Dr. Rami Abo Ali

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
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2. INJURIES TO THE UPPER LIMB ( 2 )
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
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3. PROXIMAL HUMERUS FRACTURES
 This type of fracture occur in old and middle age osteoporotic
people .
 In the majority of the cases displacement is not marked , only 20%
of cases has considerable displacement .
 The fracture occur due to fall on out stretched arm
 Proximal humerus include 4 major components these are :
1. head of humerus .
2. greater tuberosity .
3. lesser tuberosity .
4. surgical neck of the humerus .
 Classification of this fracture called neer classification .
 Clinically : history of trauma , pain ,loss of function , swelling ,
bruises on the skin , sign of axillary nerve or brachial plexus injury
may be detected .
 X-ray :a-p , lat.view or axillary view should be taken to exclude
associated dislocation .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

4. PROXIMAL HUMERUS FRACTURES
 Treatment :
 Minimally displaced fracture (majority) need only sling of the
arm for 3 weeks until the pain subside and then gentle
passive movement is advised ; active movements is
encouraged after 6 weeks .
 If there is considerable displacement of one or more of the 4
components , then manipulation is advised , if fail then open
reduction and fixation .
 If the fracture is 4 peaces and displaced and the patient is old
then do prosthetic replacement of the proximal humerus .
 Complication :
 Early : neurovascular injuries (axillary n. , a.)
 Late :
 stiffness of the shoulder ; this can minimized by early mobilization .
 avascular necrosis of the head of the humerus . 4
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

5. 5
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

6. HUMERAL SHAFT FRACTURES
 This fracture caused by fall on out stretched Hands or by
direct blow on the arm .
 Fracture above the deltoid insertion (deltoid tuberosity), the
proximal segment is adducted by pectoralis major muscle ,
and if the fracture below the deltoid insertion then the
proximal segment is abducted by the effect of the deltoid
muscle .
 Injury to the radial nerve is common with this fracture
mainly at the junction of the upper two third and the lower
one third of the shaft due to close contact of the nerve to the
bone at that site so it is very important to test for the radial
nerve function with this fracture before and after treatment
and this is done by assessing active extension of fingers and
wrist . 6
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

7. HUMERAL SHAFT FRACTURES
 Treatment :
 Conservative treatment : this include hanging cast which is p.o.p cast made
from the arm to the wrist with elbow flexed 90`, the limb is slinged from the
wrist so the weight of the cast will pull the fragments into alignment this can
be left for 2-3 weeks and then replaced by shoulder to elbow cast (u-shape
slab) for further 4-6 weeks .
 Exercise of the wrist and the fingers should be started from the beginning to
avoid stiffness.
 Exercise of the shoulder should be started as early as possible to avoid
stiffness( mainly in elderly).
 Operative treatment :
 Types of fixation :
 compresion plate and screws .
 inter locking intra medullary nail .
 external fixators .
 Indications of fixation :
 sever multiple injuries .
 open fracture .
 segmental fracture .
 pathological fracture .
 radial nerve palsy after manipulation .
 non-union .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

9. HUMERAL SHAFT FRACTURES
 Complications :
 Early :
 vascular injury (brachial artery)
 nerve injury ; radial nerve
palsy will cause wrist drop
 Late complication :
 Delayed union and non union .
 Malunion (angulation )
 Joint stiffness (minimized by
early activity).
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

10. DISTAL HUMERUS FRACTURES
 Fractures of adult distal humerus are relatively
uncommon (extra-articular ,intra-articular )
 Distal humerus fractures are most often caused
by:
 Falling directly on the elbow
 Receiving a direct blow to the elbow from
something hard
 Falling on an outstretched arm with the
elbow held tightly to brace against the fall
 Treatment Principles
 1. Anatomic articular reduction
 2. Stable internal fixation of articular surface
 3. Restoration of articular axial alignment
 4. Stable internal fixation of the articular segment to
the metaphysis and diaphysis
 5. Early range of motion of the elbow 10
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

11. DISTAL HUMERUS FRACTURES
 Treatment
 Nonoperative
 cast immobilization
 Operative
 Closed reduction and percutaneous pinning
(CRPP)
 Open reduction internal fixation (ORIF)
 Total elbow arthroplasty
 Complications
 Elbow stiffness (most common)
 Heterotopic ossification
 Nonunion
 Malunion
 cubitus valgus (lateral column fractures)
 cubitus varus (medial column fractures)
 AIN injury
 Ulnar nerve injury
 DJD
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
Heterotopic
ossification

