DEPARTMENT OF TRAUMATOLOGY AND HAND SURGERY INSTITUTE OF MUSCULOSKELETAL SURGERY UPPER EXTREMITY TRAUMA

DEPARTMENT OF TRAUMATOLOGY AND HAND SURGERY INSTITUTE OF MUSCULOSKELETAL SURGERY UPPER EXTREMITY TRAUMA Presenter: Dr Laszlo G Nöt ENGLISH PROGRAM ...
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DEPARTMENT OF TRAUMATOLOGY AND HAND SURGERY INSTITUTE OF MUSCULOSKELETAL SURGERY

UPPER EXTREMITY TRAUMA

Presenter: Dr Laszlo G Nöt

ENGLISH PROGRAM LECTURES – EN_12 - 2014

CHARACTERISTICS OF UPPER EXRTEMITY TRAUMAS

• Injuries of the upper extremities impairs peoples‟ ability to handle and get contact properly with their environment. • The upper extremity is basically „designed‟ for motion, not for the support of large loads!!

TOPICS

• Scapula • Clavicle and AC-joint • Shoulder Dislocation

• Humerus • Elbow • Forearm fractures)

fractures

(except

distal

radius

CLAVICLE FRACTURE

Mechanism: • Fall

onto shoulder (87%) • Direct blow (7%) • Fall onto outstretched hand (6%)

Trimodal distribution:

80 70 60 50 40 Percent

30 20 10 0

Group I (13yrs)

Group 2 (47yrs)

Group 3 (59yrs)

Notably: the clavicle is the last ossification center to complete (sternal end) at about 22-25yo.

CLAVICLE FRACTURE

EXAMINATION OF CLAVICLE FRACTURES

Clinical Evaluation: • Inspect and palpate for deformity/abnormal motion • Thorough distal neurovascular exam

• Auscultate the chest for the possibility of lung injury pneumothorax

Radiographic Exam • AP (PA) chest radiographs • Clavicular 45deg A/P oblique X-rays •Traction pictures may be used as well

CLAVICLE FRACTURE

CLASSIFICATION OF 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%)

CLAVICLE FRACTURE

TREATMENT OF CLAVICLE FRACTURES

I. Non-operative treatment • closed reduction, „backpack‟ („8-shaped‟) bandage; sling immobilization or Gilchrist / Desault bandage for 3 weeks. II. Operative treatment

• TEN (Titanium Elastic Nail) fixation • plate OS, „hook‟ – plate, clavicle - plate • distal end frx: usually operative • open fracture

• associated with NV injury or severe chest injury • cosmetic reason, uncontrolled deformity, nonunion, etc…

CLAVICLE FRACTURE

MIDDLE SHAFT CLAVICLE FRACTURE

CLAVICLE FRACTURE

TEN (Titanium Elastic Nail) fixation

FRACTURES OF THE SCAPULA

• relatively

rare injuries • usually: neck or the glenoid cavity are involved • facture of the body of the scapula: generally requires conservative treatment (3-4 weeks of immobilization: splint, bandage, etc…) • operative treatment: - displaced neck fracture - closed reduction is not possible - involvement of glenoid cavity (articular surface!)

`FLOATING SHOULDER`

Definition: refers to ipsilateral fracture of scapula (neck) and clavicle (or AC joint injury) Indication of operation!!

SC (sternoclavicular) DISLOCATIONS

Mechanism: • indirect (presternal dislocation) • direct (retrosternal dislocation) – accompanied with a possibly of artery, nerve or esophagus.

