conservative management of upper limb fractures
TRANSCRIPT
Conservative treatment of upper limb fractures
AssessmentReductionImmobilizationFunctional activity
Basic principles in management of a closed fracture
EconomicalNo operative risksNo displacement – ends together mostly
always unite.
Why conservative?
Reduction – by applying traction – generally in the line of the limb
After reduction, it must be prevented from redisplacing until it has united. -
Plaster slabsPlaster bandages ( casts) – full circumferenceReadymade braces
What is done?
Slab – an example
Plaster splints need 10–12 layers of plaster in upper extremities
Slabs should be dipped, squeezed, when out of water, smoothed then applied with no wrinkles.
Thickness of plaster slab
Shoulder: resting at the side of the bodyElbow: 90° angle between forearm and arm,
neutral pronation/supinationWrist: neutral supination/pronation, 20°–30°
wrist extensionThumb: thumb in 45° abduction, 30° flexionMetacarpals, MCP joint, proximal phalanges:
MCP joint in 90° flexion, DIP and PIP joints in full extension
IP joints, middle/distal phalanx: full extension at IP joints
Positions in splinting
Indications –Elbow fracturesSupracondylar fractures
Above elbow slab
Extends from the middle of the upper arm to the point just proximal to the knuckles in the dorsum of the hand.
patient's forearm is held in mid prone position with the elbow in 900 flexed position.
Above elbow slab
IndicationsNon displaced fractures of the wristSoft tissue injuries to the wrist or forearmColles fracture
Below elbow slab
Extends from a point about 5 cm below the top of the olecranon to the level just proximal to the knuckles in the dorsum of the hand and the distal crease in the palmar aspect.
The forearm is held with the elbow in a 900 flexed and the wrist in the position of function of 250 dorsiflexion.
The fingers should be free to move fully at the metacarpo-phalangeal joints.
Below elbow slab
IndicationsSoft tissue injuries to 4th and 5th fingers4th n 5th metacarpal fractureFractures of 4th n 5th phalanges
Ulnar gutter slab
measure the plaster from the fifth distal interphalangeal joint to the proximal third of the forearm
Apply the wet plaster, over the padding, to the medial or ulnar surface of the forearm.
The wrist and hand should be in a neutral position. Extend the wrist to 20° and flex the metacarpophalangeal joints to 70°.
Upper limb fractures – conservative management
Clavicle fracture
Group 1 – middle 1/3 (80%)Group 2 – distal 1/3Group 3 – proximal 1/3
Allman classification
More than 90% of clavicle fractures are successfully healed by non-operative treatment.
If the fracture is at the lateral end, the risk of nonunion is greater than if the fracture was of the shaft.
Clavicle fracture
Treatment –Board arm slingRing/quoit methodFigure of 8 bandage
Clavicle fracture
SlingSupport shoulder
girdle, raising lateral fragment upward.
Clavicle - sling
Figure of 8 bandage/brace –
Depress the medial fragment
Elderly patients tolerate clavicular bracing methods poorly
Clavicle - Figure of 8
Why sling or figure of 8?
For 4-6 weeksDuring this period, active range of motion of
the elbow, wrist and hand should be performed.
Immobilization
Acromioclavicular joint injury
Type 1 – sprain of ac ligament2- with coracoclavicular lig sprained3- with joint dislocation4 – clavicle displaced posteriorly5- displaced superiorly6 – inferior displacement
AC joint injury
Type 1-3 – conservative management4-6 – operative
Conservative managementIce packsSling for 2 weeks.
AC - conservative
Sternoclavicular joint injury
Ice for first 24 hrs.
Mild sprain – sling 3-4 daysModerate sprain – sling and swathe/ figure of
8 bandage – 1 week, then sling 4-6 weeksMedial physeal injury – sling n swathe/figure
of 8 bandage for 4-6 weeks
SC joint injury
Scapula fracture
Anatomic Type 1 – scapula bodyType 2 – acromion n coracoidType 3 – scapular neck n glenoid.
