Upper Extremities Fracture

8/9/2019 Upper Extremities Fracture

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Upper Extremities Fracture

Fanny Indarto

SMF Ilmu Bedah UKRIDA


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Clavicle Fracture

Fall direct impact

Clavicle !ractures account !or "#$% to&"% o! all !ractures and !or ''% to$$% o! !ractures a(out the shoulder#

Middle third !ractures account !or)*% o! all clavicle !ractures


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Radiolo+y

Standard anteroposterior radio+raphsare +enerally su,cient to con-rm thepresence o! a clavicle !racture and

the de+ree o! !racture displacement#


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.reatment

Most clavicle !ractures can (esuccess!ully treated nonoperatively/ith some !orm o! immo(ili0ation#

Com!ort and pain relie! are the main+oals# A slin+ has (een sho/n to +ivethe same results as a -+ure1o!1ei+ht

(anda+e providin+ more com!ortand !e/er s2in pro(lems#


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In +eneral immo(ili0ation is used !or' to $ /ee2s#

Durin+ the period o! immo(ili0ationactive ran+e o! motion o! the el(o//rist and hand should (e per!ormed#


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Sur+ery

.he sur+ical indications !or midsha!tclavicle !ractures are controversial#

.he accepted indications !oroperative treatment o! acute clavicle!ractures are open fracture,associated neurovascular

compromise, and skin tentingwith the potential forprogression to open fracture.


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3late and scre/ -xationre4uires a more extensive

exposure than intramedullarydevices (ut has theadvanta+e o! more secure

-xation#


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5lenohumeral dislocation

.he shoulder is the most commonlydislocated ma6or 6oint o! the (odyaccountin+ !or up to '7% o!

dislocations#

Most shoulder dislocations areanterior


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Mechanism

Indirect trauma to the upper extremity /ith theshoulder in a(duction extension and externalrotation is the most common mechanism#

Direct anteriorly directed impact to the posteriorshoulder may produce an anterior dislocation#

Convulsive mechanisms and electrical shoc2typically produce posterior shoulder dislocations(ut they may also result in an anterior dislocation#

Recurrent insta(ility related to con+enital orac4uired laxity or volitional mechanisms mayresult in anterior dislocation /ith minimal trauma#


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Clinical 3resentation

sli+ht a(duction and externalrotation# .he acutely dislocatedshoulder is pain!ul /ith muscular

spasm#


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A care!ul neurovascular examinationis important /ith attention toaxillary nerve inte+rity#


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Apprehension test


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Radiolo+y


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Kocher Manuveur


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Stimpson Manuveur


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Sur+ery

Indications !or sur+ery include8 So!t tissue interposition#

Displaced +reater tu(erosity !racture#

5lenoid rim !racture 97 mm in si0e#

Selective repair in the acute period :e#+# in youn+athletes;#

Sur+ical options !or sta(ili0ation include repair o!the anterior la(rum capsular shi!t capsulorrhaphy

muscle or tendon trans!ers and (ony trans!ers#Recent developments include the use o!arthroscopy !or dia+nostic and therapeuticpurposes


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Complication

Recurrent anterior dislocation8related to li+ament and capsularchan+es#

tear


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In!erior 5lenohumerale Dislocation: ?uxatio Erectae;


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3roximal humerus !ractures

most common humerus !racture:'7%;#

increased incidence in the olderpopulation is thou+ht to (e related toosteoporosis#


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Mechanism

Most common is a !all onto anoutstretched upper extremity !rom astandin+ hei+ht typically in an older

osteoporotic /oman#


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@elpeau axillary vie/


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=eer Classi-cation


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.reatment

Up to )7% o! proximal humerus!ractures are minimally displaced ornondisplaced#

Slin+ immo(ili0ation or s/athe !orcom!ort#

At $ /ee2s active ran+e1o!1motionexercises are started#

Resistive exercises are started at &"/ee2s#


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Anatomic nec2 humeral!racture

.hey re4uire open reduction andinternal -xation :


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Complications

@ascular in6ury

=erve in6ury


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umeral sha!t !racture

Common in6ury

Mechanism o! in6ury 8

Direct :most common;8 Direct traumato the arm !rom a (lo/ or motorvehicle accident results in transverseor comminuted !ractures#

"# Indirect8 A !all on an outstretched armresults in spiral or o(li4ue !racturesespecially in elderly patients#


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.reatment

Most humeral sha!t !ractures :9*%; /illheal /ith nonsur+ical mana+ement#

./enty de+rees o! anterior an+ulation *

de+rees o! varus an+ulation and up to cmo! (ayonet apposition are accepta(le and/ill not compromise !unction or appearance#

Hanging cast8 Indications include displaced

midsha!t humeral !ractures /ith shortenin+particularly spiral or o(li4ue patterns#


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Coaptation splint 8 indication 8minimalshortenin+ and !or short o(li4ue or transverse!racture patterns that may displace /ith ahan+in+ arm cast#

@elpeau dressin+ 8 indication 8 minimallydisplaced or nondisplaced !ractures that do notre4uire reduction#

Shoulder spica cast 8 indication 8 /hen the!racture pattern necessitates si+ni-canta(duction and external rotation o! the upperextremity#


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Sur+ery

Indications !or operative treatment are8 Multiple trauma

Inade4uate closed reduction or unaccepta(le malunion

3atholo+ic !racture

Associated vascular in6ury Floatin+ el(o/

Se+mental !racture

Intraarticular extension

Bilateral humeral !ractures


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Complications

Radial nerve in6ury

@ascular in6ury 8 (rachial artery

=on union

Mal union


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Distal humeral !racture

Uncommon

Intercondyle !racture mostcommon 8Fracture fragments are oftendisplaced by unopposed muscle pull at themedial (exor mass) and lateral (extensormass) epicondyles, which rotate thearticular surfaces.


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Classi-cation


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El(o/ dislocation


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Distal radius !racture

the most common !ractures o! the upperextremity#

.he incidence o! distal radius !ractures in theelderly correlates /ith osteopenia and rises inincidence /ith increasin+ a+e nearly in parallel/ith the increased incidence o! hip !ractures#

Ris2 !actors !or !ractures o! the distal radius inthe elderly include decreased (one mineraldensity !emale sex /hite race !amily historyand early menopause#


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Mechanism

.he most common mechanism o!in6ury is a !all onto an outstretchedhand /ith the /rist in dorsiexion#


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Clinical -ndin+s

/rist de!ormity and displacement o!the hand in relation to the /rist :dorsalin Colles or dorsal Barton !ractures and

volar in Smith1type !ractures;# A care!ul neurovascular assessment

should (e per!ormed /ith particular

attention to median nerve !unction#Carpal tunnel compression symptomsare common :&% to "%;


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Classi-cation


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Colles !racture

Dinner !or2 !ormation More than *% o! distal radius !ractures

are o! this pattern#

.he mechanism o! in6ury is a !all onto ahyperextended radially deviated /rist/ith the !orearm in pronation#


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Upper Extremities Fracture