Treatment: • reduction: easy BUT retention: difficult • nonoperative: 3-4 weeks immobilization • operative: K-wire, resection of clavicle proximal end

AC (acromioclavicular) DISLOCATIONS

Tossy – Rockwood Classification

DESCRIPTION OF ACROMIOCLAVICULAR JOINT DISRUPTIONS Tossy & Rockwood Classification * Type I - joint sprained without tear of either ligament Type II - AC ligaments torn but CC ligaments intact. Lateral end of clavicle is not elevated. Type III - AC and CC ligaments torn, >5 mm elevation of AC joint in unstressed X-ray. Take care to distinguish from type III (distal) clavicular fracture. Typical symptom: piano key effect!! Type IV - lateral clavicle separated and impaled posteriorly into trapezial fascia. Type V - complete separation of clavicle and scapula with gross upward clavicular displacement. Type VI - as type V but with clavicle detached inferiorly and displaced behind tendons of biceps and brachioradialis. * Prybyla D et al; Acromioclavicular Joint Separations, Medscape, Feb 2012

DIAGNOSTICS OF ACROMIOCLAVICULAR JOINT DISRUPTIONS

• Physical examination – Type III: Typical symptom: piano key effect!! • Plain radiographs are the initial choice. • Type I and II injuries may be differentiated using stressed radiographs where weights are hung from the patient's wrists, although many consider this technique to be unhelpful.

• Carefully inspect the scapula to rule out associated scapular fracture. • Be cautious to avoid overlooking a possible distal clavicle fracture. • CT or MRI only in special, selected cases, regularly to rule out malignant bone / soft tissue lesions.

THERAPY OF ACROMIOCLAVICULAR JOINT DISRUPTIONS

Types I and II injuries: - managed conservatively with ice, a sling for 1-3 weeks and non-steroidal anti-inflammatory drugs (NSAIDs) followed by physiotherapy to strengthen muscles and ligaments after the acute phase.

Type III injuries: - selected cases may benefit from surgical intervention (K-wire, tension band, hook-plate)

Types IV to VI injuries: - nearly always treated with open reduction and internal fixation. There is controversy about the efficacy of surgical reconstruction versus nonoperative intervention for grade III type injuries. However grade I and II separations seem to respond favorably to conservative management. Grade IV, V, and VI separations often require surgical reconstruction. Cote MP et al; Rehabilitation of acromioclavicular joint separations.. Clin Sports Med. 2010 Apr;29(2):213-28.

AC-DISPRUPTION – K-WIRE FIXATION

LATERAL CLAVICLE FRACTURE – TENSION BAND

LATERAL CLAVICLE FRACTURE – HOOK-PLATE OS

SHOULDER ANATOMY

Rotator cuff:

- subscapularis - supraspinatus - infraspinatus - teres minor Primary source of stability to the shoulder.

SHOULDER DISCLOCATIONS

SHOULDER DISCLOCATIONS

SHOULDER DISCLOCATIONS

EPIDEMIOLOGY

• Anterior: most common • Posterior: uncommon, Age 40: 10-15%

• Look for Concomitant Injuries!! A, Bone: Bankart, Hill-Sachs Lesion, Glenoid Fracture, Greater Tuberosity Fracture

B, Soft Tissue: Subscapularis Tear, Rotator Cuff Tear (RCT) C, Vascular: Axillary artery injury (older pts with atherosclerosis) D, Nerve: Axillary nerve neuropraxia

SHOULDER DISCLOCATIONS

Anterior Dislocation • Traumatic

• Atraumatic (Congenital Laxity)

• Acquired (Repeated Microtrauma)

SHOULDER DISCLOCATIONS

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

SHOULDER DISCLOCATIONS

Inferior Dislocations – ‘Luxatio erecta’ • 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

SHOULDER DISCLOCATIONS

Inferior Dislocations – ‘Luxatio erecta’

SHOULDER DISCLOCATIONS

Treatment I. Nonoperative treatment: closed reduction should be performed after adequate clinical evaluation and appropriate sedation - Hippocratic, Kocher, Stimson, eskimo technique (see next slides)

II. Operative Indications: irreducible shoulder (interposition), displaced greater tuberosity fractures, glenoid rim fractures bigger than 5 mm, elective repair for younger patients Postoperative management: post reduction films to confirm the position of the humeral head, pain control, immobilization for 7-21 days; then begin progressive ROM.