12. BICEPS TENDON RUPTURE
 A biceps rupture is a condition characterized by
complete tearing of one or more tendons or
muscle bellies of the biceps muscle.
 Rupture of the biceps tendon often occurs after
a sudden contraction of the biceps with
resistance to flexion and supination of the
forearm.
 Patient often experiences a painful “pop” as
the elbow is eccentrically loaded from flexion to
extension.
 When the proximal biceps tendon ruptures, the
muscle moves towards the elbow and becomes
a big ball of muscle called the Popeye sign.
 Distal biceps tendon rupture typically occurs in
athletes such as body builders or in people who
perform manual labour
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

13. BICEPS TENDON RUPTURE
 Signs and symptoms
 Sudden sharp acute pain in the upper arm
 Tenderness
 Weakness
 Sometime an audible pop or snap
 Bicep muscle cramp
 Bruising from the middle of the upper
arm down to ward the elbow
 Difficulty turning the arm palm up or palm
down a bulge in the upper arm above the
elbow
 ("Popeye Muscle") may appear
 Treatment
 Conservative ( especially in elderly and
proximal rupture ) (analgesics, ice packs,
rest)
 Surgical ( young athletes )
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

14. LATERAL/MEDIAL EPICONDYLITIS
 The common term “tennis elbow” refers to lateral epicondylitis
which affects the origin of the wrist extensor muscles, while the
term “golfer’s elbow” refers to medial epicondylitis which affects
the origin of the flexor/pronator muscles.
 Epicondylitis is an overuse injury in which the rate of tendon
damage exceeds the rate of tendon repair. This disequilibrium
causes pain at the elbow and, ultimately, leads to impaired
function - primarily in tasks that involve a power grip and require
a stable wrist joint.
 Patients with epicondylitis present with a chief complaint of pain
in the elbow on the affected side, especially with grasping.
 Patients with epicondylitis often volunteer a history of repetitive
forearm use, including sports involving rackets or bats, but also
occupational activities such as working with tools. 14
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

15. LATERAL/MEDIAL EPICONDYLITIS
 Treatment :
 It is best treated initially by a
period of relative rest ,
avoiding provocative activities
 Splinting the wrist may also be
helpful for this elbow pain
 Simple analgesics alongside
topical NSAIDs should be
prescribed to help with the
pain
 Physical therapy
 Cortisone injections
 Autologous blood products -
eg, platelet-rich plasma (PRP) 15
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

16. FRACTURES AROUND THE ELBOW IN CHILDREN
 There are six epiphysis
around the elbow.
 C-R-I-T-O-E: Capitellum,
Radial head, Internal
(medial) epicondyle,
Trochlea, Olecranon,
External (lateral) epicondyle
 Time of their appearance:-
C-1
R-3
I-5 “CRITOE”
T-7
O-9
E-11.
 These epiphysis
generally unite 2 years
after they first appear 16
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

17. FRACTURES AROUND THE ELBOW IN CHILDREN
SUPRACONDYLAR FRACTURE OF THE HUMERUS
 It is very common fracture in children , and according to the
displacement of the distal segment the fracture will be of two types :
 Extension type : it is the most common type about 95% of the cases , it is
occur due to fall on out stretched hand , the humerus breaks just above the
condyles , the distal fragment is displaced backward .
 Flexion type : it is due to direct blow on the elbow posteriorly ; it is rare
 Classification :
 Type I: undisplaced fracture .
 Type II: angulated fracture with the posterior cortex is still in continuity .
 Type III: completely displaced fracture .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

18.  Clinically :
 History of fall on out stretched hand , the child is in
pain , swelling , deformity .
 It is very important to check the distal pulsation
(radial pulse) and capillary refilling to asses the distal
circulation , also checking the nerves for any injuries (
mainly the median nerve ) .
 X-ray : the fracture is seen clearly in A-P , and lateral
views .
 In undisplaced fracture the fat-pad sign which is
triangular lucency in front of the distal humerus this
will raise the suspicion of the fracture.
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Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
FRACTURES AROUND THE ELBOW IN CHILDREN
SUPRACONDYLAR FRACTURE OF THE HUMERUS

