Upper extremity fracture

1. UPPER EXTREMITY
FRACTURE PRINCIPLE
(SHOULDER)
Marsa - Orthopaedi & Traumatologi Bandung

2. PROXIMAL HUMERUS FRACTURE
• Fractures of the proximal humerus are
classified according to the patterns of displacement of the
four major segments. These include the humeral head, the
greater and lesser tuberosities, and the humeral shaft

3. CLASSIFICATION (NEER)
• One-part fractures—Fractures without displacement
of 1 cm are not likely to disrupt the blood supply to
the humeral head and are referred to as minimally
displaced
• Two-part fractures—Isolated two-part fractures
involving the tuberosities are rare, and usually occur
as a consequence of a glenohumeral dislocation.
• Three-part fractures—Include displacement of three
segments including the humeral head, the shaft, and
one tuberosity
• Four-part fractures—Each major segment is
displaced, and the articular surface is devoid of soft
tissue
Fracture-dislocations
• Head-splitting fractures

4. CLASSIFICATION
A0/OTA
• Organizes fractures into 3
main groups and additional
subgroups based on
• Fracture location
• Status of the surgical neck
• Presence/absence of dislocation

5. RADIOLOGI PARAMETRIC
Radiographic evaluation—Standard radiographs
should be obtained to confirm the direction of the
dislocation and evaluate the shoulder for associated
fractures and any possible obstructions to reduction.

6. RADIOGRAPHS
• Complete trauma series
• True AP (grashey)
• Scapular Y
• Axillary
Scapular Y (normal)True AP (grashey) Axillary

7. RADIOGRAPHS
• Additional views
• Apical oblique
• Velpeau
• West point axillary
Apical oblique VelpeauWest point axillary

8. TREATMENT (OPERATIVE/NON OPERATIVE)

9. OPERATIVE TREATMENT OF PROXIMAL
HUMERAL FRACTURES
• Plate and Screw Fixation
ORIF is the most frequently used method of surgical treatment of proximal humeral fractures
•Indications
•Greater tuberosity displaced > 5mm
•Displaced 2-part fractures
•3-, and 4-part fractures in younger patients
•Head-splitting fractures in younger patients

10. CLAVICLE FRACTURE
• Clavicle fractures are common injuries in young, active individuals, especially those who
participate in activities or sports
where high-speed falls (bicycling, motorcycles) or violent
collisions (football, hockey) are frequent
• The majority of clavicular fractures (80% to 85%) occur in
the midshaft of the bone
• Distal third fractures are thenext most common type (15% to
20%)
• Medial third fractures are the rarest (0% to 5%

11. CLASSIFICATION
• originally divided
by Allman into proximal (Group I), middle (Group II), and
distal (Group III) third fractures.
• Neer divided distal clavicle
fractures into three subgroups, based on their ligamentous
attachments and degree of displacement
• Type I: Distal clavicle fracture with the coracoclavicular ligaments intact
Type II: Coracoclavicular ligaments detached from the medial
fragment, with the trapezoidal ligament attached to the distal fragment
IIA (Rockwood): Both conoid and trapezoid attached to the
distal fragment
IIB (Rockwood): Conoid detached from the medial fragment
Type III: Distal clavicle fracture with extension into the AC joint

12. CLASSIFICATION
• AO/OTA classification scheme of clavicle fractures. Robinson

13. RADIOGRAPHS
• Simple anteroposterior (AP) radiographs are usually sufficient
to establish the diagnosis of a clavicle fracture
• A measurement of length can be made on the chest
radiograph comparing the injured to the uninjured side: Shortening of 2 cm or more represents a
relative indication for primary fixation.
• Ideally, the radiographic beam for the AP radiograph of the clavicle should be
angled 20 degrees superiorly to eliminate the overlap of the thoracic cage and show the clavicle in
profil

14. RADIOLOGIC PARAMETRIC
• upright AP of bilateral shoulders
• axillary lateral
• 15° cephalic tilt (zanca view)
• helps to determine superior/inferior displacement

15. TREATMENT (OPERATIVE/NON OPERATIVE)
• Recent studies have made it clear that there is a
subset of
patients, especially those with shortened,
displaced fractures
who would benefit from primary operative repair
of clavicular injuries.
• a poor outcome following a clavicular fracture
(i.e., displacement of greater than 2 cm) and yet
heal promptly
(albeit in a “displaced” position) with minimal
symptomatology and full function of the involved
shoulder
• It is also clear that patient noncompliance,
especially when associated with substance
abuse, is a
clear contraindication for surgery.