SHOULDER DISCLOCATIONS

Traction technique: Hippocratic - method

SHOULDER DISCLOCATIONS

Traction technique: Stimson - method

SHOULDER DISCLOCATIONS

Traction technique: Snowbird Reduction - method

SHOULDER DISCLOCATIONS

Leverage technique: Kocher - method

PROXIMAL HUMERUS FRACTURES

PROXIMAL HUMERUS FRACTURES

Epidemiology: • Most common fracture of the humerus • Higher incidence in the elderly, thought to be related to osteoporosis • Females 2:1 greater incidence than males

Mechanism of Injury: • Most commonly a fall onto an outstretched arm from standing height • Younger patient typically present after high energy trauma such as MVA (motor vehicle accident)

PROXIMAL HUMERUS FRACTURES

Clinical Evaluation

• Patients typically present with arm held close to chest by contralateral hand. • Pain and crepitus detected on palpation

• Careful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury.

PROXIMAL HUMERUS FRACTURES

Neer – classification /Neer et al, JBJS, 1970/

Four parts: - Greater and lesser tuberosities - Humeral shaft - Humeral head

/A part is displaced if >1 cm displacement or >45 degrees of angulation is see/

PROXIMAL HUMERUS FRACTURES

Treatment • Minimally displaced fractures: - Sling immobilization (1-3 weeks), early motion • Two-part fractures: - Anatomic neck fractures likely require ORIF. (High incidence of osteonecrosis) - Surgical neck fractures that are minimally displaced can be treated conservatively. Displacement usually requires ORIF. • Three-part fractures: - Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. - Displacement requires ORIF. Elderly: consider Pölchen-th. • Four-part fractures: - In general for displacement or unstable injuries ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%).

PROXIMAL HUMERUS FRACTURES

Treatment • Nonoperative treatment: - sling, Desault-bandage, Gilchrist-bandage - early physiotherapy, Pölchen-therapy - immobilization: 1-3 weeks (frozen shoulder!!)

• Operative treatment: - Screw fixation - K-wires + external immobilization - ORIF: plate fixation - intramedullary nailing - hemiarthroplasty

PROXIMAL HUMERUS FRACTURES

Type Neer VI

PROXIMAL HUMERUS FRACTURES

Type Neer VI

PROXIMAL HUMERUS FRACTURES

Type Neer VI

PROXIMAL HUMERUS FRACTURES

Hemiarthroplasty

FRACTURES OF THE HUMERUS SHAFT

FRACTURES OF THE HUMERUS SHAFT

Special characteristics of the humerus: • The humerus is not a weightbearing bone • bordered by the two most mobile joint • good muscle coverage • the relationship between the humerus and the • radial nerve

These characteristics are needed to be considered in the planning of the treatment.

FRACTURES OF THE HUMERUS SHAFT

Mechanism of Injury • Direct trauma is the most common especially MVA (motor vehicle accident)

• Indirect trauma such as 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

FRACTURES OF THE HUMERUS SHAFT

Evaluation of Humerus Shaft Fractures Clinical evaluation: • Thorough history and physical

• Patients typically present with pain, swelling, and deformity of the upper arm • Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured.

Radiographic evaluation: • AP and lateral views of the humerus

• Traction radiographs may be indicated for hard to classify secondary to severe displacement or a lot of comminution.

FRACTURES OF THE HUMERUS SHAFT

Treatment I.

Conservative Treatment: • Goal of treatment is to establish union

with acceptable alignment • >90% of humeral shaft fractures heal with nonsurgical management • 20 degrees of anterior angulation, 30 degrees of varus angulation and up to 3 cm of shortening are acceptable • Most treatment begins with application of a coaptation spint or a hanging arm cast followed by placement of a fracture brace: Sarmiento-type brace.

FRACTURES OF THE HUMERUS SHAFT

Treatment II. Operative Treatment: • Indications

for operative treatment include: - inadequate reduction, - nonunion, - associated injuries, - segmental fractures, - open fractures, - associated vascular or nerve injuries

• Most commonly treated with plates and screws but also IM (intramedullary nails); in selected cases: external fixator.

