Fractures Of Upper Limb distal to elbow For Undergraduates

1. Upper Limb
Fractures Part 2
Dr. Apoorv Jain
D’Ortho, DNB Ortho
drapoorvjain23@gmail.com
+91-9845669975

2. • The elbow joint is a modified hinge joint formed by
3 separate articulations,
– Ulnotrochlear(hinge)
– Radocapitellar(rotation)
– Proximal radioulnar(rotation)

3. Ligaments
1- Radial collateral lig.
2- Anular lig. Of radius
3- Ulnar collateral lig.
4- Transverse lig.

5. Ulnar ligament is also known as the
medial collateral ligament. It
prevent abduction of elbow joint. It
cosists of 3 bands: Anterior,
posterior, Transverse.
Radial ligament is also called as
the lateral collateral ligament.it
prevent adduction of elbow

6. • The soft tissue restriants can be divided into
Static stabilizers
Dynamic stabilizers
• Static stabilizers include:
oJoint capsule
oLCL & MCL
• Dynamic stabilizers include Biceps,
Brachialis & Triceps

7. Stability is contributed by:
• Antero-posterior:
– Trochlea-olecranon fossa
– Coronoid fossa
– Radiocapitellar joint
– Biceps-triceps-brachialis
• Valgus:
– Medial collateral ligament complex
– Anterior capsule
– Radiocapitellar joint
• Varus:
– Lateral collateral ligament is static
– Anconeus muscle is dynamic stabilisaer

8. Two set of movements occur at the
elbow:
A)Flexion and extension at the
Ulnotrochlear joint
B)Pronation and supination at
Superior radio-ulnar joint

9. Normal range of motion:
0 to 150°flexion
85° supination & 80° pronation
Functional range of motion:
a 100° arc (30 to 130 degrees flexion)
50° supination & 50° pronation

10. Movement of elbow

11. Dislocation of the elbow
Dislocation of UlnoHumeral joint
Mechanism of injury:
Most commonly injury is caused by fall onto an
outstretched hand or elbow
• Posterior dislocation: a combination of elbow
hyperextention, valgus stress, arm abduction
and forearm supination
• Anterior dislocation: a direct force strikes the
posterior forearm with elbow in flexed position

12. • Most elow dislocations & fracture
dislocations result in injury to all
capsulo-ligamentous stabilizers of
elbow joint
• The capsuloligamentous injury
progresses from lateral to medial (HORI
CIRCLE)

14. Signs and Symptoms
Pain, Swelling and Ecchymosis
Instability, Crepitus and Deformity
(With the elbow flexed at 90 degrees,the medial &
lateral epicondyles & olecranon process should from
isosceles triangle)
 A complete peripheral neurological examination
for both motor & sensory functions should be
done
 Radial & ulnar pulses should be compared on
both sides

15. Classificaton
According to direction of
displacement of ulna
relative to the humerus
• Posterior
• Posterolateral
• Posteromedial
• Lateral
• Medial
• Anterior

16. Treatment principles
Restoration of the inherent bony
stability is goal
Ulnotrochlear and Radiocapitellar contact.
The LCL is more important than MCL in
setting of most cases of traumatic elbow
instability
MCL will usually heal properly without any
repair

17. • Parvin’s method Of Closed reduction
Patient lies prone
Physician applies gentle downward traction of
the wrist for few min, as the olecranon begin to
slip distally, the physician lift up gently on the
arm

18. • Meyn and Quigley’s
method of reduction:
Only the forearm hangs
from the side of the
stretcher as gentle
downward traction is
applied on the wrist, the
physican gudies the
reduction of olecranon
with the opposite hand

19. Surgical repair (if elbow clinically is
unstable post reduction)
Direct repair of the ligaments,capsule and
muscles
Static or Hinged external fixator application
Cross pining of the joint
Temporary bridge plating of the elbow

20. • If the elbow remains unstable
inspite of repair to lateral structures
the medial side of the elbow is
approached with care taken to
protect the ulnar nerve
• If the elbow is still unstable then an
External fixator should be placed

21. Complications
Vascular injury of brachial artery may occur
Nerve injury the medial ulnar nerve may be affected
Myositis ossificans which is more common if passive
exercise is inflicted on the patient.
Late complications
 Stiffness
 Heterotopic ossification
 Unreduced dislocation
 Recurrent dislocation
 Osteoarthritis after severe fracture dislocation.

