Upper Extremity

Injuries
Introduction
1. Sterno-clavicular dislocations
2. Acromio-clavicular dislocations
3. Gleno-humeral dislocations 10. Proximal forearm fractures

4. Clavicle fractures 11. Radius/ulna shaft fractures

12. Monteggias and Galeazzi fractures

5. Scapula fractures 13. Distal radius fractures

14. Carpal fractures and dislocations

6. Proximal humerus fractures 15. Metacarpal fractures

16. Phalangeal fractures

7. Humeral shaft fractures
8. Distal humerus fractures
9. Elbow dislocation
Anatomy of
Acromio-
clavicular
Joint
 Acromio-clavicular Joint Dislocation
Primarily in male

25% of the dislocations of the

shoulder girdle

No.1 injury in bicycle accidents

Mechanism: fall or direct blow to the point of shoulder with arm adducted
 Mechanism and Classification of AC Joint Injuries
A. Direct force(1) is applied to
the point on the shoulder

B. Grade I sprain: a few fibers of

the ACL stretch and a few tear

C. Grade II sprain (sublaxation):

the capsule and the ACL
rupture

D. Grade III sprain (dislocation)

X-ray Film of
Grade III AC Injury
 ER Management of AC Injury
Grade I, II
Immobilization in a sling

Grade III:
Immobilization
Orthopedic referral
Controversy with regard to op vs conservative tretment
Early surgery in severe lesion (AC displacement > 20 mm)
in young individuals
Brachial plexus lesions
 Brachial plexus lesions
Mechanism:
Closed injuries (can occur in 2 ways):
i. Violent lateral flexion of the neck with depression of the shoulder,
or forced abduction of the arm: Most common in young men
thrown from their motorcycles
ii. At birth during difficult deliveries

Open injuries (rare)

i. Penetration by falling objects such as glass or steel
Brachial plexus lesions
 Supraclavicular lesions
Trauma:
Mechanism of injury: blows to the head and shoulder cause
violent lateral flexion of the cervical spine and depression of
the shoulder tear the upper cords
Example: motorcyclists landing on the head and shoulder

Obstetric palsy:
the upper cords are damaged during difficult deliveries
weak deltoid, elbow flexors, wrist extensors, supinator
waiters tip position of the arm (Erbs palsy)
Supraclavicular lesions
 Infraclavicular lesions
Trauma:
Mechanism of injury: Violent abduction of the arm or
Anterior shoulder dislocation injury to the lower part of
the brachial plexus

Birth injury:
Damage to the lower cords (C7, C8, T1): Klumpkes
palsy(weakness of finger flexors and intrinsics)
 Erbs palsy
C5/6 paralysis (particularly
following a breech delivery)

paralysis of the deltoid, external

rotators of the shoulder, &
biceps

the baby's arm is held in

adduction, internal rotation and
with the elbow extended
(waiter's tip position)
 Klumpkes palsy
C7, C8 and T1 palsy

flexed elbow & paralyzed hand

 Assessment
The roots, trunks, or branches can be torn, or the roots
avulsed from the spinal cord

The more distal the lesion, the better the prognosis

Preganglionic lesions:
between the spinal cord and the distal root ganglion
never recover
Postganglionic lesions:
distal to the ganglion
can recover sometimes
 Assessment
To determine the site of the lesion clinically, assess muscle
function
Check scapular elevation(because the first branches of the plexus
are motor nerves to the rhomboids and levator scapulae)

Check the activity of the autonomic nervous system

If Horners syndrome is present, the lesion is close to the cord
(preganglionic)
 Horners syndrome

Caused by lesion of the cervical sympathetic trunk:

Pupil constriction (paralysis of the dilator pupilae muscle)
Ptosis= drooping of the upper eyelid (paralysis of the levator
palpebrae superioris
Sinking of the eye (paralysis of the smooth orbitalis muscle in
the floor of the orbit)
Vasodilatation and absence of sweating in the face and neck
(lack of sympathetic vasoconstrictive nerve supply to the
blood vessels and sweat glands)
Horners syndrome
 Treatment (Brachial plexus lesions)

If the roots are torn as they arise out of the spinal cord,
nothing can be done to restore continuity

If the lesions are distal to the ganglion, or there is a clean cut

across the nerves, surgical repair or grafting maybe possible
 Gleno-humeral Joint Dislocation
GHJ: ball and socket joint; the head of humerus is held
against the relatively flat glenoid cavity by muscles

Mechanically unstable, while permitting a range of motion

greater than any other joint

Stability: depends on muscles and ligaments

Gleno-humeral joint can dislocate anteriorly, posteriorly,

inferiorly, or superiorly; > 95% are anterior dislocations
 Anterior Shoulder Dislocation
> 95% of GHJ dislocations are anterior

