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Primary Management of Upper Limb Fractures Dr. Lulu Chamayi Objectives • Common Upper Limb Fractures • Primary Management and Immobilisation • Common UL Surgeries • Assessment of NV status • Upper Limb Complication 20/11/2024 Primary Management of Upper Limb Fractures 2 Upper Limb Bones 1. Clavicle (Collar bone) 2. Scapula ( Shoulder bone) 3. Humerus 4. Elbow 5. Radius+ Ulna 6. Hand + Wrist 20/11/2024 Primary Management of Upper Limb Fractures 3 Focused History • Hight / Low energy Injury • Mechanism Of injury • FOOSH • Direct Trauma • Any other injuries • AMPLE hx: • Allergies • Medication • PMH • Last meal • Event surrounding the time of injury 20/11/2024 Primary Management of Upper Limb Fractures 4 Focused Examination Look • Obvious deformity • Open or closed • Swelling • Ecchymosis Feel • Pulse • Temperature • Sensation Move • ROM • Motor function Joints above and below 20/11/2024 Primary Management of Upper Limb Fractures 5 Associated Red Flags of UL Fractures Swelling Remove Ring Vessel Injury Check Pulse Nerve Injury Assess – Weakness & Numbness 20/11/2024 Primary Management of Upper Limb Fractures 6 Neurovascular Observations Nerve Movement Sensation Nerve Injury ▪ Wrist Drop ▪ Numb 1 dorsal web Radial Nerve space • Unable to oppose thumb Median Nerve • Numb thumb , Index , middle fingers +1/2 ring finger • Unable to make OK sign Anterior Interosseus Nerve • Numb 4 + 5 digit Ulnar Nerve • Claw hand 20/11/2024 Primary Management of Upper Limb Fractures 7 Clavicle Fracture • Common Fracture • Young Adults – Active Patients • Mechanism of Injury – FOOSH/Direct Trauma • Common site (80%) – Middle 3 of Clavicle (Midshaft) 20/11/2024 Primary Management of Upper Limb Fractures 8 Clavicle Fracture • Common Fracture • Young Adults – Active Patients • Mechanism of Injury – FOOSH/Direct Trauma • Common site (80%) – Middle 3 of Clavicle (Midshaft) 20/11/2024 Primary Management of Upper Limb Fractures 9 Clavicle Fracture-Red Flags and NV Assessment Tenting of skin /Impending open fracture 20/11/2024 Primary Management of Upper Limb Fractures 10 Clavicle Fracture-Red Flags and NV Assessment Brachial plexus Injury= Weak+Numb Subclavian Vessel Injury (1cm from Clavicle) 20/11/2024 Primary Management of Upper Limb Fractures 11 Clavicle Fracture – Management Non-Operative Management • Stable, Undisplaced • No NV Injury • < 2cm shortening and displacement • Polysling • Analgesia 20/11/2024 Primary Management of Upper Limb Fractures 12 Clavicle Fracture – Management Operative Management • Open Fracture • Displaced Fracture with Skin tenting • Subclavian Artery or Vein Injury • Plate &Screw • Intramedullary Fixation 20/11/2024 Primary Management of Upper Limb Fractures 13 Scapula Fracture • Uncommon Fracture • Associated with High Energy Trauma • > 70% due to Road Traffic Collisions • A/w Painful Breathing and SOB 20/11/2024 Primary Management of Upper Limb Fractures 14 Scapula Fracture Body Fracture Neck fracture • Uncommon Fracture • Associated with High Energy Trauma • > 70% due to Road Traffic Collisions • A/w Painful Breathing and SOB 20/11/2024 Primary Management of Upper Limb Fractures 15 Scapula Fracture – Management Non-Operative Management Operative Management • Vast majority managed conservatively • Open Fracture • Polysling • Displaced and unstable Fracture • Regular analgesia 20/11/2024 Primary Management of Upper Limb Fractures 16Proximal Humerus Fracture • Common Fracture • Elderly population • Low energy falls • Risk factor - Osteoporosis 20/11/2024 Primary Management of Upper Limb Fractures 17Proximal Humerus Fracture – Imaging 2 Part Surgical Neck Fracture(M.C) 20/11/2024 Primary Management of Upper Limb Fractures 18Proximal Humerus Fracture – Imaging 2 Part GT fracture 20/11/2024 Primary Management of Upper Limb Fractures 19Proximal Humerus