Classification
Non Surgical Treatment: - vast majority of scapula fractures may be treated non operatively (extraarticular) - closed reduction of these frx is usually not possible - treatment consists of support of a sling and early motion - most fractures will heal by 6 weeks
Scapula fracture
A simple sling can be used
Scapula fractures
Glenohumeral dislocation
Shoulder – most commonly dislocated major joint
Anterior dislocation commonRecurrence rate – 50%
Closed reduction – Traction countertractionHippocratic techniqueStimson techniqueMilch techniqueKocher maneuver
Post reduction care – immobilzation for 2-5weeks
Anterior glenohumeral dislocation
Hippocratic technique
Milch technique
20-30min
Stimson maneuver
Subacromial Pt supine, traction appllied to adducted arm
in the line of deformityPostreduction – sling and swathe
immobilization for 3-6weeks.
Posterior glenohumeral dislocation
Luxato erectaSalute fashion – humerus 110-160 degrees
abduction and forward elevation
Reduction – traction countertraction maneuvers. Traction in line with humeral position – superiolaterally.
Immobilized in a sling for 3-6weeks.
Inferior glenohumeral dislocation
Very rareForeshortened arm held in adduction
Closed reductionTraction – inferior direction.
Superior glenohumeral dislocation
Fractures of proximal humerus
Neer classification4 parts –Greater tuberosityLesser tuberosityHumeral shaftHumeral head
Displaced if >1cm displacement/ >45 degrees angulation.
Nondisplaced Fractures<5mm of superior or 10 mm of posterior
greater tuberosity displacement in active people
<10 mm of superior displacement in non dominant arm of sedentary paients
When to put patient on non operative treatment
Nonoperative management of proximal humerus fractures usually begins with maximal support - a sling and swath equivalent worn continuously. If the patient is uncomfortable, a sitting position may be preferred for sleeping.
Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
done with asling that supports the elbow and forearm and counteracts the weight of the arm.
Additional support is provided by a swath which wraps around the humerus and the chest to restrict shoulder motion further, and keep the arm securely in the sling.
Sling and swath
Shoulder immobilizationSling and swath (A)Shoulder
immobilizer (B)Gilchrist bandage
(C)
For surgical neck fracturesWhere
disimpactation is undesirable a board arm sling is preferable
Where the fracture is disimpacted, then a cuff and collar has some potential for gravitational correction.
To reduce the risk of stiffness, immobilization should be discarded as soon as possible. This can be done progressively, beginning with elimination of the swath during the daytime and encouraging pendulum exercises.
The sling may be used on a part-time basis as soon as appropriate.
If formal physical therapy has not been prescribed, it should be considered for any patient whose range of motion is not improving as expected.
Danger - shoulder stiffness
Shaft humerus
90% of shaft fractures heal with nonsurgical management
Hanging castCoaption splintVelpeau dressingShoulder spica castFunctional bracing
Hanging castWeight of limb plus
plaster reduce the fracture and maintain reduction
Patient must remain upright/semiupright position with cast in dependent position for effectiveness.
Utilizes dependency traction and hydrostatic pressure to effect fracture reduction.
Indicated for acute treatment of humeral shaft fractures with minimal shortening.
U shaped coaptation splint/ sugar-tong splint
U shaped coaptation splint/ sugar-tong splintU – slab to the arm
and a cuff and collar to the wrist, arm bandaged to side of body
Exchanged for functional bracing 1-2 weeks after injury.
Thoraco brachial immobilization
Indicated for minimally displaced.
Passive shoulder exercises may be performed.
Velpeau dressing
Applied 1-2weeks after injury (after hanging cast/coaptation splint)
Retained until union occurs(usually 9 weeks)
Cuff and collar may be used to support the forearm.
Functional Brace
Distal humeral fractures
Supracondylar fractures
Type 1 - undisplaced or minimally displaced fractures - simple immobilization in a plastercast without any manipulation.
Type 2 - partially displaced - manipulation followed by immobilization in a plaster cast
Type 3 - completely displaced - operative
Classification
Lateral displacement- longitudinal traction exerted by griping patient wrist n forearm.
In full extension .. Distal fragment in line with shaft – due to tension from surrounding soft tissues
Posterior displacement – thumb over olecranon.