19.  Treatment :
 Non-operative : long arm
casting with less than 90° of
elbow flexion
 Operative
 closed reduction and
percutanous pinning (CRPP)
 open reduction,
percutaneous pinning
 Complications
 vascular damage
 nerve damage (most
commonly the anterior
interosseous nerve (AIN))
 Malunion
 Cubitus valgus
 Cubitus varus
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
FRACTURES AROUND THE ELBOW IN CHILDREN
SUPRACONDYLAR FRACTURE OF THE HUMERUS

20. FRACTURES AROUND THE ELBOW IN CHILDREN
FRACTURE OF THE LATERAL EPICONDYLE OF THE HUMERUS
 The most common mechanism of
injury is a fall onto an outstretched
arm with the elbow in varus, which
causes avulsion of the lateral
humeral condyle
 The fracture piece although it look
small in the x-ray but it in fact is
large and it pulled by extensor
muscle of the wrist which attached
to it .
 In sever cases the piece is rotated
by the action of the extensor
muscle and become capsized lead
to nonunion later on if not treated .
 Clinically :
 The elbow swollen and deformed ,
tenderness at the site of the
fracture .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

21. FRACTURES AROUND THE ELBOW IN CHILDREN
FRACTURE OF THE LATERAL EPICONDYLE OF THE HUMERUS
 Treatment :
 If there is no or minimal displacement
we can do back slab above the elbow
which is 90` flexed and the forearm is
neutral ; after 7 days repeat the x-ray
for checking and full p.o.p. for 3-4
weeks , followed by active
physiotherapy
 Displaced fracture need open
reduction and fixation by K-wire or
screw .
 Complications :
 Stiffness
 Delayed Union
 Nonunion
 Cubitus Valgus ± tardy ulnar nerve palsy
 Lateral overgrowth/prominence
(spurring)
 Growth arrest
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

22. FRACTURES AROUND THE ELBOW IN CHILDREN
FRACTURE MEDIAL EPICONDYLE OF THE HUMERUS
 It is occur due to fall on out stretched hands ; the medial epicondyl is
avulsed by the effect of the strong flexor muscles of the wrist .
 The most common mechanism of injury is an avulsion that can occur as a
result of a valgus stress
 If the elbow joint is dislocated or subluxated even momentarily , the
fracture piece may introduced into the joint .
 Clinically :
 History of trauma , pain and tenderness , swelling , sensation and power
of the fingers should be tested to exclude ulnar nerve damage .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

23. FRACTURES AROUND THE ELBOW IN CHILDREN
FRACTURE MEDIAL EPICONDYLE OF THE HUMERUS
 Treatment :
 Minor displacement less than 5
mm. need only back slab in
elbow flexed , after 7 days do
full p.o.p. for 2-3 weeks
 If the piece is trapped into the
joint , then it must be freed
either by manipulation under
anesthesia , if failed or the
piece is severely displaced then
we should do open reduction
and fixation by K wire or screw .
 Complication : early : ulnar
nerve damage .
 late : stiffness of the elbow . 23
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

24. PULLED ELBOW ( NURSEMAID'S ELBOW )
 If children under 4 years of
age are lifted by their hands
the radial head can slip partly
out of the annular ligament.
The child will experience pain,
will not use the arm, and the
radiographs will be normal.
 Treatment
 While holding the arm
supinated the elbow is then
maximally flexed , the
physician’s thumb applies
pressure over the radial head
and a palpable click is often
heard with reduction of the
radial head 24
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

25. DISLOCATIONS OF THE ELBOW
 Although the elbow is a mechanically
stable joint, it can be dislocated by a fall
on the outstretched arm in almost full
extension .
 Elbow dislocations are the most common
major joint dislocation second to the
shoulder
 It is the most common dislocated joint in
children
 Posterolateral dislocation is the most
common type of dislocation (80%)
 Treatment
 closed reduction and splinting at least 90°
for 10 days, early therapy
 Operative
 Complications
 Joint stiffness
 Ectopic ossification
 Neurovascular injuries
 Recurrent instability
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

26. OLECRANON FRACTURE
 The olecranon is easily fractured in
direct falls onto the point of the
elbow because the lower end of the
humerus acts like a chisel and splits
the olecranon at its narrowest point
.
 Avulsion injuries due to the pull of
the triceps muscle are also
common.
 Treatment
 Unless the fragments are
undisplaced, which is unusual,
internal fixation is needed, using
either a screw or tension band
wiring .
 Comminuted fractures in which the
fragments cannot be reassembled
and fixed can be treated by excision
of the olecranon, especially in the
elderly 26
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

