Upper limb Fracture😊

Clavicle Fracture

• Most common fracture at birth & in newborn

• Patient presents supporting the injured side with the opposite arm, pushing the elbow up.

Sites

• Most common site (tubular portion).
• Between lateral 1/3rd and medial 2/3rd
• Middle 1/3rd (80%)

• Lateral 1/3rd (15%)
• flat portion.

• Medial 1/3rd (5%).

Displacing Forces in Clavicle Fracture

• Lateral fragment:
• Pulled down by
• weight of arm +
• pectoralis muscles.

• Medial fragment:
• Pulled up by
• Sternocleidomastoid (SCM) +
• trapezius muscles.

Complications

• Malunion (most common):
• Due to displacement.

• Neurovascular injury:
• Brachial plexus,
• subclavian vessels.

• Non-union: Very rare.

Management

• Conservative Management:
• Figure of 8 bandage.
• Arm sling/arm pouch.
• Combination of both.

• Surgery (Indications):
1. Open clavicle fracture.
2. Massive displacement.
3. Acromioclavicular joint involved.
4. Neurovascular injury.

Shoulder dislocation

Shoulder Joint

• Ball & socket joint,

• most mobile,

• most commonly dislocated joint
• 50% of all joint dislocations

Anterior Dislocation

• Head of humerus dislocated anteriorly.

• Subtypes:
• Subcoracoid
• most common



• Subclavicular,
• Pre glenoid,
• Intrathoracic.

Presentation (Anterior Dislocation)

• Attitude of limb:
• Abduction & external rotated
• (loss of adduction & internal rotation).
• Arm is by the side of the body.

• Loss of shoulder contour:
• Flattened shoulder.

• History of trauma:
• Fall on outstretched hand (mechanism of injury).

• Nerve injury:
• Axillary nerve injury (most common).

Clinical Examination

1. Hamilton's ruler test:
1. Ruler over lateral epicondyle of humerus touches acromion.

2. Duga's test:
1. Difficulty in touching contralateral shoulder.

3. Callaway's test:
1. Increased girth of affected shoulder (axilla)

Axillary nerve injury:

• Motor function:
• Loss of function of
• deltoid,
• teres minor.

• Sensory function:
• Regimental badge sign
• sensory loss on lateral aspect of upper arm

X-ray (Anterior Dislocation)

• AP view:
• Empty glenoid sign.

• Lateral view:
• Subcoracoid dislocation typically seen.

Treatment (Reduction Techniques)

• Acute dislocation is an emergency,
• requiring immediate reduction.

• Methods
1. Modified Kocher's Technique (TEAM):
• Most common.
• Mnemonic: TEAM (or "TRADIM" if that helps for the actions in sequence).
• T raction.
• E xternal rotation.
• A dduction.
• M edial/internal rotation.
2. Stimson's technique:



1. Patient prone,
2. heavy object tied to dislocated limb,
3. hang limb at the edge of table/bed,
4. gradual traction overcomes muscle spasm,
5. reduction achieved.
3. Hippocratic technique:
1. Countertraction with foot,
2. traction with arm.

• Mnemonic: Dislocated patient says
• Coaching (kochers) Team (TEAM), Stinking (Stimson)
• Get a ruler () → call (callaway) durga (duga)

Complications (Shoulder Dislocation)

1. Bankart lesion (most common):

• Due to anterior dislocation of shoulder.

• Glenoid labrum tears anteroinferiorly at 4-6 o'clock position.

• → laxity of inferior glenohumeral ligament and ↓↓ stability.

• → recurrent dislocations.

Bony Bankart:

• Avulsion fracture of anteroinferior glenoid,

• along with a Bankart lesion.

Hill-Sachs lesion:

• Due to recurrent dislocation.

• posterolateral surface of the humeral head repeatedly hits anterior glenoid rim.

Note

• Most common complication of shoulder dislocation:
• Recurrent dislocation.

• Most common early complication:
• Axillary nerve injury.

• Most common late complication:
• Recurrent shoulder dislocation.

• Most common nerve injured in shoulder dislocation:
• Axillary nerve.

Posterior Dislocation

Presentation:

• Mechanism of injury:
1. High velocity muscular movement (Specific):
• In seizures.
• High voltage electric shock.
• Electroconvulsive therapy (ECT).
2. Fall on outstretched hand.
3. Trauma.

Attitude of limb:

• Adducted and internally rotated.

• Loss of abduction & external rotation.