Fracture – Imaging 3 Part GT fracture 20/11/2024 Primary Management of Upper Limb Fractures 20Proximal Humerus Fracture – Imaging 4 Part GT fracture 20/11/2024 Primary Management of Upper Limb Fractures 21 Proximal Humerus Fracture – Dangers and NV assessment • Axillary Artery Injury –Weak/ No pulse – Emergency • Axillary Nerve Injury –Numb C5 – Regimental Badge Palsy 20/11/2024 Primary Management of Upper Limb Fractures 22 Proximal Humerus – Management Non-Operative Management • Minimally displaced surgical and anatomical neck fracture • GT # -Displaced <5mm • Collar & Cuff Gravity • Analgesia 20/11/2024 Primary Management of Upper Limb Fractures 23 Proximal Humerus – Management Non-Operative Management • Minimally displaced surgical and anatomical neck fracture • GT # -Displaced <5mm • Not a surgical candidate • Collar & Cuff • Analgesia 20/11/2024 Primary Management of Upper Limb Fractures 24 Proximal Humerus – Management Operative Management • GT displaced >5mm • Displaced 2-part # • 3 & 4 part #in younger patient • CRPP , Plate & Screw ,IM nail 20/11/2024 Primary Management of Upper Limb Fractures 25Shaft Humerus Fracture • Common Fracture • Young Adults • Mechanism of Injury – High Energy Trauma 20/11/2024 Primary Management of Upper Limb Fractures 26Red flags & NV assessment ▪ Wrist Drop st ▪ Numb 1 dorsal web space 20/11/2024 Primary Management of Upper Limb Fractures 27Shaft of Humerus Fracture – Management Non-Operative Management • Vast majority is managed conservatively • Humeral Brace / U slab • Analgesia 20/11/2024 Primary Management of Upper Limb Fractures 28Shaft of Humerus Fracture – Management Non-Operative Management • Vast majority is managed conservatively • Humeral Brace / U slab • Analgesia 20/11/2024 Primary Management of Upper Limb Fractures 29 Shaft of Humerus Fracture – Management Operative Management • Comminuted Fracture • Open Fracture • Vascular Injury • IM nailing / Pate & Screw 20/11/2024 Primary Management of Upper Limb Fractures 30 Elbow Fracture • All ages . • Low and High energy Mechanism • Focusing on Supracondylar and olecranon fracture. 20/11/2024 Primary Management of Upper Limb Fractures 31Red flags and NV Assessment • All Nerves –Median, Ulnar , radial and AIN • Brachial artery 20/11/2024 Primary Management of Upper Limb Fractures 32 Supra Condylar Fracture • Most Common traumatic fracture in children • MOI- Fall on outstretched hand • Extension Type (Most common >95%) , Flexion <5% • Associated with AIN injury Flexion Type Extension Type 33 20/11/2024 Primary Management of Upper Limb Fractures Supra condylar fracture - BOAST Guideline •Limb Assessment: Assess radial pulse, capillary refill, and nerve function (radial, median, ulnar) on presentation and pre-surgery. •Surgery Timing: Perform surgery on the day of injury; night-time surgery only if urgent •Urgent Surgery Indications: Urgent surgery needed for absent radial pulse, impaired perfusion, open injury, or threatened skin viability. •Vascular Impairment: Most vascular issues resolve with fracture reduction; brachial artery exploration not needed if no signs of ischaemia 34 20/11/2024 Primary Management of Upper Limb FracturesSupra Condylar Fracture-Management Non-Operative management • Undiplaced fracture • Type II fractures that meet the following criteria • anterior humeral line intersects the capitellum • Mild swelling Operative Management • Type II , III, IV supracondylar fractures • flexion type 35 20/11/2024 Primary Management of Upper Limb Fractures Olecranon Fracture Olecranon Fracture • lead to loss of extensor mechanism. • MOI- Direct Blow /FOOSH 36 20/11/2024 Primary Management of Upper Limb Fractures Olecranon Fracture –Management Management :- • Non-operatively -nondisplaced fractures with intact extensor mechanism • Operatively Managment –Displaced # with loss of extensor mechanism 