SURGERY CBL 3 UPPER LIMB FRACTURES

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UPPER LIMB FRACTURES CBL

Osteoporotic fractures: occur with minimal trauma

Pathological fractures: no trauma

Stress fractures: due to prolonged unaccustomed activity but no trauma

ANATOMY: outer envelope is cortical bone while inner core is cancellous bone

:::::::::::::::::::::::::::: humerus ::::::::::::::::::::::::

ANATOMY

muscle insertion for pec major, deltoid and corachobrachialis

muscle origin for brachialis, biceps and brachioradialis

median + ulnar nerve run along shaft while radial nerve is in spiral groove in between proximal and medial epicondyle

MODE OF INJURY

direct trauma usually a transverse fracture

indirect trauma usually spiral fracture

fall on outstretched hand: high velocity comminuted fractures

minimal trauma: pathological fractures in elderly

fractures mostly in middle third (60%)

Investigations: XR, MR/bone scan (pathological fractures), calcium levels

Initial mgt: pain relief, splint, x-ray exam, temporary splintage

definitve mgt: sugar tong humeral brace and regular XRs

conservative mgt: fn-al brace for shaft fractures

indications for surgery: open fracture, neurovascular injury, segmental fractures, polytrauma, floating elbow, floating shoulder, adequate alignment

INTRAMEDULLARY NAILING

anterograde/retrograde**

indicated in patho, segmental and osteoporotic fractures

COMPRESSION PLATING

method of choice for fixing fractures

better union rate and lower complication rate compared with nailing

COMPLICATIONS OF SURGERY (definite): infection, delayed/non union, nerve damage (radial nerve palsy)

most humeral fractures treated conservatively

radial nerve involvement should be checked

90% heal well

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hand and wrist fractures

COLLES FRACTURE

#1 distal radius fracture

FOOSH

#1 in older women due to osteoprosis

on XR consider: angulation, impaction, displacement, joint involvement, other fractures (ulnar styloid, carpal bones)

MGT

conservative: with closed reduction (immediate in neurovascular damage) and plaster cast immobilisation,

surgical: open plating, external fixation, closed manipulation

COMPLICATIONS: malunion w/ dinner fork deformity, median nerve palsy, carpal tunnel

SCAPHOID FRACTURES

#1 carpal fracture

15-30y males

caused by FOOSH or forced dorsiflexion (steering wheel)

CFs: tenderness in anatomical snuffbox, scaphoid tubercle and longitudinal compression of scaphoid

Investigations: scaphoid series (3/4 plain X-Rays), 2nd line is MRI

Dx is difficult with XR

MGT:

Immobilise in plaster cast

Follow-up

internal fixation (screw/wire) to reduce risk of complication

bone grafting potentially for non union

Comps: non/mal union, OA, scapho-lunate dissociation, avascular necrosis

BOXER'S FRACTURE

- #1 metacarpal fracture: 5th metacarpal neck with volar (palmar) displacement

- usually after a punch

- MGT: check for other injuries, abx for open wounds, most will heal with minimal immobilisation/splintage, may require operative fixation with percutaneous wires.