> 50% of all major joint dislocation

Mechanism:
Indirect or direct forces
Increased abduction
 Mechanism of Anterior Dislocation
Violent abduction and external rotation of the arm
Dislocation of humeral head from glenoid
When arm is adducted / lowered, the humeral head displaces
medially
 Hamiltons Ruler Sign
The shoulder has a flatter appearance than usual and the
elbow points outwards
Ruler touches acromion process and the lateral condyle of the
humerus
 Complications
Axillary nerve injury :
Partial / complete deltoid
muscle paralysis,
paresthesias
 Complications
Axillary nerve injury :
Flattening of the deltoid
area associated with
paralysis of the m. due to
damage to the axillary n.
 Complications
Axillary a. injury:
Damage by traction
(pressure from the
humeral head)
 Complications
Muscle injury:
Rotator cuff m. tears
Impossible reduction :
If reduction is not
undertaken within a few
days of dislocation
Stiffness and loss of
movement:
adhesions or fibrosis in
the rotator cuff
 Shoulder dislocation Treatment
Manipulation and Reduction under general anaesthesia / sedation
Relaxation method / Hanging arm technique
Hippocratic method
Kochers method
Stimson technique
Scapular manipulation
Modified Hippocratic method
Hippocratic method Modified Hippocratic method
Kochers method
 Kochers method
Flex elbow to 90 degrees
and support the arm
Grasp the wrist and with
traction at the forearm,
slowly externally rotate the
humerus
After full external rotation,
this is followed by gentle
adduction and internal
rotation
Immobilization After Reduction
 Associated Injuries
Old untreated
fracture/dislocation of
the head and neck of the
humerus of 10 months
duration in a 34 year old
man.
The shoulder was stiff
and painful, and the
axillary n. had been
damaged with paralysis
of the deltoid m.
 Posterior Shoulder Dislocation
Less common
Caused by a direct blow to the shoulder in internal rotation
or after an epileptic seizure
Characteristic light bulb appearance
 Recurrent dislocation of the shoulder:
the use of a Huckstep
titanium staple and
screw
 Inferior Shoulder Dislocation

Inferior dislocation of the shoulder: due to paralysis of the deltoid

(rare)
 Clavicle fractures
Classification
Proximal third: 5%
Middle third: 80%
Distal third: 15%
 Clavicle fracture
Middle third
80%, since middle third is weakest
Treatment:
Sling and early motion
Figure of 8clavicular strap for pain control
 Clavicle fracture
Lateral third
Comprise 15%
Treatment:
Non-displaced: sling and early
motion
Displaced: usually coraco-clavicular
ligament rupture
Non-union occurs in 25%
Surgical fixation
Articular surface: sling and early
motion
 Clavicle fracture
Medial third
Comprise 5%
Treatment:
Non-displaced: sling and early
motion
Displaced: surgical reduction and
fixation.
 Proximal Humeral Fracture
Neer system: 4 segments of
proximal humerus assessed
Anatomic neck
Surgical neck
Lesser tuberosity
Greater tuberosity
Neer
Classification
 Treatment
One-part fracture: sling and early motion
Discontinue sling and start pendulum exercise within 1~3 days to
prevent stiffness
> Two-part fracture: surgery needed
Complications
Most common: adhesive capsulitis(frozen shoulder)
Multi-part fractures: avascular necrosis of the humeral head
Neurovascular injury
 Humeral Shaft Fracture
Displaced differently depending on level of fracture
and pull of attached muscles
Initial and definitive treatment for non-displaced
fracture: coaptation splint
Indications for surgical fixation
Segmental, spiral, communicated, or open
fracture
Failed close reduction
Ipsilateral elbow dislocation
Ipsilateral forearm fracture
Vascular compromise
 Complications
Mal-union
Soft tissue injury
Nerve injury
Vascular injury
Elbow
Supracondylar
Fracture of
Humerus

Mechanism: Most occur in children after fall on outstretched hand

In adult, fall on outstretched hand typically produces elbow
dislocation rather than supracondylar fracture
In children, collateral ligaments surrounding the elbow joint are
stronger than distal humerus
Fat pad sign
 Treatment
Non-displaced
Posterior long arm splint for 1~2 wks
Early range of motion
Displaced
Closed reduction followed by posterior long arm splint for 4~6 wks
Surgical fixation for failed closed reduction, associated injuries, or
to allow early motion
 Complications in Pediatric Supracondylar Fracture

Vascular injury
Compartment syndrome
Volkmanns ischemic contracture
Necrosis of flexor muscles fibrosis contracture
Median nerve injury
Mal-union
Myositis ossificans
 Condylar Fracture
Transcondylar
fracture
Lateral condylar
fracture
Medial condylar
fracture
Intercondylar fracture
Complications
Posterior Elbow Dislocation
Olecranon displaced posteriorly
Most common (85%)
Prominent olecranon with
palpable notch
20% with ulnar/median
neuropraxia
Possible brachial a. injury
 Reduction of Posterior Elbow Dislocation
Palm-palm technique
Grasp patients hand with palm
to palm and fingers interlocked
Place examiners elbow in
patients antecubital fossa
Distract dislocation by pushing
downward on patients distal
humerus with examiners elbow
Pull posteriorly dislocated elbow
back into anatomic position
 Post-reduction

