The document discusses various fractures of the upper limb, including: pulled elbow in children, fractures of the proximal radius (head, neck), Monteggia and Galeazzi fractures involving the forearm bones and dislocations, fractures of both bones of the forearm, distal radius fractures including Colles' fracture, and scaphoid fractures. Treatment options depend on the type and location of the fracture, and may involve closed reduction, casting, external fixation, plating, or intramedullary nailing. Complications include nonunion, malunion, neurovascular injuries, and arthritis.

1. UPPER LIMB FRACTURES
D VA U SH R A
r RN AM
RESIDENT IN ORTHOPEDICS AND TRAUMATOLOGY
OSMANIA GENERAL HOSPITAL

2. Topics
• Fractures of proximal end of radius.
• Fractures of proximal end of ulna.
• Fractures of both bones of the forearm.
• Fractures around wrist
• Injuries of hand.

4. Pulled elbow
• Traumatic subluxation
• 2-6yrs age
• Jerk on forearm
• Pain in elbow n tenderness in proximal radius
• Radiographs normal
• Rx simple manipulation of FA into supination with
elbow stabilised
• Palpable click, pain decreases n normal
movement restored.
•

5. Proximal End of RADIUS

6. Types
• Fracture Head.
• Fracture neck.
• Epiphyseal injuries.

7. Fracture head of radius
• Mechanism: Forcible valgus strain, head
against capitellum, loose fragments into joint.
• Masons classification

8. Symptoms
• Pain on the outside of the elbow
• Swelling in the elbow joint
• Difficulty in bending or straightening the
elbow accompanied by pain
• Inability or difficulty in turning the forearm
(palm up to palm down or vice versa)

9. Treatment
• Type I Fractures
• Type I fractures are generally small, like cracks,
and the bone pieces remain fitted together.
• The fracture may not be visible on initial X-rays,
but can usually be seen if the X-ray is taken three
weeks after the injury.
• Nonsurgical treatment involves using a splint or
sling for a few days, followed by early motion.
• If too much motion is attempted too quickly, the
bones may shift and become displaced.

10. Treatment
• Type II Fractures
• Type II fractures are slightly displaced and involve a larger piece of
bone.
• If displacement is minimal, splinting for one to two weeks, followed
by range of motion exercises, is usually successful.
• Small fragments may be surgically removed.
• If the fragment is large and can be fitted back to the bone, the
orthopaedic surgeon will first attempt to fix it with pins or screws. If
this is not possible, however, the surgeon will remove the broken
pieces or the radial head.
• For older, less active individuals, the surgeon may simply remove
the broken piece, or perhaps the entire radial head.
• The surgeon will also correct any other soft-tissue injury, such as a
torn ligament.

11. • Type III Fractures
• Type III fractures have multiple broken pieces of bone,
which cannot be fitted back together for healing.
• Usually, there is also significant damage to the joint
and ligaments.
• Surgery is always required to remove the broken bits of
bone, including the radial head, and repair the soft-
tissue damage.
• Early movement to stretch and bend the elbow is
necessary to avoid stiffness.
• A prosthesis (artificial radial head) can be used to
prevent deformity if elbow instability is severe.

12. Complications
• Myositis ossificans

14. Olecranon fracture
• Mechanism
• A direct blow. This can happen in a fall (landing
directly on the elbow) or by being struck by a
hard object (baseball bat, dashboard of a car
during a crash).
• An indirect fracture. This can happen by landing
on an outstretched arm. The person lands on the
wrist with the elbow locked out straight. The
triceps muscle on the back of the upper arm help
"pull" the olecranon off of the ulna.

15. Symptoms
• Sudden, intense pain
• Inability to straighten elbow
• Swelling over the bone site
• Bruising around the elbow
• Tenderness to the touch
• Numbness in one or more fingers
• Pain with movement of the joint

17. • Radiographs
– recommended views
• AP/lateral radiographs
– true lateral essential for determination of fracture pattern
– additional views
• radiocapitellar may be helpful for
– radial head fracture
– capitellar shear fracture
• CT
– may be useful for preoperative planning in
comminuted fractures

18. Nonoperative
• immobilization
– indications
• nondisplaced fractures
• displaced fracture is low demand, elderly individuals
• Technique
• immobilization in 45-90 degrees of flexion for
3 weeks
• begin motion at 3 weeks