22. RADIAL HEAD
FRACTURE

23. EPIDEMIOLOGY
 4% of all fractures and 30% of all elbow
fractures
 1/3 patients associated injury to shoulder,
humerus, forearm,wrist or hand.
 Rare in children due to cartilagenous nature of
radial head
 Radial neck fracture more common in children

24. Anatomy of proximal radius
RadioCapitellar joint transmit 50-60% load
across elbow

25. Radius Head Surgical Anatomy
Important for:
 Valgus Stability
 Posterolateral Rotatory
Stability
 Longitudinal Forearm
Stability
 (Along With Interossi
Membrane & Druj)

26. Elbow Stability
MCL & Ulnohumeral Joint: Primary Stabilizer
Radial Head & Capsule: Secondary Stabilizer

27. Mechanism Of Injury
(1) Fall On Outstreched Hand (most Common)
Distal Radius
Interossi Membrane(forearm)
Radial Head Impaction Against Capitellum
(2) Valgus Injury To Elbow/Direct Injury
Mcl Rupture/Olecranon Fracture Unstable Elbow

28. Signs and Symptoms
 Swelling
 Ecchmosis
 Anconeus Triangle Fullness
 Range Of Motion Restriction
 Stability
 Active Finger Extension
 Forearm/Interossi Membrane Tenderness
 Wrist Tenderness
ESSEX LOPRESTI Lesion

29. Essex Lopresti Lesion
 This is defined as
longitudinal disruption of forearm
interosseous ligament,
usually combined with radial head
fracture and/or dislocation
plus distal radioulnar joint injury

30. Muscle Attachment Around Proximal
Radius:
 SUPINATOR ATTACHMENT AT PROXIMAL RADIUS.
 BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.

31. Posterior Interossei Nerve At Risk:
 Posterior Interosseous Nerve Traverses From Anterior To
Posterior Through Supinator Muscle.
 Always Check Pre Operative Active Finger Extension

32. Radiographic Findings
 STANDARD AP AND LATERAL X RAY of elbow
 OBLIQUE(GREEN SPAN)VIEW
 FOREARM AND WRIST X RAY IF REQUIRED

33. X RAY FINDINGS

34. Classification Of Radial Head Fractures
Mason classification
Type I
Minimally displaced, no
mechanical block to rotation,
intraarticular displacement <2mm
Type II
Displaced fx >2mm or angulated,
possible mechanical block to
forearm rotation
Type III Comminuted and displaced fx,
mechanical block to motion
Type IV Radial head fracture with elbow
dislocation
MORREY MODIFIED MASON CLASSIFICATION BY QUANTIFYING DISPLACEMENT
AREA >30% AND DISPLACEMENT OF >2 MM

35. Treatment Goal
 Correction Of Any Block To Forearm Rotation
 Early Mobilisation Of Elbow And Forearm
 Stability Of Elbow And Forearm
 Prevention Of Secondary Osteoarthrosis Of
Elbow

36. Non Operative Treatment
 Indication:
 Isolated Radial Head Fracture With Mason Type 1
(Undisplaced <2mm)
 Plaster Slab For 3 Weeks
 Early Active Mobilization Of Elbow
 Persistant Pain.Inflammation,contracture
Suspect Capitellar Fracture

37. Operative Management
(Open Reduction & Internal Fixation)
 INDICATION FOR ORIF:
 Mason type II with mechanical block(displaced)
 Large fragment >2 mm
 Mason type III where ORIF feasible(>3 FRAGMENT POOR
OUTCOME)
 Mechanical block to motion (lignocaine inj in elbow joint)
 Presence of other complex ipsilateral elbow injuries(without
metaphyseal bone loss)
 FRAGMENT EXCISION LEADS TO INSTABILITY
 TRY TO PRESERVE SMALLEST FRAGMENT