Immobilize in long arm splint with elbow in 90 degree flexion

for 1 wk

Active range of motion exercise in 1 wk

 Anterior Elbow Dislocation

Less common (15%)

Presents with elbow fully extended

Neurovascular injuries common

Associated with triceps avulsion

 Olecranon Fracture

Direct force on elbow

Surgery usually needed

 Radial Head Fracture
Fall on outstretched arm
X-ray signs:
Radiocapitellar line
Appearance of abnormal
fat pad
Types of Radial Head fx
 Treatment
Non-displaced: Displaced:

<1/3 of articular surface involved

<1 mm separation
No mechanical block of joint motion and <
Rx: sling, early motion
1/3 of articular surface involved
Long arm posterior splint, followed by early
motion
Mechanical block of joint motion, >3 mm
depression of 1/3 articular surface, or > 1mm
displacement
Excision of radial head, followed by early motion
in the elderly
Surgical fixation in young pts
 Treatment
Severely comminuted

Initially apply posterior

long arm splint
Consider surgical excision
of radial head
 Radius Shaft Fracture
Because of protection by musculature, most radial shaft #
require a significant force

Most are associated with ulna #

Most are displaced #

Rx:
Non-displaced: long arm cast
Displaced: surgical fixation
 Ulna Shaft Fracture
Non-displaced
Proximal 1/3: requires open reduction & internal fixation (ORIF)
Distal 2/3: long arm volar splint

Displaced:
Requires ORIF
Monteggia Fracture /
dislocation

Displaced proximal 1/3 ulnar

shaft # with radial head
dislocation
Always obtain elbow X-ray in
displaced shaft # to avoid
missing the dislocation

Rx: surgical fixation

 Galeazzi Fracture/dislocation
Displaced distal radius # with associated distal radio-ulna
joint(DRUJ) dislocation
Fractures at junction of middle and distal 1/3 of radius more
commonly associated with DRUJ dislocation
Always obtain wrist X ray in displaced radius shaft fracture to
avoid missing a Galeazzi fracture/dislocation
To determine DRUJ dislocation, look for:
Over 5mm shortening of radius
Fracture of ulnar styloid
DRUJ space widened over 2mm
Rx: requires surgical fixation
 Distal Radius Fractures
Colles fracture

Smiths fracture

Bartons fracture

Radial styloid fracture

 Colles fracture
Most common wrist fracture due to forceful wrist extension,
usually by fall on out stretched hand
Distal radial metaphysis fracture; Dorsal angulated;
Displaced proximally and dorsally
Radiographic appearance:
Dorsal angulation of the plane of the distal radius
Distal radius fragment is displaced proximally and dorsally
Radial displacement of the carpus
Ulnar styloid may be fractured
 Closed reduction of Colles #
Indications for closed reduction
Over 5 mm loss in radial length
Over 10 degree dorsal tilt
Method
Hematoma block
Attach finger-straps and apply counterweight(10-
20lb) from arm
Manipulate by applying pressure dorsally to
restore normal length and volar tilt
Apply a cylindrical short arm cast and immobilize
with wrist in slight flexion and ulnar deviation
 Indications for Surgical Fixation
After closed reduction there remains
Over 5 mm loss in radial length
Over 15 degree dorsal tilt

Open #

Comminuted #

Intraarticular #
 Smiths Fracture
Flexion fracture with volar displacement of distal radius
Reverse Colles fracture
Rx:
Closed reduction
Often unsuccessful due to flexor muscle pull
Surgical fixation usually necessary
 Bartons Fracture
Intra articular rim fracture of distal
radius

Rx:
Non-displaced #: short arm cast with wrist
in neutral position

Displaced: closed reduction & casting

> 50% articular surface involved or

inadequate reduction: surgical fixation
 Radial Styloid # (Chauffeurs #)

Non-displaced: cast
immobilization

Displaced: surgical
fixation
Bones of
the hand
 Wrist Anatomy
1. The carpal bones arranged in 2
rows forming 3 smooth arcs
2. Carpal bones separated by a
uniform 1-to 2-mm space
3. The scaphoid is elongated
4. The radius has an ulnar inclination
of 13~30 degrees
5. Radial styloid process projects
8~18mm
6. Half the lunate articulates with the
radius, with equal length over ulna
 Scaphoid Fracture
Most common carpal #
Common after a fall onto an outstretched hand
Pain over radial aspect of wrist
Clinically suspect when anatomic snuff box tenderness is
present
When clinically suspected:
Short arm thumb spica splint
F/U PE & X ray in 7~10 days
 Treatment for Scaphoid #
Nondisplaced:
Long arm thumb spica cast for 2-4 wks
Followed by short arm thumb spica for 4-6 wks

