management of fractures - dr matthew sherlock
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Management of common upper limb fractures in Adults and Children
Dr Matthew SherlockShoulder and Elbow Orthopaedic Surgeon
Outline Immobilisation choicesAdults
Clavicle FracturesProximal Humeral FracturesWrist Fractures
ChildrenElbow FracturesForearm Fractures
Immobilising Upper Limb #s Immobilisation choices
Slings – triangular, immobiliserCollar and cuffPlaster
Backslab, full cast (short arm, long arm), U-slab, hanging cast
Removable splintsBraces
Choice is determined by forces displacement
Immobilising Upper Limb #sClavicle/AC joint injuries
Weight of arm displacement
Immobilising Upper Limb #sClavicle/AC joint injuries
Weight of arm displacement
Support arm with sling +/-waist strap
Immobilising Upper Limb #s Proximal humerus
Involving tuberosities Pull of rotator cuff displacement Prevent active movement of arm,
Immobilising Upper Limb #s Proximal humerus
Involving tuberosities Pull of rotator cuff displacement Prevent active movement of arm,
waist strap important.
Immobiliser sling
Immobilising Upper Limb #sProximal humerus
MetaphysisRotator cuff balancedFracture angulation worsened
Axial load Shoulder extension
Immobilising Upper Limb #sProximal humerus
MetaphysisRotator cuff balancedFracture angulation worsened
Axial load Shoulder extension
Collar and Cuff
Immobilising Upper Limb #s Humeral Shaft
Muscle pull displacement Pectoralis major/ lat dorsi Deltoid
Immobilising Upper Limb #s Humeral Shaft
Muscle pull displacement Pectoralis major/ lat dorsi Deltoid
Gravity maintains alignment Arm should hang
Plaster immobilisation possible
Immobilising Upper Limb #s Humeral Shaft
Muscle pull displacement Pectoralis major/ lat dorsi Deltoid
Gravity maintains alignment Arm should hang
Plaster immobilisation possible
U-Slab plaster
Immobilising Upper Limb #s Humeral Shaft
U-slab Uncomfortable, heavy Temporary
U-Slab plaster
Immobilising Upper Limb #s Humeral Shaft
U-slab Uncomfortable, heavy Temporary Change to Sarmiento brace after
1-2 weeks.
Functional brace
Immobilising Upper Limb #s Elbow Fractures
Adults Ideally don’t immobilise elbow for
more than 3 weeks! Commonly surgery is indicated to
enable stable fixation and early ROM
Immobilising Upper Limb #s Elbow Fractures
Children Supracondylar #
Stable in flexion
Immobilising Upper Limb #s Elbow Fractures
Children Supracondylar #
Stable in flexion
Positioning arm in flexion is more important than the actual plaster
Immobilising Upper Limb #s Elbow Fractures
Children Supracondylar #
Stable in flexion
Positioning arm in flexion is more important than the actual plaster
Immobilising Upper Limb #s Forearm Fractures
Clavicle fracturesMidshaft – most common
Distal
Medial - uncommon
Clavicle fracturesMechanism of injury
Clavicle fractures Initial treatment
Very painful fractureArm immobiliser not
collar and cuff Figure 8 bandage
Ice
Midshaft Clavicle fracturesAll undisplaced fractures can be
treated conservatively Immobiliser slingDiscontinued once pain subsides (3-5
weeks)Self administered ROM and strengthening
Midshaft Clavicle fractures Indications for surgery
Absolute Open fracture, skin compromise Progressive neurological deficit
Relative Shortening Displacement/comminution Non-union
Midshaft Clavicle fracturesHow much shortening?
Ledger et al. JSES 2004
Biomechanical and anatomical CT study Patients with clavicular malunion >15mm
Reduction of muscular strength of adduction, extension, and internal rotation
Reduced peak abduction velocity
Increased upward angulation of clavicle at SCJ and increased anterior scapular version
Midshaft Clavicle fracturesHow much shortening?
Assessment Clinical measurement
Midshaft Clavicle fracturesHow much shortening?
Assessment Clinical measurement Assess scapular position
Midshaft Clavicle fracturesHow much shortening?
Assessment Clinical measurement Assess scapular position Radiology – Xray/CT
Midshaft Clavicle fracturesSurgical Options
Plate fixation Intramedullary screw
Midshaft Clavicle fracturesPlate fixation
ComminutionSoft bone/smokers Less compliant patients
Midshaft Clavicle fractures Intramedullary screw
2 part fracturesYoung patients (girls)Avoid above shoulder
ROM first 6 wks
Distal Clavicle FracturesBeware of these fractures!