38.  PRONATE FOREARM WHILE FIXATION

39. Which implant to use?
 Mini fragment screw(2.4 or 2.7
mm)(counter sink must)
 Headless compression compression
screw/Herbert screw
 Low profile plate/mini t plate(in safe
zone/postero lateral)
 K WIRE

40. COMPLICATION OF ORIF
 PIN INJURY
 HARDWARE FAILURE
 HARDWARE IMPINGEMENT
 STIFFNESS OF ELBOW
 RESTRICTION OF SUPINATIONPRONATION

41. Radial Head Replacement
 To prevent proximal migration of the radius
 Silicon implant poor outcome : SILICON SYNOVITIS
 Titanium/vitallium metallic implant of choice

42. RADIAL HEAD EXCISION
 INDICATION:
 Low demand, sedentary patients
 In a delayed setting for continued pain of an isolated radial
head fracture
 CONTRAINDICATION:
 In children
 Presence of destabilizing injuries (Essex-lopresti
lesion,fracture dislocation elbow(mason type 4),monteggia)
 Terrible triad of elbow(coronoid fracture,MCL deficiency)

43.  Common injury
 Potential for functional
impairment and frequent
complications

44.  First surgeon to recognize these injuries was
Pouteau 1783. His work was not widely
publicized.
 Later Abraham Colles 1814 gave the classic
description of “Colles fracture”
 Advent of X rays at the end of nineteenth
century contributed much to the understanding
of different patterns of injury.

45.  One sixth of all fractures treated in the
Emergency Room (16%)
 Bimodal distribution
 less than 30 years (70% men)
 over 50 years (85% women)
 Males age 35 or older - 90 per 100,000 population

46.  Occurs through the distal metaphysis of the
radius
 May involve articular surface.
 Mechanism of injury
 forced extension of the carpus,
 impact loading of the distal radius.

47.  History
 Wrist is typically swolen with ecchymosis and
tender
 Visible deformity of the wrist, with the hand
most commonly displaced in the dorsal
direction less comonly in volar direction
 Movement of the hand and wrist are painful.
 Adequate and accurate assessment of the
neurovascular status of the hand is performed,
before any treatment is carried out.

48.  General physical exam of the patient, including
an evaluation of the injured joint, and a joint
above and below
 Radiographs of the injured wrist-pa and lat
view , oblique view
 CT scan of the distal radius to know extent of
intrarticular involvement

49.  Distal radius – 80% of axial load
 Scaphoid fossa
 Lunate fossa
 Sigmoid notch – DRUJ
 Distal ulna

50.  Scaphoid and lunate
fossa
 Ridge normally exists
between these two
 Sigmoid notch: second
important articular
surface
 Triangular
fibrocartilage
complex(TFCC): distal
edge of radius to base
of ulnar styloid

51.  Articular Surface
 Scaphoid facet
 Lunate facet
 Sigmoid notch

53.  Ulnar inclination (avg 23°)
 Volar tilt (avg 11 to 12°)
 Radial Height (avg 11 mm)
 Ulnar variance (+/- 1 mm)

54. Measurement of Radial Length and
Inclination
Inclination = 23
degrees

56.  Intra-articular fxs with multiple
fragments
 centrally impacted fragments
 DRUJ incongruity

57.  Column theory
 Gartland/Werley
 Frykman
 Weber (AO/ASIF)
 Melone
 Fernandez (mechanism)

58. Extra-
articular
Radio-carpal
joint
Radio-ulnar joint
Both joints
{
Same pattern as
odd numbers,
except ulnar
styloid also
fractured