Flex the elbow while maintaining traction.
Reduction is then held by cuff and collar in as much flexion as the presence of radial nerve will tolerate and elbow kept inside the clothing.
Correction of displacements
Posterior long arm splint in atleast 90 degrees of elbow flexion with forearm in neutral
Posterior splint immobilization for 1-2 weeks.Then hinged brace for 6 weeks, when
radiographic evidence of healing present.
Supracondylar fracture
Conservative treatmentIndicated for non displacedElderly patients who are debilitated
Transcondylar fracture
Most common distal humeral #
Intercondylar fractures
Type 1 – non displacedType 2 – slight displacement, no rotation of
fragmentsType 3 – with rotationType 4 – comminution of articular surface
Riseborough and radin classification
Indicated for nondisplaced, elderly, with significant comorbid conditions
Options includeCast immobilization Bag of bones – arm placed in cuff and collar
with as much flexion as possible after reduction. The idea is to obtain a pseudarthrosis
Intercondylar fractures
Lateral and medial condylar fractures
Milch classificationType 1 – lateral trochlear ridge left intactType 2 – trochlear ridge part of condylar
fragment
Condylar fractures
Consists of posterior splinting with elbow flexed to 90 degrees with forearm in
supination – for lateral condylar fractures pronation – medial condylar
Condylar fractures
For nondisplaced fracturesImmobilization in posterior splint for 3 weeksFollowed by elbow motion.
Capitellum fractures
Laugier’s fractureExtremely rarePosterior splinting for 3 weeksFollowed by range-of-motion exercises.
Trochlea fractures
A crepe bandage applied over wool to limit swelling and a sling for 3-4weeks is usually adequate.
Lateral – immobilization followed by elbow motion
Medial – immobilization for 10-14 days in posterior splint with forearm pronated, elbow and wrist flexed.
Epicondylar fractures
Immobilization in posterior elbow splint in relative flexion.
Until pain freeFollowed by movement and strengthening
exercises.
Fractures of supracondylar process
Elbow dislocation
Posterior dislocation is most common.
Direction of displacement relative to humerus
PosteriorPosteriolateralPosteriomedialLateralMedialAnterior
Classification
Reduction should be performed with elbow flexed while providing distal traction.
Parvins method and Meyn n Quigleys method
Post reduction x –raysPost-reduction management - Posterior
splint at 90 degrees and elevationRecovery may take 3-6 months.
Proximal forearm fractures
Immobilization of the elbow in a cast or splint is only indicated in undisplaced and stable fractures. A splint may be faster to apply, and easier to remove.
The time of immobilization should be as brief as possible to prevent stiffness of the elbow. Ideally, this would be 2 or 3 weeks.
While the patient is in the cast, finger and shoulder movements are to be encouraged.
Proximal forearm
Above elbow cast with slingAn above elbow cast is
applied with the elbow flexed 90 degrees and the forearm in mid-pronation-supination position. Either fiberglass or plaster cast material may be used.
Avoid constricting the antecubital area.
Trim the cast as needed to protect axilla and around thumb and fingers.
Secure the injured arm with a sling
Olecranon fractures
Type 1 – non displaced Type 2 – displaced – stableType 3 – displaced - unstable
Type 1 managed by non operative
Mayo classification
Long arm cast/splint with elbow in 45-90 degrees of flexion.
Gradual initiation of range of motion after 5-7 days
Cast can be removed after 3 weeks, avoiding active flexion past 90 degrees
Olecranon fracture
Radial head
Classification – mason
Type 1 – nondisplacedType 2 – marginal # with displacementType 3 – comminuted # entire headType 4 – with dislocation of elbow
Radial head fracture
SlingEarly range of motion 24-48hrs after pain
subsides.
Radial head fracture
Nonoperative treatment is indicated in simple transverse fractures with only one bone involved where reduction can be achieved and maintained.
Middle Forearm fractures
Apply a well padded long arm cast in relaxed supination of the forearm.
Apply the cast from the distal palmar crease to the mid-arm with the elbow in 90° flexion, the wrist in slight volar flexion, and the ulna in deviation.