19. Operative
• tension band technique
– indications
• transverse fracture with no comminution
– outcomes
• excellent results with appropriate indications
• technique
– converts distraction force of triceps into a compressive force
– engaging anterior cortex of ulna with Kirschner wires may prevent wire migration
– avoid overpenetration of wires through anterior cortex
• may injury anterior interosseous nerve (AIN)
• may lead to decreased forearm rotation
– use 18-gauge wire in figure-of-eight fashion through drill holes in ulna
• cons
– high % of second surgeries for hardware removal (40-80%)
– does not provide axial stability in comminuted fractures

20. Olecranon Fracture
ORIF with Tension Band Wiring

21. • plate and screw fixation indications
– comminuted fractures
– Monteggia fractures
– fracture-dislocations
– oblique fractures that extend distal to coronoid

22. • technique
– place plate on dorsal (tension) side
– oblique fractures benefit from lag screws in addition to
plate fixation
– one-third tubular plates may not provide sufficient
strength in comminuted fractures
– may advance distal triceps tendon over plate to avoid
hardware prominence
• pros
– more stable than tension band technique
• cons
– 20% need second surgery for plate removal

24. • intramedullary fixation
indications
– transverse fracture with no comminution (same as tension band
technique)
• excision and triceps advancement
indications
– elderly patients with osteoporotic bone
– fracture must involve <50% of joint surface
– nonunions
• outcomes
– salvage procedure that leads to decreased extension strength
– may result in instability if ligamentous injury is not diagnosed
before operation

25. Complications
• Symptomatic hardware
– most frequent reported complication
• Stiffness
– occurs in ~50% of patients
– usually doesn't alter functional capabilities
• Heterotopic ossification
– more common with associated head injury
• Posttraumatic arthritis
• Nonunion
– rare
• Ulnar nerve symptoms
• Anterior interosseous nerve injury
• Loss of extension strength

26. Terrible triad of elbow
• A traumatic injury pattern of the elbow
characterized by
– posterolateral dislocation
– radial head fx
– coronoid fracture
• Mechanism is fall on extended arm that leads to
– valgus stress produces posterolateral dislocation
– structures of elbow fail from lateral to medial
• anterior bundle of MCL last to fail
• LCL disrupted in most cases

27. • Nonoperativeimmobilize in 90 deg of flexion
for 7-10 days
• Operativeacute radial head
stabilization, coronoid ORIF, and LCL
reconstruction, MCL reconstuction if needed

28. Monteggia fracture

29. • Injury defined as
– proximal 1/3 ulnar fracture with associated radial
head dislocation
• Epidemiology
– rare in adults
– more common in children with peak incidence
between 4 and 10 years of age
• different treatment protocol for children

30. classification

31. • Symptoms
– pain and swelling at elbow joint
• Physical exam
– inspection
• may or may not be obvious dislocation at radiocapitellar joint
• should include skin integrity
– ROM & instability
• may be loss of ROM at elbow due to dislocation
– neurovascular exam
• PIN neuropathy
– radial deviation of hand with wrist extension
– weakness of thumb extension
– weakness of MCP extension
– most likely nerve injury

32. • Radiographs
– recommended view
• AP and Lateral of elbow, wrist, and forearm
• CT scan
– helpful in fractures involving
coronoid, olecranon, and radial head

33. Rx
• Operative
• ORIF of ulna shaft fracture
• ORIF of ulna shaft fracture, open reduction of
radial head
• IM Nailing of ulna

34. complications
• PIN neuropathy
– up to 10% in acute injuries
– treatment
• observation for 2-3 months
– spontaneously resolves in most cases
– if no improvement obtain nerve conduction studies
• Malunion with radial head dislocation
– caused by failure to obtain anatomic alignment of ulna
– treatment
• ulnar osteotomy and open reduction of the radial head

36. Fracture both bones of forearm

37. BB FA Fracture
• Mechanismdirect trauma
– often while protecting one's head
• indirect trauma
– motor vehicle accidents
– falls from height
– athletic competition

38. • closed versus open
• location
• comminuted, segmental, multifragmented
• displacement
• angulation
• rotational alignment

39. • Radiographsrecommended views
– AP and lateral views of the forearm
• additional views
– oblique forearm views for further fracture
definition
– ipsilateral wrist and elbow
• to evaluate for associated fractures or dislocation
• radial head must be aligned with the capitellum on all
views