59. Group A: Extra-
articular
Group B: Partial
Intra-articular
Group C:
Complete Intra-
articular

60.  Type I Extraarticular, undisplaced
 Type 2 Extraarticular, displaced
 Type 3 Intraarticular, undisplaced
 Type 4 Intraarticular, displaced

61.  Type A Extraarticular
 Type B Partial articular
 B1–radial styloid fracture
 B2–dorsal rim fracture
 B3–volar rim fracture
 B4–die-punch fracture
 Type C Complete articular

62. Rikli & Regazzoni, 1996
3 Columns: Radial, Intermediate, Medial

63.  Radial Column
Lateral side of
radius
 Intermediate
Column
Ulnar side of
radius
 Ulnar Column
distal ulna
Radial column
Intermediate column
Ulnar column

64.  I. Bending-metaphysis
bending with loss of
palmar tilt and radial
shortening ,DRUJ
injury(Colles, Smith)
 II. Shearing-fractures
of joint surface
(Barton, radial styloid)

65.  III. Compression-
intraarticular fracture
with impaction of
subchondral and
metaphyseal bone (die-
punch)
 IV. Avulsion-fractures of
ligament attachments
(ulna, radial styloid)
 V. Combined/complex -
high velocity injuries

66.  Assess involvement of dorsal or volar rim
 Is comminution mainly volar or dorsal?
 is one of four cortices intact?
 Look for “die-punch” lesions of the
scaphoid or lunate fossa.
 Assess amount of shortening
 Look for DRUJ involvement

67.  COLLES #
-extra articular or intra articular distal radius -
clinicaly described as dinner fork deformity
-mechanism---fall on to an hyper extended ,radialy
deviated wrist with the forearm in pronation

68.  # distal radius with volar angulation or
volar displacement of the hand and
distal radius
 mechanism—fall on to a flexed wrist
with the forearm fixed in supination
 unstable pattern often requires ORIF
because of difficulty in maintaining
closed reduction

69.  # disdlocation or subluxation of
wrist in which the dorsal or volar
rim of distal radius is displaced
 mechanism-fall on to a dorsiflexed
wrist with the forearm fixed in
pronation
 unstable # requires ORIF

70.  Avulsion # with extrinsic ligaments
remaining attached to styloid fragment
 Mechanism-compression of scaphoid
against styloid with the wrist in
dorsiflexion and ulnar deviation
 Often associated with intercarpal
ligament injury
 Requires ORIF

71. five factors indicative of instability
(1)initial dorsal angulation of more than 20
degrees (volar tilt),
(2) dorsal metaphyseal comminution,
(3) intraarticular involvement,
(4) an associated ulnar fracture, and
(5) patient age older than 60 years

72.  Preserve hand and wrist function
 Realign normal osseous anatomy
 Promote bone healing
 Avoid complications
 Allow early finger and elbow ROM

73.  Casting
 Long arm vs short arm
 Sugar-tong splint
 External Fixation
 Joint-spanning
 Non bridging
 Percutaneous pinning
 Internal Fixation
 Dorsal plating
 Volar plating
 Combined dorsal/volar plating
 focal (fracture specific) plating

74.  Low-energy fracture
 Medical co-morbidities
 Minimal displacement-
acceptable alignment

75.  Obtaining and then maintaining an
acceptable reduction.
 Immobilization:
 long arm
 short arm adequate for elderly patients
 Frequent follow-up necessary in order to
diagnose redisplacement.

76.  Anesthesia
 Hematoma block
 Intravenous sedation
 Bier block
 Traction: finger traps and weights
 Reduction Maneuver (dorsally angulated fracture):
 hyperextension of the distal fragment,
 Maintain weighted traction and reduce the distal
to the proximal fragment with pressure applied
to the distal radius.
 Apply well-molded “sugar-tong” splint or cast,
with wrist in neutral to slight flexion.
 Avoid Extreme Positions!