Flatten the volar and dorsal surfaces of the forearm.
Long arm cast
Radius and ulna shaft
nondisplaced – rareLong arm cast in neutral rotation with elbow
flexed to 90 degrees.
Both radius and ulna
Where displacement is slight, conservative treatment may be used.
A long arm plaster should be applied with the hand in mid pronation.
The plaster is retained until the union is advancing(usually about 8 weeks)
Plaster
Ulna fractures
Fracture of proximal ulna accompanied by radial head dislocation.
Monteggia fracture
Type 1 – ant dislocation radial head, #ulna diaphysis
Type 2 – post/postlat dislocation radial head , # ulna diaphysis
Type 3 – lat/antlat dislocation radial head, # ulna metaphysis
Type 4 – ant dislocation radial head with # both radius n ulna within proximal 3rd at the same level.
Closed reduction and casting should be reserved only for pediatric population.
Bado classification
Isolated ulna fracturePlaster immobilization in sugar tong splint for
7-10daysFollowed by functional bracing for 8 weeksOr immobilzation in a sling with compression
wrap.
Nightstick fractures
Suitable for isolated ulnar fractures.
Timing of the change from cast to brace should be after 10 days.
The sleeve should be molded firmly into the interosseous space.
The brace should not limit elbow or wrist flexion or extension and only slightly limit pronation and supination.
The brace should be adjusted following decreasing swelling and may be removed for hygienic purposes.
Ulnar sleeve
Galeazzi # - # of radial diaphysis at junction middle n distal 1/3rd with disruption of distal radioulnar joint.
Fracture of necessity
Closed treatment associated with high failure rate.
Radial shaft
Distal forearm fractures
Distal radius fractures
Gartland and werleyFrykman - based on pattern of intraarticular
involvementFernandez – mechanism based classificationAOMayoMeloneEponymic
Classification
CollesSmithBartonChauffer’s fracture
Distal radius fractures - eponyms
Length – within 2-3mm of other wristPalmar tilt -0, dorsal angulation upto 10
degreesRadial inclination - <5 degree loss
Radiographic parameters for acceptable reduction
Colle’s fracture
A Colles fracture, is a distal fracture of the radius in the forearm with dorsal (posterior) displacement of the wrist and hand. ( at cortico-cancellus junction)
Dinner fork deformity
Colles
Manual reductionAs a principle, the first
step in reduction is to disimpact the distal fragment by increasing the dorsal angulation.
Then, with traction applied, the distal fragment is pushed distally, and flexed, in order to reduce the palmar cortex and to restore palmar inclination. Any traction is then released.
Change the grip to allow free application of the plaster.One hand holds the thumb fully extended.The other holds three fingers (avoiding cupping of the hand) maintaining slight traction.The limb should be in full pronation, full ulnar deviation at the wrist and slight palmar flexion.
Plaster application
Colle’s cast
Smith’s fracture
The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles' fracture which the fragment is displaced dorsally.
Garden spade deformity
Smith’s fracture
As a principle, the first step in reduction is to disimpact the distal fragment of a Smith’s fracture by increasing the palmar angulation. Then, with traction applied, the distal fragment is pushed distally, and extended, in order to reduce the dorsal cortex and restore normal inclination. Any traction is then released.
Smiths fracture
an above elbow cast is retained for 6-8 weeks. It may be changed, with careful maintenance of position, at 2-3 weeks.X-rays are taken at 5 days, 10 days and 3 weeks to check fracture reduction.
Casting above elbow
Bartons fracture
A Barton's fracture is an intra-articular fracture of the distal radius with dislocation of radiocarpeljoint.
Barton’s fracture
Bartons fracture Manual reduction With traction applied, the
distal fragment is pushed distally, and flexed in order to reduce the palmar cortex and restore palmar inclination. Any traction is then released.
The heel of one hand is used as a fulcrum. Firm pressure, directed anteriorly corrects remaining posterior displacement or anterior angulation, visible in lateral x-rays.