16. SCAPULAR FRACTURE
• Scapula fractures occur relatively infrequently. According to various
studies, they account for 0.4% to 0.9% of all fractures and
for about 3% to 5% of all fractures of the shoulder girdle.38,157,159
• The reason for such low incidences is that the scapula is well
protected against injury by a robust muscular envelope, the surrounding
bones (clavicle, humerus), and its mobility and location on the elastic
chest wall.
• Scapula fractures result mostly
from high-energy trauma and, therefore, are often found in
polytrauma patients

17. CLASSIFICATION (AO/OTA )
Glenoid fossa, extraarticular,
simple
Glenoid fossa,
extraarticular, wedge
Glenoid fossa, extraarticular, multifragmentary
Glenoid fossa, complete
articular, articular
Body and processes,
acromion
Body and processes, coracoidBody and processes, body

18. CLASSIFICATION (AO/OTA )
Glenoid fossa, partial
articular, anterior simple
Glenoid fossa, partial articular, anterior
multifragmentary
Glenoid fossa, partial articular,
posterior simple
Glenoid fossa, partial articular,
posterior multifragmentary
Glenoid fossa, partial
articular, transverse simple
Glenoid fossa, partial
articular, transverse
Glenoid fossa, complete
articular, articular simple,
neck simple
Glenoid fossa, complete articular,
articular simple, neck

19. RADIOGRAPHS
• Anteroposterior radiograph of the entire shoulder
girdle
covering the whole scapula, the whole clavicle, AC and SC
joints, and proximal humerus is part of the basic
examination
in a suspected scapula fracture
• Neer I projection, the true anteroposterior radiograph of
the
scapula, is used to assess the glenohumeral joint space
• Neer II projection, also called Y-view, is a true lateral
scapula projection. This projection allows assessment of
scapular
body fractures in terms of translation, angulation, and
overlap
of fragments
• Other special projections, axillary in particular, are
recommended by some authors as complementary views,

20. TREATMENT (OPERATIVE/NON OPERATIVE)
• Indications/
The main indication for operative treatment of the glenoid
fractures is displacement, that is, a gap, or step-off, ≥3 to 10
mm, with the simultaneous involvement of 20% to 30% of the
articular surface and/or persisting subluxation of
the humeral head
Current indications
for operative treatment are fractures of the scapular body and
neck with the following types of displacement.
• 100% translation of fragments of the lateral border
• t 30- to 40-degree angulation of main fragments of the lateral
border
• t Mediolateral displacement of the glenoid in relation to the
lateral border of the scapular body of more than 1 to 2 cm
• t GPA less than 20 degrees

21. ACROMIOCLAVICULAR JOINT DISRUPTION
• AC joint injuries are best classified according to the extent of
damage inflicted by a given force. However, unlike other joints,
the differential diagnosis of sprains of the AC joint is based on
the severity of injury sustained by the capsular ligaments (AC
ligaments) and extracapsular ligaments (CC ligaments)
As well as s the supporting musculature (deltoid and
trapezius muscles).
Therefore, injuries to the AC joint are graded according to
the
amount of injury to the AC and CC ligaments. Injuries in
this
anatomic area have traditionally been referred to as “AC
joint injuries,” although they have varying degrees of
disruption between
the scapula and the clavicle, not limited to the one
particular joint