20/11/2024 Primary Management of Upper Limb FracturesRadius and Ulna Fracture Radius and ulnar shaft fractures common fractures of the forearm MOI –Direct Trauma / Road Traffic Accident 38 20/11/2024 Primary Management of Upper Limb FracturesMonteggia Fracture dislocation Galeazzi Fracture Dislocation Fracture of Proximal Third of the ulna Fracture of distal third of radius shaft + + Radial Head Dislocation Dislocation of the distal radio ulnar Joint 20/11/2024 Primary Management of Upper Limb Fractures 39Red flags & NV assessment • Median Nerve Injury • Ulnar Nerve Injury • Radial Artery Injury • Ulna Artery Injury 20/11/2024 Primary Management of Upper Limb Fractures 40Radius and Ulna Fracture Management Non-Operative Management • More common and successful in children • Rarely indicated in adults, most require operative treatment • Analgesia • Above elbow back slab 20/11/2024 Primary Management of Upper Limb Fractures 41Radius and Ulna Fracture Management Operative Management • Nearly all both bone fractures in patients 10 year or older are surgical candidates • open fractures with significant bone loss • open reduction internal fixation (ORIF) • closed reduction and intramedullary fixation (IMN) 20/11/2024 Primary Management of Upper Limb Fractures 42Wrist Fracture Distal radius Fracture • Most common orthopaedic injury • High / Low energy injury • MOI – FOOSH • 50% are intra-articular • Main risk factor : Ostoporosis 20/11/2024 Primary Management of Upper Limb Fractures 43Wrist Fracture - Eponyms Colles Fracture • Extra articular ( most Common) • Dorsal angulation and displacement • Dinner Fork deformity • Fall on outstretched hand 20/11/2024 Primary Management of Upper Limb Fractures 44Wrist Fracture - Eponyms Smith Fracture • Extra articular • Volar angulation and displacement • Garden Spade Fork deformity • Fall on the back of the hand 20/11/2024 Primary Management of Upper Limb Fractures 45Wrist Fracture - Eponyms Barton’s Fracture • Intraarticular distal radius fracture • Dorsal or volar displacement • Fall on outstretched hand 20/11/2024 Primary Management of Upper Limb Fractures 46Wrist Fracture –Red flags and NV assessment Median Nerve injury 20/11/2024 Primary Management of Upper Limb Fractures 47 Wrist Fracture – Management Non-Operative Management •Extra-articular •< 5mm radial shortening • Adequate analgesia • Closed reduction under Haematoma block /Biers block • Put in below elbow back slab 20/11/2024 Primary Management of Upper Limb Fractures 48Wrist Fracture – Management Operative Management • Unstable Fracture • dorsal angulation > 5° or > 20° of contralateral distal radius • volar or dorsal comminution 20/11/2024 Primary Management of Upper Limb Fractures 49 Hand Fractures • Metacarpal Fractures are the most common hand injury • Divided into fractures of the head, neck, or shaft. • MOI-direct blow to hand or rotational injury with axial load 20/11/2024 Primary Management of Upper Limb Fractures 50 Hand Fracture– Management Non-Operative Management •Must be stable pattern •No rotational deformity Bedford splint Neighbour strapping 20/11/2024 Primary Management of Upper Limb Fractures 51 Hand Fracture– Management Operative Management • open fx • intra-articular fxs • rotational malalignment of digit • significantly displaced or angulated fractures multiple metacarpal shaft fractures 20/11/2024 52 Primary Management of Upper Limb FracturesKey T akeaways 1.Spot the Red Flags: Always check for NV injuries, open fractures, or skin tenting. 2.Immobilize & Assess: Stabilize fractures, manage pain, and get imaging early. 3.Know When to Operate: Unstable or NV-compromised fractures need urgent referral. 4.Follow Guidelines: BOAST/NICE recommendations ensure safe, effective care. 20/11/2024 53 Primary Management of Upper Limb Fractures THANK YOU Dr. Lulu Chamayi 9/4/20XX Presentation Title 54