FRACTURES OF THE HUMERUS SHAFT

Preoperative X-rays

FRACTURES OF THE HUMERUS SHAFT

Postoperative X-rays

FRACTURES OF THE DISTAL HUMERUS

Supracondylar humerus fractures: COMPLICATIONS: - Neurovascular

complications (brachial artery,

median nerve) - Compartment-syndrome, - Volkmann‟s Contracture - Myositis ossificans or calcific tendinitis

FRACTURES OF THE DISTAL HUMERUS

Holstein-Lewis Fractures COMPLICATIONS:

- Distal 1/3 fractures - May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum

FRACTURES OF THE DISTAL HUMERUS

Bicondylar intraarticular humerus fractures: • Intra-articular fracture • Complications:* - heterotopic ossification (4%), - infection (4%), - ulnar nerve palsy (7%), - failure of fixation (5%), - non-union (2%).

* Helfet DL, Schmeling GJ: Bicondylar intraarticular fractures of the distal humerus in adults. Clin Orthop Relat Res. 1993 Jul;(292):26-36.

FRACTURES OF THE HUMERUS SHAFT

AO - Classification

FRACTURES OF THE DISTAL HUMERUS

Treatment

Nonoperative treatment: - Splint / cast fixation, brace fixation

Operative treatment: - ORIF: plate + screw fixation - Retrograde intramedullary nail - K-wire + additional fixation - External fixation

Special importance: in case of an intraarticular fracture, anatomic restoration of the articular surface, stable fixation, and early motion are the optimal treatment goals.

FRACTURES OF THE DISTAL HUMERUS

Treatment – postoperative X-ray

Olecranon osteotomy

ELBOW DISCLOCATIONS

ELBOW DISCLOCATIONS

Epidemiology • Accounts for 11-28% of injuries to the elbow • Posterior dislocations are the 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

ELBOW DISCLOCATIONS

Evaluation Clinical Evaluation: - Patients typically present guarding the injured extremity - Usually has gross deformity and swelling - Careful NV exam in important and should be done prior to radiographs or manipulation - Repeat after reduction

Radiographic Evaluation: - AP and lateral elbow films should be obtained both pre and post reduction - CT-scan, MRI may be requested after reduction - Careful examination for associated fractures

ELBOW DISCLOCATIONS

Treatment Posterior Dislocation: - Closed reduction under sedation - Reduction should be performed with the elbow flexed while providing distal traction - Post reduction management includes a posterior splint with the elbow at 90 degrees - Open reduction for severe soft tissue injuries or bony entrapment

Anterior Dislocation: - Closed reduction under sedation - Distal traction to the flexed forearm followed by dorsally direct pressure on the volar forearm with anterior pressure on the humerus

ELBOW DISCLOCATIONS / FRACTURES

Associated Injuries – Radial Head Fracture

Radial head fx (5-11%) • Mason-classification • Treatment: -Type I: conservative -Type II/III: attempt ORIF vs. radial head replacement

- No role for solely excision of radial head in 2006. This question is still debated.

ELBOW DISCLOCATIONS / FRACTURES

Associated Injuries

Coronoid process fractures (5-10%)

Medial or lateral epicondylar fx (12-34%)

ELBOW DISCLOCATIONS / FRACTURES

Instability Scale

Type I Posterolateral rotary instability, lateral ulnar collateral ligament disrupted

Type II Perched condyles, varus instability, ant and post capsule disrupted

Type III A: posterior dislocation with valgus instability, medial collateral ligament disruption B: posterior dislocation, grossly unstable, lateral, medial, anterior, and posterior disruption

ELBOW DISCLOCATIONS / FRACTURES

Olecranon Fracture

ELBOW DISCLOCATIONS / FRACTURES

Tension Band Fixation

ELBOW DISCLOCATIONS / FRACTURES

Radial Head Fracture

ELBOW DISCLOCATIONS / FRACTURES

Titanium Screw Fixation

ELBOW DISCLOCATIONS / FRACTURES

Elbow Dislocation

ELBOW DISCLOCATIONS / FRACTURES

After Closed Reduction

FOREARM FRACTURES

Epidemiology Epidemiology: • Highest ratio of open to closed than any other fracture except the tibia • More common in males than females, most likely secondary MVA, contact sports, altercations, and falls

Mechanism of Injury: • Commonly associated with MVA, direct trauma missile projectiles, and falls.