The above elbow cast is maintained for 6-8 weeks, but may be changed at 2-3 weeks, with careful maintenance of position. Check x-rays must be taken at 4 and 12 days to monitor fracture
Casting above elbow
Fracture of scaphoid
Scaphoid fracture
A scaphoid cast. it goes above the patient's elbow, that it ends just proximal to his distal palmar crease and the interphalangeal joint of his thumb, and that his thumb is able to touch his index finger.
Scaphoid cast
Tuberosity fractures: 6 weeks. At that time, check x-rays and start physiotherapy.
Undisplaced waist fractures: 8-12 weeks. If union is not achieved by this time, continue with immobilization for an extra 4 weeks.
Duration of immobilization
Fractures of hand
Stable fractures – buddy taping or splinting, with repeat radiographs in 1 week.
Unstable fractures – reduced. - immobilization with cast, cast with outtrigger splint, gutter splint or anterio-posterior splints.
Buddy strapingAdjacent non injured finger is used as a
splint.
General considerations
Fracture of metacarpels
Stable reductions - splinted in position – metacarpal-phalangeal flexion >70 degrees to minimize joint stiffness.
Metacarpal head
Fracture of metacarpelsDisplacement
usually occurs as a flexion deformity that can be reduced by exerting pressure on the metacarpal head from the palmar aspect, either directly, or using the proximal phalanx as a piston.
A splint may be applied with the hand in an intrinsic plus (Edinburgh) position and the wrist in slight extension of 20-30 degrees.
Immobilization with palmar splint
A standard forearm cast is applied, including the wrist joint in 30 degrees of extension, and the aluminium splint is incorporated in the cast.
This aluminium splint must be pre-bent to 90 degrees proximal to the level of the MCP joint of the injured finger. The finger is taped to this splint in an intrinsic plus position. Correct rotational alignment must be checked. The other fingers are not immobilized.
Immobilization with a forearm cast and finger splint
Attelle fonctionelleThis technique
allows immediate mobilization of the interphalangeal joints of all fingers. Its application, however, is difficult, and correct exercising must be supervised by a hand therapist.
Bennet’s fracture
Bennet’s fractureBennett’s injury is a
fracture subluxation of the first carpo-metacarpal joint.
During the application of the plaster, it is important to exert pressure from the dorsal aspect onto the first metacarpal base, and from the palmar aspect over the first metacarpal head.
Immobilize the wrist in a well-padded below-elbow cast with the wrist slightly extended, and the thumb immobilized in a position of slight abduction, with appropriate moulding of the cast.
Rolando’s fracture
Rolando’s fracture is a 3-part intraarticular fracture of the base of the thumb metacarpal. A T- or Y-shaped fracture, a comminuted bennett fracture or a fracture with dorsal and palmar fragments.
Rolandos fracture
Rolando’s fractureImmobilize the
wrist in a well-padded below-elbow plaster with the wrist slightly extended, and the thumb immobilized in a position of slight abduction
Finger fractures
Fractures of proximal phalynx
Reduction is achieved by applying longitudinal traction to the finger and flexing the MCP joint.Rotational malalignment is also corrected
Fracture of proximal phalynx
Immobilization with palmar splintImmobilization with a forearm cast and finger
splintAttelle fonctionelle
Proximal phalynx
Fractures of distal phalynx
Using a dorsal splint has the advantage of leaving the patient with the ability to pinch while the digit is immobilized.
Do not immobilize the PIP joint.
Fractures of distal phalynx
Baseball finger/dropped fingerFracture of dorsal lip with disruption of
extensor tendon.
Full time extension splinting for 6-8 weeks.
Mallet finger
Conservative treatment -
Mostly for undisplaced or minimally displaced fractures
Slab thickness for upper limb – 10-12 layers of plaster
Joints not included in cast/slab must be exercised.
Regular checkup x-rays to see for union.Generally immobilization for around 6 weeks.
Summary
Fracture Time for it to HealCollar bone (clavicle) 3-8 weeks
Shoulder blade (scapula)
6 weeks
Upper arm (humerus)
4-10 weeks
Lower arm (radius,ulna)
6 weeks
Wrist 4-12 weeksFingers 4-6 weeks
Time to heal
The endPresentation by Pendurthi Suneel