1. The document discusses various types of upper limb trauma including fractures of the clavicle, humerus, forearm, and distal radius as well as dislocations of the shoulder and elbow. 2. Key fracture classifications discussed include the Allman classification for clavicle fractures, Neer classification for proximal humerus fractures, and Bado's classification for Monteggia fractures. 3. Common mechanisms of injury involve falls onto an outstretched arm. Imaging workup involves radiographs to identify fracture patterns and displacements.

1. UPPER LIMB TRAUMA
DR.ROHAN JOHN JACOB

2. Topics
• Clavicle
• Humerus
• Forearm
• Distal Radius
• Shoulder Dislocation
• Elbow dislocation

4. Clavicle Fractures
• Mechanism
• Fall onto shoulder (87%)
• Direct blow (7%)
• Fall onto outstretched hand (6%)
• The clavicle is the last ossification center to
complete (sternal end) at about 22-25yo.

5. Clavicle Fractures

6. Clavicle Fractures
• Radiographic Exam
• AP chest radiographs.
• Clavicular 45deg A/P oblique X-rays

7. Clavicle Fractures
• Allman Classification of Clavicle Fractures
• Type I Middle Third (80%)
• Type II Distal Third (15%)
• Differentiate whether ligaments attached to
lateral or medial fragment
• Type III Medial Third (5%)

9. Proximal Humerus Fractures

11. Proximal Humerus Fractures
• Epidemiology
• MC fracture of the humerus
• Higher incidence in the elderly, related to
osteoporosis
• Females 2:1 males
• Mechanism of Injury
• MC fall onto an outstretched arm from standing
height
• Younger patient typically present after high
energy trauma such as Motor Vehicle Accident

12. NEER CLASSIFICATION OF PROXIMAL
HUMERUS FRACTURES

13. Humeral Shaft Fractures

14. Humeral Shaft Fractures
• Mechanism of Injury
• Direct trauma MC - MVA
• Indirect trauma -fall on an outstretched hand
• Fracture pattern depends on stress applied
• Compressive- proximal or distal humerus
• Bending- transverse fracture of the shaft
• Torsional- spiral fracture of the shaft
• Torsion and bending- oblique fracture usually
associated with a butterfly fragment

15. Humeral Shaft Fractures
• Radiographic evaluation
• AP and lateral views of the humerus

16. Humeral Shaft Fractures
• Holstein-Lewis Fractures
• Distal 1/3rd fractures
• May entrap or lacerate radial nerve as the
fracture passes through the intermuscular
septum

18. Forearm Fractures

19. Forearm Fractures
• Epidemiology
• Highest ratio of open to closed than any other
fracture except the tibia
• males > females,MC secondary to MVA,
contact sports, altercations, and falls
• Mechanism of Injury
• Commonly associated with mva, direct trauma
missile projectiles, and falls

20. Forearm Fractures
• Radiographic Evaluation
• AP and lateral radiographs of the forearm
• Don’t forget to examine and take x-ray of the
elbow and wrist

21. MONTEGGIA FRACTURE DISLOCA
TION
• a fracture of the proximal third shaft of ulna
with an associated radial head dislocation
it

22. EPIDEMIOLOGY
• Monteggia fractures constitute about 1 to
2% of forearm fractures.

23. BADO’s
Classification
• Type I : Anterior dislocation of the radial
head
• is dislocated anteriorly and the ulna
has a fracture in the diaphyseal or
proximal metaphyseal area.
 Most common type

24. BADO’s
Classification
 Type II : Posterior dislocation: The radial
head is posterior/posterolaterally
dislocated, the ulna is usually fractured in
the metaphysis.
 Associated with nerve palsy (PIN) and
poor prognosis

25. BADO’s
Classification
• Type III: Lateral dislocation : There is
lateral dislocation of the radial head with a
metaphyseal fracture of the ulna.

26. BADO’s
Classification
 Type IV : Anterior dislocation with radius
shaft fracture
 the pattern of injury is the same as with
a type I injury, with the inclusion of a
radius shaft fracture below the level of
the ulnar fracture.

27. MECHANISM OF INJURY
 Type I:forced pronation of forearm
 Type II:axial loading of forearm with flexed
elbow
 Type III – forced abduction of elbow
 Type IV - Type I mechanism in which radial
shaft additionally fails

28. RADIOGRAPHIC EVALUATION
• Anteroposterior (AP) and Lateral x-rays of
the forearm.

29. GALEAZZI FRACTURE OR PIEDMONT
FRACTURE
• The combination of fracture of the distal or
middle third of the shaft of the radius and
dislocation of the distal radioulnar joint.
• counterpart of the Monteggia fracture-
dislocation
• also known as a reverse Monteggia fracture.

30. Epidemiology
• most often in males
• estimated to account for 7% of all forearm
fractures in adults

31. Mechanism of injury
• as indirect trauma : due to a fall on an outstretched
hand (FOOSH) with a superimposed rotation force
• Rotation determines direction of angulation
– Pronation  flexion injury ( dorsal angulation )
– Supination  extension injury (volar angulation)
• direct trauma to the wrist, typically on the
dorsolateral aspect

32. Types
• Type I
• apex volar
• Caused by axial loading of forearm in
supination
• dorsal displacement of radius and volar
dislocation of distal ulna

33. • Type II
• apex dorsal
• fractures are caused by axial loading of
forearm in pronation
• anterior displacement of radius and dorsal
dislocation of distal ulna

34. GALEAZZI FRACTURE

35. Greenstick fracture
• incomplete fractures of long bones
• young children, MC less than 10 years of age.
• MC mid-diaphyseal, affecting the forearm and
lower leg.
• distinct from torus fractures.