FOREARM FRACTURES

Evaluation Clinical Evaluation: • Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of function at the hand • Careful exam is essential, with specific assessment of radial, ulnar, and median nerves and radial and ulnar pulses • Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for compartment syndrome

Radiographic Evaluation: • AP and lateral radiographs of the forearm • Don’t forget to examine and x-ray the elbow and wrist

FOREARM FRACTURES

Ulna Diaphysis Fractures • These include nightstick and Monteggia fractures • Monteggia denotes a fracture of the proximal ulna with an associated radial head dislocation • Monteggia fractures classification: Type I: Anterior Dislocation of the radial head with fracture of ulna at any level- produced by forced pronation Type II: Posterior/posterolateral dislocation of the radial headproduced by axial loading with the forearm flexed Type III: Lateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysis- forced abduction of the elbow Type IV: anterior dislocation of the radial head with fracture of radius and ulna at the same level- forced pronation with radial shaft failure

FOREARM FRACTURES

Radius Diaphysis Fractures • Fractures of the proximal two-thirds can be considered truly isolated • Galeazzi or Piedmont fractures refer to fracture of the radius with disruption of the distal radial ulnar joint • A reverse Galeazzi denotes a fracture of the distal ulna with disruption of radioulnar joint

Mechanism: • Usually caused by direct or indirect trauma, such as fall onto outstretched hand • Galeazzi fractures may result from direct trauma to the wrist, typically on the dorsolateral aspect, or fall onto outstretched hand with pronation • Reverse Galeazzi results from fall with hand in supination

COMBINED FOREARM FRACTURES COMBINATION OF INJURIES - BONE AND SOFT TISSUE

1. Galeazzi fracture dislocation: radial shaft fracture with dislocation of the distal radioulnar joint.

2. Monteggia fracture dislocation: ulnar shaft fracture with dislocation of the radial head.

3. Essex Lopresti lesion: proximal radial fracture, disruption of the interosseous membrane, disruption of the distal radioulnar joint.

accompanied with dislocation and interosseal membrane rupture

FOREARM FRACTURES Preoperative X-rays: Forearm Fracture

FOREARM FRACTURES Postoperative X-rays: ORIF – plate OS

COMBINED FOREARM FRACTURES Preoperative X-ray I: Essex-Lopresti Injury

Radio-ulnar dissociation (comparative X-ray)

COMBINED FOREARM FRACTURES Preoperative X-ray II: Essex-Lopresti Injury

Radial Head Fracture

COMBINED FOREARM FRACTURES Postoperative X-ray: Essex-Lopresti Injury

UPPER EXTREMITY TRAUMA THERE ARE SEVERAL DIFFERENT TYPES OF CLASSIFICATIONS… WHICH OF THEM SHOULD I LEARN FOR THE EXAM?? BASIC REQUIREMENTS for the EXAM:

Here are some hints to help…

UPPER EXTREMITY TRAUMA

BASIC REQUIREMENTS for the EXAM: Here are some hints to help…

(at least: I – II – III) • Principles (not details!!) of Neer-classification • How to differentiate a posterior glenohumeral dislocation? • Principles of AO-classification - A: extra-articular - B: partially articular - C: intra-articular, comminuted fracture • Galeazzi / Monteggia / Essex-Lopresti injuries • Tossy-classification

UPPER EXTREMITY TRAUMA

If you are interested in, please, check the following links for further information: 1. AO Surgery Reference & Online Education www.aotrauma.org: 2. Wheeles‟ Textbook of Orthopaedics www.wheelessonline.com

3. OTA Education Resources – really useful site with online lectures http://ota.org/education/resident-resources/core-curriculum/upperextremity/

THANKS FOR YOUR ATTENTION!

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