Displaced:
> 1 mm separation
Closed reduction followed by a thumb spica cast
Surgical fixation if closed reduction unsuccessful
Thumb spica Splint
 Lunate Fracture
Highest incidence of avascular
necrosis(Keinbocksdisease) of any carpal #
Suspect when there is tenderness in lunate
fossa regardless of whether or not confirmed
by radiograph.
Palpate just distal to the center of distal
radius
Wrist flexion causes lunate to move against
the examiners finger and increases
tenderness
 Lunate Fracture
When clinically suspected
Short arm thumb spica splint
Follow up in 7~10 days

Non-displaced
Short arm cast for 4-6 wks

Displaced
Surgical fixation
 Lunate Dislocation
Most commonly dislocated carpal bone
Volar displacement most common
Dorsal displacement rare
Associated with median nerve injury
PA view: triangular piece of pie appearance
Lateral view:
Lunate volarly or dorsally displaced in relation
to lunate fossa of radius and not associated with
proximal surface of capitate
Spilled tea cup appearance
 Lunate Dislocation Treatment
Immobilize in neutral position
Surgical reduction
Closed reduction(volar dislocation)
Dorsi-flexion of wrist while applying
volar to dorsal force on lunate to reduce
into lunate fossa
Palmar flexion of wrist to reduce
capitate into concavity of distal lunate
 Peri-Lunate Dislocation
Dorsal dislocation most common
PA view: distal capal row overrides proximal
carpal row and creates crowded carpal sign
Lateral view:
Lunate in lunate fossa
Capitate proximal surface dorsally or volarly
displaced out of concavity of distal lunate
 Treatment of peri-lunate dislocation
Immobilize in neutral position
Closed reduction
Finger trap distraction for 5~10 min with muscle
relaxation/pain control
Dorsi-flexion of wrist
Longitudinal traction
Volar flexion so capitate can reduce over dorsal rim of
lunate
Surgical fixation usually necessary
 Scapholunate dislocation
Commonly from a fall onto an outstretched hand in slight ulnar
deviation
Instability of scapholunate ligament
PA view:
Suspected when scapholunate joint space > 2mm
Confirmed when scapholunate joint space > 4mm
Rx:
Immobilize initially in thumb spica splint
Closed reduction
Surgical fixation and ligament repair
Intercapal fusion
Scapholunate dislocation
The scaphoid and lunate
are separated by a gap of
> 3mm, and the scaphoid
appears shorter from
rotation with a dense
ring
 Metacarpal fractures
Non-displaced: splinting at ED

Unstable fracture: operative fixation

Bennetts fracture

Boxers fracture
 Bennetts Fracture
Intraarticular fracture at
base of 1st metacarpal
Associated with dislocation or
subluxation of the
carpometacarpal (CMC)
joint, by pull of the abductor
pollicis brevis and longus
 Treatment of Bennetts Fracture
Initial Rx: thumb spica splint
Definitive Rx: surgical
fixation with percutaneous
pinning
 Boxers fracture
Fracture of distal 5th
metacarpal bone
Striking with closed fist
Indications for surgical
fixation
Rotational deformity
Angulation over 40o
 Phalanx fracture
Non-displaced shaft #: splinted to the adjacent finger for 2-3
weeks
Oblique # and # with rotational deformity: unstable, require
operative fixation
Comminuted tuft:
Frequent nail bed involvement
Subungual hematoma: should be drained
If nail avulsed: trim and replace its base to prevent
adhesion and subsequent nail deformities
Phalanx fracture Treatment
 Take home Messages
Suspect grade III AC joint dislocation if CC distance > 11~13
mm or there is a difference of > 5 mm in bilateral CC distance
Suspect a SC dislocation with tenderness over medical clavicle
CT scan to r/o mediastinal injuries in posterior dislocation SC
joint
Suspect shoulder dislocation in any shoulder injury
Do not attempt reduction of 2-part proximal humeral fracture
dislocations in ED
Supracondylar fractures are associated peripheral nerve injuries
and brachial artery entrapment
 Take Home Messages
Radial head fractures are often missed; Presence of joint
effusion on lateral view may be the only clue
Monteggia fracture: fracture of ulna shaft with dislocation of
proximal radio-ulnar joint
Galeazzi fracture: fracture at distal radius, with distal ulnar
dislocation
Posterior elbow dislocation much more common than
anterior dislocation; Reduce simple dislocations after pain
control
Assume scaphoid fracture in the presence of anatomic
snuffbox tenderness
Thank you