27. FRACTURES OF THE RADIAL HEAD AND NECK
 mechanism of injury : fall on outstretched
hand (elbow in extension + forearm in
pronation ) most force transmitted from wrist
to radial head.
 Treatment
 Treatment varies according to the type of
fracture.
 Undisplaced fractures and those with little
displacement need blood aspirating from the
joint, a soft supporting bandage and early
mobilization.
 Displaced fractures through the radial neck
with more than 30° of angulation cause a
painful restriction of pronation and supination
if left untreated.
 The displacement should be corrected, by
open reduction if necessary.
 Comminuted fractures. Grossly displaced or
comminuted fractures of the radial head are
best treated by radial head excision and early
mobilization.
 Prosthetic replacement of the radial head has
been tried but excision is usually preferred
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

28. FRACTURES OF THE RADIUS AND ULNA
 Mechanism of injury :
 Fractures of the shaft of both bones occur
commonly in road traffic accidents , it can
ben caused by :
 twisting force , which cause spiral fracture in
both bones in different levels .
 direct blow , lead to transverse fractures at the
same level.
 Additional rotation which lead to more
displacement can be caused by the pronator
muscles (pronator teres , pronator quadratus
) in the middle and the lower thirds ,and the
supinator muscles (biceps , supinator ) in the
upper third of the forearm.
 Clinically :
 Fracture is usually quite obvious but we
should do checking of the nerves and arteries
(distal pulsation )distal to the site of the
fracture which can be affected by
compartment syndrome .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

29. FRACTURES OF THE RADIUS AND ULNA
 Treatment
 In children : with green stick fracture , the closed treatment is usually
successful because the thick periosteum tend to guide and control
the reduction ; after reduction we put back slab above elbow which
is 90` flexed and ask the patient to elevate the limb to decrease the
edema ; after 10 days we change the slab to complete p.o.p. if the
fracture is in the upper third we put the fore arm in supination , if it
in the middle third we put the fore arm in neutral and if it in the
distal third we put the fore arm in pronation . The p.o.p. should be
left for another 4 weeks . Followed by physiotherapy .
 Open reduction is indicated in :
 if the fracture can not be reduced .
 if the reduction is unstable .
 The fixation will be by plate and screw , intramedullary nail,
 In adult : closed reduction of this fracture in adult is very difficult and
redisplacement in the cast is common so most of the surgeons prefer
the open reduction and fixation from the beginning by plate and
screws .
 Open fracture : need external fixation because internal fixation can
not be used in compound fracture
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

30. 30
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

31. FRACTURES OF THE RADIUS AND ULNA
 Complication
 Early :
 nerve injury . It is rarely occur in this fracture but it can be caused by the
surgeons e.g. posterior interosseous nerve .
 vascular injury . Ulnar and radial arteries .
 compartment syndrome .
 Late :
 delayed union and nonunion .
 malunion which lead to limitation of pronation and supination
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

32. ISOLATED ULNAR SHAFT FRACTURE
 Isolated ulnar shaft fractures are rare fractures of the forearm caused
by either direct blow to the forearm ("nightstick" fracture) or indirect
trauma (fall).
 Diagnosis and treatment plans made primarily by physical exam and
plain radiographs.
 Minimally displaced are often treated nonsurgically, while treatment
has historically been surgical open reduction and internal fixation
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

33. MONTEGGIA FRACTURE DISLOCATION OF THE ULNA
 It is fracture of the proximal third of the ulna with dislocation or
subluxation of the proximal radio- ulnar joint or radial head .
 Clinically : the ulnar deformity is usually obvious but the dislocated
head of radius is masked by the swelling .
 X-ray : in isolated fracture ulna it is essential to take true a-p and
lateral views of the elbow ; the normal radial head is usually
pointing to wards the capitulum in monteggia it is not ; in addition
to appearance of the fracture .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

34. MONTEGGIA FRACTURE DISLOCATION OF THE ULNA
 Treatment :
 the most important point in treatment is to restore the length of the fractured
ulna and only in this case the dislocation will be reduced and remain stable ; so
in adult this mean operation (reduction and fixation by plate and screws) if the
dislocation not reduced , then open reduction of the joint .
 In children if the fracture is green- stick then manipulation under anesthesia can
be helpful, but if the fracture is complete then open reduction and fixation like
adult .
 Complication :
 nerve injury : which occur either due to manipulation or during surgery
 malunion : unless the fracture has been perfectly reduced , the radial head
remain dislocated and limiting elbow flexion , limitation of pronatiopn and
supination ; if this happened in children no treatment but if occur in adult then
excision of the head of the radius can be done
 non union of the ulna : the treatment by rigid internal fixation and bone graft .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