22. CLASSIFICATION

23. RADIOLOGIC PARAMETRIC
Anteroposterior Views Axillary Lateral View
Zanca view
Stryker Notch View

24. TREATMENT (OPERATIVE/NON OPERATIVE
• There is a general consensus supporting nonoperative treatment of Rockwood type I and type II AC joint
injuries Both
type I and type II AC joint injuries are treated in the acute setting with an initial period of immobilization.
Although both
type I and type II AC injuries are on the lower end of the spectrum, both types may remain symptomatic several
years following injury
• The nonoperative treatment of AC injuries consists of an
immobilization device and the so-called skillful neglect.127
Immobilization devices consisted of many variations including slings, adhesive tape strappings, braces,
harnesses, traction
techniques, and plaster casts
• Among these immobilization
devices, the sling has been the more recently acknowledged
and applied method of conservative treatment.

25. TREATMENT (OPERATIVE/NON OPERATIVE
• Indications
The treatment goals for AC joint dislocations include a pain-free
shoulder movement in a range of motion arc approaching normal. Various opinions exist regarding the
optimal surgical treatment for these injuries. Operative intervention should be clearly
discussed with each patient, as the objectives are different for
each patient
• operative treatment is generally the accepted
method for active healthy patients with complete AC joint injuries (types IV, V, and VI) because of the
significant morbidity
associated with the injury pattern that can lead to a persistently
dislocated, unstable AC joint, with a change in scapular kinematics, and shoulder dysfunction

26. DISTAL HUMERUS
FRACTURES

27. DEFINITION
• A distal humerus fracture is defined as a
fracture with an epicenter that is located
within a square whose base is the distance
between the epicondyles on an
anteroposterior radiograph.

28. CLASSIFICATION BY AO/OTA
• 1 : Humerus
• 13 : Distal Segment
• 13-A : Extra articular fracture
• 13-B : Partial articular fracture
• 13-C : Complete articular fracture

30. 13-A : EXTRA ARTICULAR FRACTURE
• Involve the epicondyles or the distal humerus metaphyseal level

32. 13-B : PARTIAL ARTICULAR FRACTURE
• There remains some continuity between the humeral shaft and the articular segment.
• Include unicondylar fractures and sagittal plane or shear fractures of the articular
surface involving the capitellum, trochlea, or both.
• Also be classified by MILCH system  based on whether the lateral portion of the
trochlea remains attached to the humeral shaft.
Type 1 = the lateral eminence of the trochlea remains attached to the humeral shaft
Type 2 = the lateral eminence of the trochlea is apart of the column fracture

34. 13-C : COMPLETE ARTICULAR FRACTURE
• There is no continuity between the articular segments and the humeral shaft.
• It is intracondylar fractures.

36. RADIOLOGICAL PARAMETRIC
• Standard anteroposterior and lateral radiographs of the elbow are usually sufficient
for diagnosis, classification, and surgical templating.

37. SURGICAL INDICATION
• Distal humerus fractures are generally complex injuries with associated
fragmentation, bony instability, osteopenia, and soft tissue injury.
• Surgical indication is to the decrease the risk of functional impairment which is
relatively high when these injuries are managed nonoperatively.
• ORIF of these injuries is considered gold standard.

38. TIMING OF SURGERY
• Be best managed with early surgery within 48 to 72 hours.
• Early surgery may lead to decreased complications such as HO and stiffness.

42. MIDDLE SHAFT HUMERI
FRACTURE

43. CLASSIFICATION
• 1 = Humerus
• 12 = Diaphyseal
• 12-A = Simple fractures
• 12-B = Wedge fractures
• 12-C = Complex fractures
• 3 zone = P (Proximal), M (Middle), D (Distal)
• 3 morphological = S (Simple), I (Intermediate), C (Complex), t (Slightly oblique), s
(Spiral)

46. RADIOLOGICAL PARAMETRIC
• Any patient with a suspected humeral shaft fracture should undergo x-ray
investigation in two planes at 90 degrees to each other.
• The ipsilateral shoulder and elbow joints must be included in the x-ray image, in
order to exclude either fracture extension or an associated injury to the joint.

48. SURGICAL INDICATION