High non-union rate when displaced
Displacement often missed
Treatment also determined by relationship to and the integrity of the CC ligs
Distal Clavicle FracturesDisplaced fractures require surgery in all
but the elderly (low demand) patient.
Distal Clavicle FracturesBeware of inadequate imaging
Distal Clavicle FracturesBeware of inadequate imaging
Distal Clavicle FracturesBeware of inadequate imaging
Distal Clavicle Fractures Initial management
with immobiliser sling
Non-operative Rx for undisplaced fractures with intact CC ligs
Distal Clavicle FracturesSurgical management
Distal Clavicle FracturesSurgical management
Proximal Humerus FracturesThird most common fracture after hip
fracture and Colles fracturesMore common in femalesHistorically 15-20% required surgeryThey generally result in some long term
functional disability
Classification SystemsNeer
Classification SystemsAO/ASIF
Surgical decision making
Not bad enough for surgery Too bad to fix
Surgical decision making
Sling/ Collar & Cuff Hemi/Reverse TSA
Not bad enough for surgery Too bad to fix
Surgical decision making
Sling/ Collar & Cuff ORIF Hemi/Reverse TSA
Not bad enough for surgery Too bad to fix
Surgical decision making
Sling/ Collar & Cuff ORIF Hemi/Reverse TSA
Goal is maximum shoulder function and minimal shoulder pain.
Not bad enough for surgery Too bad to fix
Surgical decision makingDisplacement and angulation
Painful Impingement Significant ROM loss Risk of non-union
Neer – 1cm and or 45 degrees???
Surgical decision makingNon-op vs ORIF vs Prosthesis
Determined by risk of AVN age of patient Medical comorbidities Bone quality Functional demands
Surgical decision makingNon-op vs ORIF vs Prosthesis
Determined by risk of AVN age of patient Medical comorbidities Bone quality Functional demands
Greater Tuberosity Fracture Usually displaced
posteriorly (by infraspinatus) and superiorly (by supraspinatus)
>5mm requires reduction previously 1cm shown to have poor
outcomes. Depends on fragment size and
articular involvement Superior displacement – impingment in
abduction
Greater Tuberosity Fracture Undisplaced
Immobiliser sling for 5-6 wks until healed
Elbow ROM Watch closely for displacement
Greater Tuberosity FractureLarge fragment
Screw fixation – open/arthroscopicTension band suturingAnchors
Greater Tuberosity FractureLarge fragment
Screw fixation – open/arthroscopicTension band suturingAnchors
Greater Tuberosity FractureLarge fragment
Screw fixation Tension band suturingAnchors
Advanced Fracture Management Course
Approach:mini deltoid split/ arthroscopic
Greater Tuberosity FractureLarge fragment
Screw fixation – open/arthroscopicTension band suturingAnchors
Small fragmentTreat like a cuff tear
Arthroscopic repair
Greater Tuberosity FractureMy Preference
Large fragment good bone Screw fixation (mini-open or
arthroscopic)
Small fragment or large with soft bone Suture anchor fixation
(Intraosseous equivalent/bridge)
Lesser Tuberosity Fracture Rare If large and displaced block
internal rotation Open reduction and screw
fixation +/- biceps tenodesis.