35. GALEAZZI FRACTURE DISLOCATION OF THE RADIUS
 It is caused by fall on the hand , there is fracture in the lower third of the
radius and dislocation of the inferior radio- ulnar joint .
 Clinically : it is much more common than monteggia , prominence and
tenderness over the lower end of the ulna is an important point in
examination
 Treatment : the most important point is to restore the length of the
fractured radius , other wise the dislocation will not reduced .
 In children close reduction is possible but if fail , then open reduction and
fixation .
 In adult , the treatment will be by open reduction and internal fixation .
 Complication :
 The most important complication is limitation of pronation and
supination .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

36. FRACTURES OF THE DISTAL RADIUS
COLLES` FRACTURE
 Colles` fracture
 This fracture is described by Ibraham colles` in 1814 .
 It is a transverse fracture of the distal end of the radius with
posterior (dorsal) displacement of the distal fragment.
 It is the most common of all fractures in the human being ;
mainly in old osteoporotic people , but it occur in all age groups .
It is occur due to fall on out stretched hands
 The fracture that Colles described:
 1. Was within 1 inch (2.5 cm) of the wrist joint.
 2. Had dorsal angulation of the distal fragment.
 3. Had dorsal displacement of the fragment.
 4. Was associated with a fracture of the ulnar styloid.
 Colles’ fracture is most often caused by a fall on the outstretched
arm in patients over 50, usually women.
 Deformity. The obvious deformity of a Colles’fracture is the
classical ‘dinner fork’ of backward angulation
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

37. FRACTURES OF THE DISTAL RADIUS
COLLES` FRACTURE
 Clinically :
 The deformity of this fracture
called dinner – fork deformity .
 The patient also has the sign
and symptoms of any other
fracture like pain , tenderness ,
loss of function , swelling …..etc
 X-ray : there is transverse
fracture of the radius at the
cortico – cancellous junction ,
and the distal fragment is
displaced posteriorly ( dorsally)
; some time it is severely
comminuted or crushed 37
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

38. FRACTURES OF THE DISTAL RADIUS
COLLES` FRACTURE
 Treatment :
 Nonoperative
 closed reduction and splint/cast immobilization
 Operative
 Closed reduction percutaneous pinning (CRPP)
 Open reduction and internal fixation (ORIF)
38
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

39. FRACTURES OF THE DISTAL RADIUS
COLLES` FRACTURE
 Complication :
 Median nerve neuropathy [carpal- tunnel syndrome (CTS) ]
 The extensor pollicis longus (EPL) rupture.
 malunion : it is common due to unreduced fracture or due to
redislpacement .
 delayed union and non union .
 stiffness of the wrist ,fingers, elbow and shoulder
 sudeck`s dystrophy (Complex regional pain syndrome (CRPS)
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

40. SMITH FRACTURE :
 it is the same as colles` fracture but the distal segment is
displaced anteriorly
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

41. RADIAL STYLOID PROCESS FRACTURE :
 Here the fracture line extend from the articular surface of the
radius laterally .
 Mechanism of injury:
 Direct blow to distal radius or fall onto outstretched hand, often with
compression of scaphoid against styloid fragment
 Known as Chauffeur's fracture
 Treatment :
 Although these fractures are often undisplaced, they are relatively
unstable and often benefit from percutaneous lag-screw fixation or
pinning .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

42. BARTON`S FRACTURE
 It is intra-articular fracture of the lower end of the radius with
subluxation of the wrist joint.
 It is of two types :
 Volar Barton's`: called true Barton fracture and it
associated with volar subluxation of the carpus . The
fracture line run obliquely across the volar lip of the radius
into the wrist joint . The distal segment displaced anteriorly
carrying the carpus with it .
 dorsal Barton`s: it is the reverse of the volar one
 Treatment :
 The fracture easily reduced but it is unstable so it can easily
redisplaced so the treatment will be by open reduction and
fixation by special plate called Buttress plate 42
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

43. 43
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

44. 44
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali