result of the trauma.
❑ Signs and symptoms: pain out of proportion, paresthesia, a tense
swelling and difficulty moving the limb.
2. Nonunion and malunion.

Fractures of both the Radius and Ulna – X-ray

Monteggia’s Fracture - Dislocation
• Fracture of the proximal third of the ulna with dislocation of the proximal
head of the radius; occurring at the proximal part of the ulna causing its
shortening, therefore the radial head dislocates in the direction of the
angulation of the broken ulna.
• Usually, the cause is a fall on the hand and forced pronation of the
forearm.
• Treatment: ORIF with plates/screws on the ulna and reduction of the
radius.
❑ The radial head is only reduced after the ulna is put back in place and
fixated.
• Can cause injury to the radial nerve (posterior interosseous nerve injury);
finger drop.

Monteggia’s Fracture – Dislocation – X-ray

Galeazzi Fracture -Dislocation
•Fracture at the distal part of the radius causing its shortening
with dislocation of the distal radioulnar joint.
•You manage the fracture by first reducing the radius and then
reducing the radioulnar joint.
•Tenderness over the lower end of the ulna is the striking
feature.
•Treatment:
❑Adults: ORIF and fixation of distal radioulnar joint with k –
wires.
❑Children: closed reduction
•Can cause injury to the ulnar nerve.

Galeazzi Fracture Dislocation – X-ray

Galeazzi Fracture Dislocation – x-ray

Colles’ Fracture
•Risk factors include osteoporosis. Originally it was described in elderly and/or post-menopausal women.
•Displaced fractures produce a distinctive dorsal tilt just above the wrist – the so-called ‘dinner-fork
deformity’.

Colle’s fracture- dorsal displacement

Colles’ Fracture
•Complications:
1. Complex regional pain syndrome which is very common and
occurs as a result of the trauma. High doses of vitamin C as
well as exercise can help in the prevention of this syndrome.
2. Circulatory impairment.
3. Nerve injury: median nerve (carpel tunnel).
4. Rupture of the extensor pollicis longus tendon can occur
several weeks after the fracture.
•Treatment: Closed reduction and fixation with cast (4 – 6 weeks)
+ early ROM (Range of motion).

Smith’s Fracture
•Smith's Fracture is a fracture of the distal end of the
radius caused by a fall on the back of the hand
(flexed), resulting in a ventral displacement of the
fractured fragment. It is also known as a reverse Colles
fracture.
•Treatment is reduction and fixation; the forearm can
be immobilized in a cast for 6 weeks.
•Complications:
1. Median nerve compression (carpal tunnel
syndrome).
2. Distal radio-scaphoid arthritis; chronic wrist pain.

Smith’s Fracture- ventral displacement

Fracture of the Radial
Styloid Process
•The injury is typically caused by compression of
the scaphoid bone of the hand against the
styloid process.
•The fracture line is transverse.
•Treatment is often open reduction and internal
fixation.

Fracture of the Radial Styloid Process

Scaphoid Fracture
•Scaphoid fractures account for almost 75% of all carpal fractures. The
usual mechanism is a fall on the hand with wrist extended.
•The blood supply of the scaphoid diminishes proximally (Blood supply
comes from distal end to proximal end).
•There may be slight fullness in the anatomical snuffbox and a
localized tenderness in the same place, and that is an important
diagnostic sign.

Scaphoid Fracture
Treatment:
• Non-displaced : Thumb Spica (6 – 8 weeks).
• Displaced: ORIF and one-month immobilization.
Complications:
1. Avascular necrosis.
2. Nonunion.
3. Osteoarthritis (especially in missed fractures)/
Stiffness of the wrist.
4. Malunion: humpback deformity; volar angulation
of the proximal and distal ends.

Fifth Metacarpal Neck Fracture
(Boxer’s Fracture)
•Associated with a punching injury (immature boxers).
• Normally, one punches with their 3rd metacarpal bone so that
the force transmits from the head to the carpal bones to the
radius which will support it. However a punch with the 5th
metacarpal, the force will go through the neck which is not
supported.
•Distal part of the fracture is displaced anteriorly producing a
shortening of the affected finger (depressed knuckle.)
•Treatment: conservative (closed reduction)
•Only problem is absence of knuckle.

Fifth Metacarpal Neck Fracture (Boxer’s Fracture)

Mallet Finger
•If the fingertip is forcibly bent during active extension, the
extensor tendon may rupture, or a flake of bone may be
avulsed from the base of the distal phalanx.
•This sometimes occurs when the finger is stubbed when
catching a ball.
•Treatment:
❑ Splinting the distal joint continuously in extension for 8
weeks and then at night only for another 4 weeks.
❑ Operative fixation is rarely needed.

Avulsion of the Flexor
Tendon
•Forced hyperextension of the distal
interphalangeal (DIP) joint while the finger is
actively flexing.
•The patient cannot actively flex the tip of the finger.
The flexor digitorum profundus tendon is avulsed,
either rupturing the tendon itself or taking a
fragment of bone with it.
•Treatment: surgically repair the tendon by sewing
the cut ends together.

Upper limb fractures

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