40. Nonoperative
• functional fx brace with good interosseous
mold
– indications
• isolated nondisplaced or distal 2/3 ulna shaft
fx (nightstick fx) with
– < 50% displacement and
– < 10° of angulation
– outcomes
• union rates > 96%
• acceptable to fix surgically due to long time to union

41. Operative
• ORIF without bone grafting
• ORIF with bone grafting
• external fixation
• IM nailing

43. ORIF with DCP
CRIF or ORIF with Rush/ Square Nail

44. Complications
• Synostosis
• Infection
• Compartment syndrome
• Nonunion
• Malunion
• Neurovascular injury
Refracture

45. Galeazzi Fractures

46. • Defined as
• distal 1/3 radius shaft fx AND
• associated distal radioulnar joint (DRUJ) injury

47. • Mechanism
• direct wrist trauma
– typically dorsolateral aspect
• fall onto outstretched hand with forearm in
pronation

48. • Symptoms
– pain, swelling, deformity
• Physical exam
– point tenderness over fracture site
– ROM
• test forearm supination and pronation for instability
– DRUJ stress
• causes wrist or midline forearm pain

49. • Radiographsrecomended views
– AP and lateral views of forearm, elbow, and wrist
• findings
– signs of DRUJ injury
• ulnar styloid fx
• widening of joint on AP view
• dorsal or volar displacement on lateral view
• radial shortening (≥5mm)

50. Rx
• Operative
• ORIF of radius with reduction and
stabilization of DRUJ
– indications
• all cases, as anatomic reduction of DRUJ is required
• acute operative treatment far superior to late
reconstruction

51. Complications
• Compartment syndrome
• Neurovascular injury
• Refracture
• Nonunion
• Malunion
• DRUJ subluxation

53. Monteggia Fracture Dislocation
Dislocation
Fracture

54. Dislocation
Fracture
GALEAZZI FRACTURE DISLOCATION

55. Distal Radius Fractures
• Most common orthopaedic injury with a bimodal
distribution
– younger patients - high energy
– older patients - low energy / falls
• 50% intra-articular
• Associated injuries
– DRUJ injuries must be evaluated
– radial styloid fx - indication of higher energy
• Osteoporosis
– high incidence of distal radius fractures in women >50
– distal radius fractures are a predictor of subsequent fractures
• DEXA scan is recommended in woman with a distal radius fracture

56. Dinner fork Deformity

58. Colles’ Fracture
• Transverse fracture at the
cortico-cancellous junction of
distal radius often associated
with ulnar styloid fracture

59. Colles’ fracture
Displacements
• Impaction
• Dorsal shift
• Dorsal tilt
• Radial shift
• Radial tilt
• Supination

60. Eponyms
Die- A depressed fracture of the lunate fossa of
punch the articular surface of the distal radius
fxs
Barton' Fx dislocation of radiocarpal joint with intra-
s fx articular fx involving the volar or dorsal lip
(volar Barton or dorsal Barton fx)
Chauff Radial styloid fx
x
er's fx
Colles' Low energy, dorsally displaced, extra-
fx articular fx
Smith's Low energy, volar displaced, extra-articular
fx fx

61. • Successful outcomes correlate with
– accuracy of articular reduction
– restoration of anatomic relationships
– early efforts to regain motion of wrist and fingers
• Nonoperative
– closed reduction and cast immobilization
• indications
– extra-articular
– <5mm radial shortening
– dorsal angulation <5° or within 20° of contralateral distal radius
• technique (see below)

63. • Indications
– most extra-articular fxs
• Technique
– rehabilitation
• no significant benefit of physical therapy over home exercises for
simple distal radius fractures treated with cast immobilization
• Outcomes
– repeat closed reductions have 50% less than satisfactory results
• Complications
– acute carpal tunnel syndrome
• (see complications below)
– EPL rupture
• (see complications below)

64. Colles cast

65. • Operative
• surgical fixation
• CRPP,
• External Fixation,
• ORIF)

66. Complications
• Median nerve neuropathy (CTS)
Ulnar nerve neuropathy
EPL rupture
Radiocarpal arthrosis (2-30%)
Malunion and Nonunion
ECU or EDM entrapment
Compartment syndrome
• RSD/CRPS