Surgical Neck FractureAcceptable displacement and
angulation depends on: patients age activity level functional demands
Surgical Neck FractureSkeletally immature
Adults
Patient Age (yr) Allowable Displacement or Angulation
<5 Up to 70 degrees angulation, 100% displacement
5–12 Up to 40–70 degrees angulation
>12 Up to 40 degrees angulation, <50% displacement
2 Part Surgical Neck FractureOptions
Closed reduction + Kwires Intramedullary nailCirclage suturesPlate fixation
2 Part Surgical Neck FractureClosed reduction + Kwires
2 Part Surgical Neck FracturePlate fixation
2 Part Surgical Neck FracturePlate fixation
3 and 4 Part Fractures
3 and 4 Part FracturesSurgical Treatment Options
Open reduction + K wiresCirclage wires/sutures + Rush pins/Enders
rodsCRKW (Resch) Intramedullary nail Locking plate
(hemiarthroplasty/reverse)
3 and 4 Part FracturesSurgical Treatment Options
Open reduction + K wiresCirclage wires/sutures + Rush pins/Enders
rodsCRKW (Resch) Intramedullary nail Locking plate
(hemiarthroplasty/reverse)
Historical
Technically difficult
3 and 4 Part FracturesApproach
Deltopectoral
Mini-deltoid split – Percutaneous plating
(Extensile lateral)
Percutaneous Plating Beach chair Spider arm holder
Percutaneous Plating Beach chair Spider arm holder II – opposite side
Percutaneous Plating Beach chair Spider arm holder II – opposite side
Lateral deltoid split
Percutaneous Plating Get control of
tuberosities LT + biceps tenodesis GT
Percutaneous Plating Get control of
tuberosities LT + biceps tenodesis GT Elevate head if
impacted
Percutaneous Plating Get control of
tuberosities LT + biceps tenodesis GT Elevate head if
impacted
Percutaneous Plating Insert plate under
deltoid/axillary nerve
Percutaneous Plating Lock proximally and
distally
Percutaneous Plating Lock proximally and
distally
Percutaneous Plating Final images
AP Lateral Axillary view
Percutaneous Plating Final images
AP Lateral Axillary view
Percutaneous Plating
Percutaneous Plating Bone grafting
Elevation of valgus impacted fracture
Cancellous bone defect ?possible cause of late
failure and collapse
Injectible bone graft Ca PO4 Sets hard – support
head, fixation for screws
Deltopectoral Approach I use DP approach
when: Extensive medial
calcar/shaft extension Excessive rotation of
head fragment Head split (access
through rotator interval)
Deltopectoral Approach
Deltopectoral Approach Fracture reduction techniques
Double plating method
Some fractures are too comminuted to get stable fixation with 1 plate
Deltopectoral Approach Fracture reduction techniques
Double plating method
Some fractures are too comminuted to get stable fixation with 1 plate
Use orthogonal platesfor increased strength
Distal Humeral FracturesSupracondylar
Extension Type – COMMON!!Flexion Type (rare)
EpiphysealEpicondylarCondylar
Supracondylar FracturesExtension Type
Grade 1 (Undisplaced)
Grade 2 (Partially)
Grade 3 (Completely)
Supracondylar FracturesExtension Type
Unstable in extension
Reduction is maintained with elbow held FLEXED!!!
FLEXION IS MORE IMPORTANT THAN PLASTER IMMOBILISATION
Supracondylar Fractures This treatment is worse
than nothing at all!
Plaster is dead weight on fracture!!
Supracondylar Fractures This treatment is worse
than nothing at all!
Plaster is dead weight on fracture!!
Apply collar and cuff in flexion.
Leave on until fracture union (3-4 wks)
Shirts over the top!
Supracondylar Fractures Mx
Grade 1
Collar & Cuff in flexion for 3/52
+/- Backslab
Supracondylar Fractures MxGrade 2
Closed Reduction under anaesthetic
If unstable (rotationally) – add K-wires
Immobilize in flexion
Supracondylar Fractures MxGrade 3
Usually severely swollen
delay increases difficulty of reduction
Vascular compromise Neurological deficit -
AIN
Occasionally open reduction required!
Supracondylar FracturesComplications
Early Arterial Injury Compartment Syndrome Nerve Palsy
Late Volkmann’s Ischaemic Contracture Malunion
Complications: Cubitus Varus
Residual Posteromedialdisplacement results in internal rotation and varus deformity of the distal fragment.
This results in loss of the normal carrying angle, the so-called “gunstock” deformity.
Complications: Cubitus Varus
Bauman’s angle
Lateral Condyle Fractures15% of elbow fractures in childrenMechanism:
Avulsion secondary to FOOSH with forearm supinated.
Compression injury secondary to FOOSH with elbow flexed.
Lateral Condyle Fractures:Milch Classification
Type IType II
Lateral Condyle Fractures:Treatment
Can be confused sometimes with a supracondylar fx - cannot make this mistake.
Lateral Condyle Fractures:TreatmentNondisplaced: Immobilization in simple
backslabDisplaced: Reduce and pin.
Why reduce? Congruent joint surface Prevent nonunion Prevent growth arrest
Usually Open Reduction, then 2 pins Immobilize 6 weeks, then remove pins.
Lateral Condyle Fracture
Lateral Condyle Fracture
Lateral Condyle Fracture
Elbow Dislocations
Reduce Immobilise in backslab
for 3 weeks
Elbow Dislocations
Reduce Immobilise in backslab
for 3 weeks
Make sure radial head reduced
Elbow Dislocations
Reduce Immobilise in backslab
for 3 weeks
Make sure radial head reduced
and medial epicondyle is not in joint!