77.  Radial length: within 2-3 mm of the
contralateral wrist
 Palmar tilt: neutral tilt
 Intrarticular step-off or gap< 2mm
 Radial inclination <5° loss
 Carpal malalignment: absent
 Ulnar variance: no more than 2 mm of
shortening compare to ulnar head

78.  High-energy injury
 Open injury
 Secondary loss of reduction
 Articular comminution, step-off, or gap
 Metaphyseal comminution or bone loss
 Loss of volar buttress with displacement
 DRUJ incongruity

80. External fixation:
The treatment of choice for
distal radius fractures in the
1980’s

82.  A spanning fixator is
one which fixes
distal radius
fractures by
spanning the carpus;
I.e., fixation into
radius and
metacarpals
 Use for comminuted
fracture

84.  Mal-union
 Pin track infection
 Finger stiffness
 Loss of reduction; early vs late
 Tendon rupture

85. Non-spanning External
Fixator

87.  Bulky
 Poor screw hold in porosis and comminution
 Screws do not buttress
 Cutaneous radial nerve injury
 Pin tract infection
 Reflex sympathetic dystrophy

89.  intrafocal pinning
through fracture site
 buttress against
displacement
 Drawback-tendency to
translate distal fragment
in opposite direction

90.  Useful for elevation of depressed articular
fragments and bone grafting of metaphyseal
defects
 required if articular fragments can not be
adequately reduced with percutaneous
methods

91.  Based on location of comminution.
 Dorsal approach for dorsally angulated
fractures.
 Volar approach for volar rim fractures
 Radial styloid approach for buttressing of
styloid
 Combined approaches needed for high-energy
fractures with significant axial impaction.

92. Classical Henry
approach(chung)
Extended carpal tunnel approach
VOLAR

93. Volar –Henry Approach

94.  Fracture line is
exposed
Volar plate positioned, insertion
of first screw

96. Courtesy J. Orbay, MD

97. -
DORSAL
APPROACH
3rd DC –EPL
(extensile)
1-2nd DC

98. Dorsal Plating, PCP and Ex Fix

99.  Generally not prefere because of high rate of
complication like
- tendon dysfunction and rupture
- tenosynovitis of extensor tendons
 indicated for-
dorsal die-punch fractures or fractures
with displaced dorsal lunate facet fragments

101. -less tendon irritation than dorsal

102. Fixed angle locked screws
,,variable angle

104.  radial column,
 dorsal cortical wall,
 dorsal ulnar split,
 volar rim, and
 the central
intraarticular
fragment

105.  Radial pin-plate
For stabilization of radial column
Ulnar pin-plate
for stabilization of dorsal ulnar
split fragment

106. simultaneously
stabilization of
dorsal wall fragment
and intraarticular
component

107. Volar approach,
application
buttress plate

108. Dorsal approach,
application of 2 “L”
buttress plates

109. EPL Tendon

110. Extensor retinaculum repaired
beneath EPL to prevent erosion
against plate- EPL left transposed

111.  reduce articular incongruities
 also diagnose associated soft tissue lesions
 minimally invasive

112.  Arthritis/arthrosis
 Loss of motion
 Hardware complications
 Nerve compression/neuritis
 Osteomyelitis
 Persistent pain/pain syndromes (CRPS)
 Tendon (rupture, lag, trigger, tenosynovitis)
 Delayed union/nonunion/malunion
 Radioulnar (synostosis, disturbance)

113.  External fixators still have a role in the
treatment of distal radius fractures
 Spanning ex fix does not completely correct
fracture deformity by itself
 Should usually combined with percutaneous
pins (augmented fixation)

114.  new plating techniques allow for accurate
and rigid fixation of fragments
 Plating allows early wrist ROM
 Volar, smaller and more anatomic plates are
better tolerated
 combination treatment is often needed

115.  Olecranon Fracture
 Forearm Fractures (including Galleazi and
Monteggia)

116.  Commonly asked questions:
 Volkmann’s Ischaemic Contracture
 Reflex Symathetic Dystrophy (Sudeck’s
Osteodystrophy)
 Important topics (must read):
 Bennet’s and Rolando’s Fractures
 Scaphoid Fractures