67. Treatment
• Conservative most of the cases
Manual reduction and below elbow cast
Techinque of reduction
 Disimpaction
 Palmar flexion
 Ulnar deviation
 Pronation
• Surgery- Unstable/Communited/intraarticular-
ORIF or External Fixation

68. ORIF

69. K wire fixation

70. External fixation

73. Barton’s fracture
• Fracture of distal end of radius involving
articular surface
• Types
Dorsal barton
Volar Barton

76. Smith’s Fracture
• Reversed Colles’ fracture
• GARDEN SPADE DEFORMITY
TREATMENT:
• Reduction held in 30 degree Dorsiflexion of
wrist and supination of Forearm with above
elbow plaster

78. Pain in the snuff box after FOOSH

80. Scaphoid fracture
• Scaphoid is most commonly fractured carpal bone.
• Most common mechanism is axial load across hyper-
extended and radially deviated wrist.
– common in contact sports
• Incidence of fracture by location
– waist -65%
– proximal third - 25%
– distal third - 10%
• distal pole is most common location in kids due to ossification
sequence
• Incidence of AVN with fracture location
– proximal 5th AVN rate of 100%
– proximal 3rd AVN rate of 33%

81. Blood supply
• major blood supply is dorsal carpal
branch (branch of the radial artery)
– enters scaphoid in a nonarticular ridge on the
dorsal surface and supplies proximal 80% of
scaphoid via retrograde blood flow
• minor blood supply from superficial palmar
arch (branch of volar radial artery)
– enters distal tubercle and supplies distal 20% of
scaphoid

82. • Radiographs should include
– AP and lateral
– AP view of the scaphoid with the hand in ulnar
deviation
– 45° pronation view

84. • Bone scan
– effective to diagnose ocult fractures
• specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72
hours
• positive within 24 hours, perform at 72 hours
• MRI
– effective diagnose ocult fractures
– allows immediate identification of fractures and ligamentous injuries
in addition to assessment of vascular status of bone (vascularity of
proximal pole)
• CT scan with 1mm cuts
– less effective than bone scan and MRI to diagnose occult fracture
– can be used to evaluate location of fracture, size of fragments, extent
of collapse, and progression of nonunion

85. Scaphoid Fracture
• Most commonly fractured of carpal bones
• Any fracture at the waist or proximal third of
bone cuts off blood supply to the proximal pole
leading to AVN of prox pole or Non Union of
fracture
TREATMENT
 Scaphoid Cast immobilsation for undisplaced
fracture
 ORIF with HERBERT’s screw for displaced fracture

86. Scaphoid Cast

87. Herbert Screw Fixation

89. Intraarticular # base of 1st Metacarpal with
carpometacarpal dislocation
A K A Bennett’s Fracture Dislocation

91. Bennett fracture
• Intra-articular fracture/dislocation of base of
1st metacarpalsmall fragment of 1st
metacarpal continues to articulate with
trapezium
• lateral retraction of 1st metacarpal shaft
by APL and adductor pollicis

92. Treatment
• closed reduction & cast immobilization
– indications
• nondisplaced fractures
– technique
• reduction maneuver with traction, extension, pronation, and
abduction
• reduction and percutaneous K wire stabilization to
adjacent metacarpals
– indications
• displaced fractures in which a adequare reduction is obtains
• ORIF
– indications
• reduction and percutaneous K wire stabilization to adjacent
metacarpals

93. Often requires ORIF with K wires

96. ROLANDO’s fracture
• Communited Intra-articular fracture of base of
first metacarpal
• Similar to a Bennett fracture but more extensive
comminution and displacement
– less common than Bennet's fx
– worse prognosis
• Treatment
– ORIF
• indications
– most cases

101. Mallet finger
• A finger deformity caused by disruption of
the terminal extensor tendon distal to DIP joint
– the disruption may be bony or tendinous
• Mechanism
– traumatic impaction blow
• usually caused by a traumatic impaction blow to the tip of
the finger in the extended position.
• forces the DIP joint into forced flexion
– dorsal laceration
• a less common mechanism of injury is a sharp or crushing-
type laceration to the dorsal DIP joint

102. Mallet finger
• Flexion deformity of DIP jt due to
injury of extensor digitorum
tendon often with a chip of bone

105. Rx
• Nonoperativeextension splinting of DIP joint
for 6-8 weeks
• OperativeCRPP vs ORIF
• surgical reconstruction of terminal tendon