Medial epicondyle fractures Incarcerated medial epicondyle
Incarcerated
Medial epicondyle fractures Incarcerated medial epicondyle
Open reduction internal fixation
Elbow dislocationDisplaced radial neck fracture
Elbow dislocationDisplaced radial neck fracture
Open reduction K-wire fixation
Forearm FracturesDistal radius fractures most common
upper limb paediatric fracture > supracondylar fractures >shaft fractures
Forearm fracture most commonly associated with the trampoline!
Treatment more difficult the more proximal the fracture
Forearm FracturesTreatment is determined by:
Age of patient (remodelling potential)Displacement
Angulation, translation, rotation, shorteningCosmetic appearanceAim to restore forearm rotation
Forearm FracturesPlastering techniques
Maintenance of reduction requires 3 point moulding
Forearm FracturesPlastering techniques
Maintenance of reduction requires 3 point moulding
Distal Third FracturesBuckle or Torus Injuries
Minimally displaced
Stable
3-4/52 in cast – short arm sufficient
Distal Third FracturesDisplaced Greenstick Fractures
? Reduce
If 20 Degrees of tilt or
If clinically deformed
Distal Third Fractures Complete Fractures
CR & POP +/- wires Above elbow cast
Redisplacement common
Careful FU
Remodel well
Distal Third Fractures
Distal Third Fractures
Distal Third Fractures
Distal Third Fractures
Distal Third FracturesEpiphyseal
Injuries
Usually Salter Harris I or II
Displaced – reduction and short arm cast
Remodel well
Don’t manipulate late
Forearm Shaft Fractures
Less remodelling Accept less than 10 degrees angulation
Closed reduction under GA Always above elbow moulded cast
Warn parents the cast will look bent!
Recheck Xray 1 week 5% redisplacement rate
Plaster for upto 6 weeks
Forearm Shaft Fractures
Isolated radius fracture
Forearm Shaft Fractures
Isolated radius fracture
Forearm Shaft Fractures
Both bones shaft fracture
Forearm Shaft Fractures
Both bones shaft fracture
Forearm Shaft Fractures
Both bones shaft fracture
Forearm Shaft Fractures
Both bones shaft fracture
Monteggia Fracture Dislocation Ulna fracture mid to
proximal 1/3 Radial head dislocation
Line through radial shaft and head BISECTS capitellum in ANY VIEW
Never accept ISOLATED ulna fracture
Examine & X-ray joint above and below
Monteggia Fracture Dislocation Ulna fracture mid to
proximal 1/3 Radial head dislocation
Line through radial shaft and head BISECTS capitellum in ANY VIEW
Never accept ISOLATED ulna fracture
Examine & X-ray joint above and below
Adult Distal Radius Fractures Most common adult fracture Usually in elderly due to
osteopenia/porosis Usually associated with high energy
trauma in young adults
Adult Distal Radius Fractures Types:
Colles Smiths Bartons Chauffeurs Intraarticular
Generally plain Xray adequate CT scan if intraarticular involvement
Adult Distal Radius Fractures Surgical Indications:
Loss radial length 3mm or more
Adult Distal Radius Fractures Surgical Indications:
Loss radial length 3mm or more Decreased radial inclination
Adult Distal Radius Fractures Surgical Indications:
Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees
Adult Distal Radius Fractures Surgical Indications:
Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees Step in articular surface 2mm or more
Adult Distal Radius Fractures Surgical Indications:
Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees Step in articular surface 2mm or more
Other indications: open #, progressive neurological deficit.
If redisplacement outside these limits can be avoided with plaster best outcomes.
Adult Distal Radius Fractures Factors that make failure of
conservative management more likely: Dorsal comminution Osteopenia High energy injury
Adult Distal Radius Fractures Conservative management:
Plaster for 6 week Short arm cast only Physiotherapy
Adult Distal Radius Fractures Locking plate fixation
New locking plates have dramatically improved surgical outcomes
Early therapy has improved patients return in range of motion and function
Adult Distal Radius Fractures Locking plate fixation
New locking plates have dramatically improved surgical outcomes
Early therapy has improved patients return in range of motion and function
Recommended treatment for displaced unstable fractures in adults is: Locking plate fixation Early range of motion, with removable splint
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