36. Mechanism
 Greenstick fractures - force applied to a bone results in bending of
the bone such that the structural integrity of the convex surface is
overcome.
 disintegration of the cortex results in fracture of the convex surface.
 the bending force applied does not break the bone completely and
the concave surface of the bent bone remains intact.
 This can occur following an angulated longitudinal force applied
down the bone (e.g. an indirect trauma following a fall on an
outstretched arm), or after a force applied perpendicular to the
bone (e.g. a direct blow).
 different, and much less common, than the torus fracture that
results in buckling of the cortex on the concave side of the bend
and an intact convex surface.

38. Greenstick fracture
• Radiographic features
• Plain radiograph
• usually mid-diaphyseal
• occur in tandem with angulation
• incomplete fracture, with cortical breach of
only one side of the bone.

39. Distal Radius Fractures

40. Distal Radius Fractures
• Epidemiology
• MC fractures of the upper extremity
• Common in younger and older patients as a result of
direct trauma such as fall on an outstretched hand
• Increasing incidence due to aging population
• Mechanism of Injury
• MC a fall on an outstretched extremity with the wrist in
dorsiflexion
• High energy injuries- significantly displaced, highly
unstable fractures

41. COLLES FRACTURE

42. Definition:
• It was first described by Abraham colles in 1814.
• Colles fracture is the fracture at the distal end of
radius, at its cortico cancellous junction(about 2cm
from the distal articular surface).
• It is not just the fracture of distal radius but
the fracture dislocation of the inferior radio-ulnar
joint.
• Most common age group is above forty years,
occuring most commonly in women.

43. Mechanism of Injury-
• Fall on an outstretched hand.

44. Patho-Anatomy:
• Displacement: The fracture line runs transversely
at the cortico-cancellous junction. In many cases
one or more displacements may occur as follows.:
• Impaction of fragments
• Dorsal displacement
• Dorsal tilt
• Lateral displacement
• Lateral tilt
• Supination

45. Clinical features:
• Pain
• Swelling
• Deformity- There is classic ‘dinner-fork
deformity’ seen in colles’ fracture.
• Radial styloid process lies in the same level or
little higher than the ulnar styloid process.

46. Dinner-fork Deformity-

47. Diagnosis:
•It is important to differentiate Colles’ fracture
from other fractures occurring at the same site,
such as Smith’s fracture, Barton’s fracture by
looking at the displacements.

48. X-RAY:
• Lateral view
• Dorsal tilt- It can be detected by looking at
the direction of distal articular surface
• AP view
• Lateral tilt- similarly it can be detected by
looking at the articular surface if it faces
medially it is normal,if it becomes horizontal or
faces laterally ,a lateral tilt is present.

51. AP VIEW OF LEFT SHOULDER

52. Shoulder Dislocations

53. Shoulder Dislocations
• Epidemiology
• Anterior: Most common
• Posterior: Uncommon, 10%, Think
Electrocutions & Seizures
• Inferior: Rare, hyper-abduction injury

54. Shoulder Dislocations
• Radiographic Evaluation
• True AP shoulder
• Axillary Lateral

55. Shoulder Dislocations
• Anterior Dislocation Recurrence Rate
• – Age 20: 80-92%
• – Age 30: 60%
• – > Age 40: 10-15%
• Look for Concomitant Injuries
• Bony: Glenoid Fracture, Greater Tuberosity Fracture
• Soft Tissue: Subscapularis Tear
• Vascular: Axillary artery injury (older pts with
atherosclerosis)
• Nerve: Axillary nerve neuropraxia

56. Shoulder Dislocations
• Anterior Dislocation
• Traumatic
• Atraumatic (Congenital Laxity)
• Acquired
• (Repeated Microtrauma)

57. Shoulder Dislocations
• Posterior Dislocation
• Adduction/Flexion/IR at time of injury
• Electrocution and Seizures cause overpull of
subscapularis and latissimus dorsi
• Look for “lightbulb sign” and “vacant glenoid”
sign
• Reduce with traction and gentle anterior
translation

59. Shoulder Dislocations
• Inferior Dislocations
• Hyperabduction injury
• Arm presents in a flexed “asking a question”
posture
• High rate of nerve and vascular injury
• Reduce with in-line traction and gentle
adduction

61. NORMAL ELBOW X RAY

62. NORMAL ELBOW X RAY

68. Normal Alignment
• Anterior humeral line- line drawn along
anterior surface of humeral cortex should pass
through the middle third of the capitellum
• Radiocapitellar line- Line drawn through the
proximal radial shaft and neck should pass
through to the articulating capitellum

72. Elbow Dislocations
• Epidemiology
• 11-28% of injuries to the elbow
• Posterior dislocations most common
• Highest incidence in the young 10-20 years and usually
sports injuries
• Mechanism of injury
• Most commonly due to fall on outstretched hand or elbow
resulting in force to unlock the olecranon from the trochlea
• Posterior dislocation following hyperextension, valgus
stress, arm abduction, and forearm supination
• Anterior dislocation ensuing from direct force to the
posterior forearm with elbow flexed

73. Elbow Dislocations
• Radiographic Evaluation
• AP and lateral elbow films should be obtained
both pre and post reduction
• Careful examination for associated fractures

74. Elbow Dislocations
• Associated injuries
• Radial head fracture (5-11%)

76. Elbow Dislocations
• Associated injuries
• – Coronoid process fractures (5-10%)

77. Elbow Dislocations
• Associated injuries
• – Medial or lateral epicondylar fracture (12-
34%)