• Shoulder contour: Not lost.

• Pain: Positive (+).

X-Ray: 

• Light bulb/Electric bulb sign

Inferior Dislocation

Presentation:

• Mechanism of injury: 
• Hyperabduction.

• Attitude of limb: 
• Arm by the side of the head
• AKA luxatio erecta

• Note: Superior shoulder dislocation unlikely
• due to the acromion process.

Shaft of Humerus Fracture

• Proximal humerus: Neer Classification

Features: 

• Fracture between the surgical neck of humerus & supracondylar area.

Complication: 

• Radial nerve injury
• Closely associated with shaft

Management:

• Conservative: 
• U-slab/Hanging cast (Needs to be erect).

• Surgical: 
• ORIF (Open Reduction and Internal Fixation)
• with Plates + Screws.

Holstein-Lewis Fracture

• Site: 
• Junction of upper 2/3rd & lower 1/3rd
• Radial nerve perforates lateral intermuscular septum here

• Causes: 
• Entrapment of tethered radial nerve.

• Presentation:
• Wrist drop
• Thumb drop
• Finger drop
• Sensory loss

• Treatment (Rx): 
• Cock-up splint (Dynamic > Static).

• Mnemonic: Holstein Lewis → H L → Humerus lower

Fractures Around the Elbow

Lateral Condylar Fracture vs. Supracondylar Fracture (Comparison Table)

• Milch classification

• 3-point bony relationship
• also disturbed in
• medial condyle fracture
• olecranon fracture,
• intercondylar fracture
• elbow dislocation.

Lateral Condyle Fracture

 

• Commonly occurs in children.

• Salter-Harris Type IV.

Complications:

• Elbow stiffness.

• Non-union:
• Due to pull by common extensor group of muscles.
• Compromised vascularity.

• Damage to lateral growth plate: 
• Growth of medial > lateral condyle.
• → Cubitus valgus
• Stretching of medial elbow structures,
• → Late / Tardy ulnar nerve palsy 
• develops over weeks-months

Carrying Angles of Elbow:

• Normal:
• Males: 5°,
• Females: 7°-10°

• Cubitus varus:
• Forearm towards midline.

• Cubitus valgus:
• Forearm away from midline.

Supracondylar Fracture

• Most common fracture around the elbow in children (m/c).

Mechanism of injury: 

• Fall on an outstretched hand → Hyperextension injury.

• Salter harris type 2 > 1

Types:

Based on displacement:

• Extension type (m/c): 
• Posterior displacement due to pull of triceps.

• Flexion type:
• Anterior displacement (Rare).

Gartland Classification:

Type I: 

• Undisplaced (Fracture line may not be visible).
• Associated with Sail/Fat pad sign.
• Fat pad/Sail sign: 
• Hematoma around fracture pushes away fat,
• creating a sail-shaped lucency around the supracondylar area.

Type II: 

• Anterior cortex breached,

• Posterior cortex intact (Incomplete fracture).

Type III: 

• Displaced complete fracture.
• Associated with Fish tail sign.

Management:

• Undisplaced fracture:
• Conservative.

• Displaced fracture:
• Surgery.

• Dunlop traction: 
• For temporary stabilisation of fracture.

• Baumann's angle: 
• Used to determine adequate fracture reduction.

• Mnemonic: supracondylar → On top of continent → Extended () trip to Gartland island → children () → sailing with paddles (sail/fat pad) → saw fish tails () → island kandapo break itt (brachial) → dun dun dun (dunlop) sound islandil → bow (bauman) cheyth → they also carried a Myr (Medial tilt, IR) french (french osteotomy) gun (gunstock)

Complications:

• Note in children: 
• Most common fracture causing
• neurovascular injury &
• compartment syndrome.

Early

• Vessel injury (m/c): 
• Brachial artery.
• → Compartment syndrome → Volkmann Ischemic contracture.

• Nerve injury (m/c): 
• Anterior interosseous > Median > Radial.

Late:

1. Malunion (m/c):
• Cubitus varus/gunstock deformity 
• m/c deformity
• Due to medial tilt +
• internal rotation of distal fragment.
• Rx:
• If only cosmetic and asymptomatic
• No surgery needed in a growing child.
• Wait until skeletal maturity
• Modified French osteotomy.
• Lateral closing wedge osteotomy
• Ideal timing:
• age 6–10 years

2. Myositis Ossificans.
• Definition: Muscle (myo) → bone (ossificans).

• Cause: Usually trauma, Massaging

Compartment Syndrome

Clinical features (The 5 P's and a Puffiness):

1. Pain on passive stretch
1. Most important sign
2. Earliest

2. Puffiness

3. Pallor.

4. Paraesthesia.

5. Paralysis
1. Late sign

6. Pulselessness
1. Very late sign

Investigation: 

• Manometer
• Useful in unconscious patients



• Normal: < 10 mmHg.
• Compartment syndrome: > 30 mmHg.

Treatment:

• Immediate removal of dressing/cast.

• Fasciotomy
• If no symptomatic improvement
• Longitudinal incisions
• both superficial and deep compartments
• reduce pressure and improve vascularity.
• Wound left open till pressure falls.

Volkmann's Ischemic Contracture

• Untreated compartment syndrome
• → fibrosis of forearm muscles
• Due to ischemia

Treatment

• (Based on severity of contracture):
• Mild:
• Turn buckle splint (Passive stretching).

• Moderate:
• Max page (muscle sliding) operation.
• Severe:
• Bone shortening.

• Mnemonic: Volk (Woke) → buckle and turn () max pages ()

Malunion

Gunstock/Cubitus varus deformity:

• Most common complication of supracondylar fracture.

• Most common deformity.

• Due to medial tilt + internal rotation of distal fragment.

• Rx: Modified French osteotomy.

Myositis Ossificans

• Rare complication.

• Most common muscle involved: 
• Brachialis

• Most common joint involved: 
• Elbow > Hip.

• Pathogenesis:
• Massage of fracture
• Fracture hematoma dislodges
• Settles inside muscle
• Bone forms inside muscle
• Restriction of movement.

• Mnemonic: Brayil massage cheyth

Olecranon Fracture

• Fracture fragment gets pulled by triceps.

• Treatment: 
• Tension band wiring with K-wires.

Elbow Dislocation & Pulled Elbow

Elbow Dislocation

• Ulno-humeral dislocation.

• Most common dislocation in children.

• Most common type: 
• Posterior/posterolateral.

• Most common nerve injured: 
• Ulnar nerve.

Note: Terrible (Hotchkiss) triad of elbow:

1. Posterior elbow dislocation.

2. Coronoid fracture.

3. Radial head fracture.

Radioulnar Synostosis

Pulled Elbow (Nursemaid's Elbow)

Mechanism of injury

• (in children < 5 years):
• Unossified smaller radial head in larger annular ligament (unstable).
• Axial traction of extended & pronated elbow.
• Radial head pulled out of annular ligament.

Attitude of limb: 

• Extended elbow & pronated forearm

Treatment:

• Self-limiting.

• If painful:
• Flex elbow & forcefully supinate forearm.
• Hyperpronation (Not recommended).

Forearm Fractures

Monteggia Fracture

• Mnemonic: MUGR

• Fracture of upper 1/3rd ulna +

• Proximal Radioulnar Joint (PRUJ) disruption
• Radial head dislocation

BADO Classification:

• Type I (m/c): Radial head dislocation anteriorly.
• Type IV: Radial head dislocation anteriorly + fracture of radius.

• Type II: Radial head dislocation posteriorly.

• Type III: Radial head dislocation laterally.

Complications:

• Most common injured nerve: 
• Posterior interosseous nerve
• Branch of radial nerve

Night Stick #

• Lathi

• Elderly abuse

 

Galeazzi/ Reverse Monteggia Fracture/ Piedmont Fracture

• Fracture of radius +

• Distal Radioulnar Joint (DRUJ) disruption/
  Triangular Fibrocartilage Complex injury

• Mnemonic: Reverse montagia → Pied montagia → Piedmont

 

Piano Key Sign: 

• Ulna lifted distally,

• goes down when pressed upon.

Fractures At Wrist

Comparison Table

Colle's Fracture

• Fracture of distal end of radius at cortico-cancellous junction.

• Common in elderly post-menopausal females.
• Fall on out stretched hand

Displacements (DILS): 

• Mnemonics: "DILS"
1. Dorsal tilt/shift.
2. Impaction (Causes dinner fork deformity).

3. Lateral tilt/shift.
4. Supination.

Treatment:

1. Colle's/Hand shaking cast (Conservative):
• Below elbow cast.
• Position: PROPA gUNDa
• Pronation,
• palmar flexion of wrist.
• ulnar deviation,

2. Surgery.

Sequence of reduction of Colle's fracture:

1. Countertraction

2. Traction

3. Palmar Flexion (to correct the dorsal tilt)

4. Ulnar deviation (to correct the radial tilt)

Complications:

• Malunion: 
• Dinner fork deformity (m/c).

• Sudeck's dystrophy/
  Complex Regional Pain Syndrome (CRPS)/
  Reflex Sympathetic Dystrophy Fracture: 
• Tense swelling,
• shiny skin,
• tingling & numbness,
• paraesthesia,
• anhidrosis.

• Rupture of extensor pollicis longus tendon.

• Carpal tunnel syndrome:
• Median nerve compression.

• Non-union (Rare).

Smith Fracture/Reverse Colle's Fracture

• Extra-articular fracture of distal end of radius with volar displacement.

• Results in Garden spade deformity.

Mechanism of injury: 

• Fall on an outstretched hand with wrist in flexion.

Chauffeur's Fracture

• AKA Hutchinson's/Backfire Fracture.

• Isolated radial styloid fracture.

• Intraarticular

• Mnemonic: Chauffer fired at Hutchinson

Hutchinson's

• H → Herpes Zoster Ophthalmicus

• U → subUngual Melanoma (superficial spreading melanoma)
• Hutchinson sign

• T → Triad → congenital syphillis
• Peg shaped teeth
• Interstitial Keratitis (IK + SNHL)
• SNHL

• CH → Chauffeur's Fracture/Backfire Fracture
• Intra articular #

• Son → looking older → Hutchison Gilford
• LMN A gene defect (laminopathy).
• Progeria (onset: Child)

• PUPIL → Hutchinson Pupil
• Herniation of uncus (medial temporal lobe) → compresses ipsilateral CN III → same side pupillary dilatation.
• Kernohan’s notch phenomenon:
• False localizing sign
• Ipsilateral pupil dilatation
• Ipsilateral UMN palsy

Barton's fracture:

• Intraarticular.
• Mnemonic: bARt → ARticular

• If fracture involves volar aspect -
• volar Barton's fracture/ Reverse Barton's fracture.

Spilled Tea Cup Sign

• Lunate dislocation

Fractures of Hand

Carpal Bones

• Mnemonics: 'She Looks Too Pretty, Try To Catch Her'.
• Starting from proximal row, radial to ulnar, then distal row, radial to ulnar
• Scaphoid (S):
• Most common fracture
• Lunate (L):
• Most common dislocated
• Triquetrum (T).
• Pisiform (P):
• Smallest.
• Trapezium (Tz).
• Trapezoid (Td).
• Capitate (C):
• Largest.
• Hamate (H).

Scaphoid Fracture

• Mechanism of injury: 
• Fall on an outstretched hand.

• Age group: 
• Young adults.

• Clinical Features: 
• Pain/swelling in anatomical snuff box.

• Evaluation:
• X-ray: 
• Oblique view (Best).
• AP & Lateral views may not show the fracture.
• MRI: 
• For fractures not visible on X-ray.

• Complications:
• Non-union (m/c).
• Avascular necrosis of proximal pole of scaphoid.

Treatment:

• Undisplaced fracture:
• POP (Plaster of Paris) applied
• glass holding position.

• Displaced fracture:
• OR (Open Reduction) +
• IF (Internal Fixation)
• with Herbert screw.

Note:

Scapho-lunate ligament injury: 

• Ligament injury → Scapho-lunate dissociation: 
• Terry Thomas sign.
• (really bad to name it his name → shouldn’t have done that)

• Mnemonic: thomas ne theri vilich → wrist ligament pottiyapo

Fracture of Base of First Metacarpal

• Intra-articular fracture of trapezio-metacarpal joint.

• Displacing forces: 
• Abductor pollicis longus (APL) pull.

• Bennet's Fracture: 
• Partial,
• displaced fracture.

• Rolando's Fracture: 
• Complete comminuted (T/Y shaped),
• undisplaced fracture.
• Mnemonic: Ronaldo (rolando) de thumb → bent (bennet) and break ayi → but ronaldo (Rolando) is undisplacable and complete

Boxer's Fracture

• Fracture of neck of 5th metacarpal.
• Typically from punching an object with a closed fist

Mallet Finger vs. Jersey Finger (Comparison Table)

• Ex communist (Extensor digitorum communis) → Malli (Mallet) ye stalk (Stax splint) cheyth