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Trauma. Dr. DUJUNHUA 杜峻华. Department of Orthopaedics , the First Affiliated Hospital , Medical Collage , Zhejiang University 浙江大学医学院附属第一医院 骨科 Call me : 13858039976. Trauma of the Upper Limb. Content. Clavicle Fractures Shoulder Dislocations Humerus Fractures

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dr dujunhua
Dr. DUJUNHUA 杜峻华

Department of Orthopaedics,

the First Affiliated Hospital,

Medical Collage,

Zhejiang University

浙江大学医学院附属第一医院 骨科

Call me:13858039976

trauma of the upper limb
Trauma of the Upper Limb

Content

  • Clavicle Fractures
  • Shoulder Dislocations
  • Humerus Fractures
  • Fractures of the Forearm
  • Distal radius fractures
clavicle fractures
Clavicle Fractures
  • Mechanism
    • Fall onto shoulder (87%)
    • Direct blow (7%)
    • Fall onto outstretched hand (6%)
slide5

Classification

  • Type I Middle Third (80%)
  • Type II Distal Third (15%)
  • Type III Medial Third (5%)
slide6

Clinical Evaluations

  • Pain
  • Local deformity/abnormal motion
  • Radiography
treatments
Treatments
  • Conservative Treatment:

Eight bandage immobilization for 4 weeks.

slide8

Treatments

  • Surgery
  • Fractures with neurovascular injury
  • Fractures with severe associated chest injuries
  • Open fractures
  • Cosmetic reasons, uncontrolled deformity
  • Nonunion
shoulder dislocations
Shoulder Dislocations
  • Epidemiology
    • Anterior: Most common
    • Posterior: Uncommon, 10%
    • Inferior: Rare, hyperabduction injury
slide10

Evaluations

  • Clinical Evaluation
    • Lose of a round shape of the shoulder
    • Dysfunction
    • Dugas sign (+)
slide11

Evaluations

  • Radiographic Evaluation
slide12

Treatments

  • Closed Reduction
  • Hippocratic technique: effective for one person
  • Appropriate sedation
slide14

Post-reduction

    • Dugas sign (-)
    • Reduced local pain
    • Post X-ray films are a must to confirm reduction
    • Immobilization for 1-2 weeks before progressive ROM
  • Operative indications
    • Irreducible shoulder, failed due to soft tissue interposition
    • With fractures of the humeral head
    • Habitual dislocations
slide15

Proximal Humerus Fractures

  • Most common fracture of the humerus
  • Higher incidence in the elderly, thought to be related to osteoporosis
  • Females 2:1 greater incidence than males
  • Most commonly due to a fall onto an outstretched arm from standing height;
slide16

Proximal Humerus Fractures

  • Minimally displaced fractures- Sling immobilization, early motion
  • Complicated fractures: Open reduction and internal fixation (ORIF)
slide17

Humeral Shaft Fractures

  • Commonly resulted from indirect injury
  • Indirect injury results in Spiral or Oblique fractures
  • Complications : - Radial nerve injury

- Delayed union & non-union

slide18

Clinical Evaluation

  • pain, swelling, deformity of the upper arm
  • Careful nerve exam is important as the radial nerve is in close proximity to the humerus and can be injured: wrist drop
treatments1
Treatments
  • Closed reduction & immobilization with a splint or hanging cast .
  • Goal of treatment is to establish union with acceptable alignment
  • >90% of humeral shaft fractures heal with nonsurgical management
treatments2
Treatments
  • Open reduction internal fixation by plate and screws or internal locking nail.
  • Indications: inadequate reduction, nonunion, associated injuries, open fractures, segmental fractures, associated vascular or nerve injuries
slide22

Supra-condylar Fracture of Humerus

  • More common in Children
  • Indirect injury
slide25

Fractures of the Forearm

  • Direct trauma or falling on the outstretched hand
  • Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of function at the hand
  • Careful exam is essential, with specific assessment of radial, ulnar, and median nerves and radial and ulnar pulses
  • Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for compartment syndrome
slide28

Monteggiafractures

A fracture of the proximal ulna with an associated radial head dislocation

slide29

Distal radius fractures

  • One of the most common fractures in elderly;
  • Gross deformity of the wrist with variable displacement of the hand;
  • Most common: Colles fractures
slide30

Distal Radius Fractures

  • Colles’ Fracture :

Fracture of the distal end of the radius, most common among elderly women, related to postmenopausal osteoporosis

  • Mechanism :

Falling on outstretched hand, with wrist between 40-90 degrees of dorsiflexion

  • Pathological Anatomy :

The distal fragment is displaced upwards, dorsally and

laterally producing the classical dinner fork deformity

radiographic evaluation
Radiographic Evaluation
  • Normal bony relationships of the wrist

11 Deg

23 Deg

11 mm

treatment
Treatment
  • Displaced fractures require and attempt at reduction.
    • Hematoma block-10ccs of lidocaine or a mix of lidocaine and marcaine in the fracture site
    • Reproduce the fracture mechanism and reduce the fracture
    • Place in cast
slide33

Manipulative reduction

  • Use the soft tissue hinge to reduce fracture
operative management
Operative Management
  • For the treatment of intraarticular, unstable, malreduced fractures.
trauma of the lower limb
Trauma of the Lower Limb

Content

  • Hip Fractures / Dislocations
  • Femur Fractures
  • Patella Fractures
  • Tibia Fractures
slide37

Hip Dislocations

  • Significant trauma, usually MVA
  • Posterior: Hip flexion, inner rotation, adduct
mechanism
Mechanism
  • Anterior: rare
slide39

Closed Reduction: Emergency

  • Emergency is necessary for reducing risk of DVT and AVN, under anesthesia
  • Need a team!
  • Allis Maneuver
slide40

After Reduction

  • Repeat AP pelvis film
  • No flexion >60 degrees
  • Early mobilization under aid
  • Follow the risk of avascular necrosis
hip neck fractures
Hip Neck Fractures
  • One of the most common fractures in the elderly
  • Female > male
  • May result from a simple fall
  • Intra-capsular fracture
slide43

Classifications

  • Garden Classification
    • I Valgus impacted
    • II Non-displaced
    • III Complete: Partially Displaced
    • IV Complete: Fully Displaced
  • Functional Classification
    • Stable (I/II)
    • Unstable (III/IV)

I

II

III

IV

slide44

Treatments

  • Non-operative
  • Very little role
  • Traction
  • Operative
  • ORIF (canulated screws or DHS)
  • Hemiarthroplasty (>65 years old)
  • Total Hip Replacement
intertrochanteric hip fractures
Intertrochanteric Hip Fractures
  • Extra-capsular femoral fractures
  • To inferior border of the lesser trochanter
slide48

Treatments

  • Typically surgery: DHS, DCP, PFN
slide49

Femoral Shaft Fractures

  • Intra-madullary nail
  • ORIFwith plate and screws
slide50

Distal Femur Fractures

  • High energy, multiple trauma
  • High incidence of post-traumatic arthritis if the knee was disrupted
patella fractures
Patella Fractures
  • History: MVA, Fall onto knee
  • Clinical evaluation
  • Pain, swelling, contusions, lacerations
  • Palpable defect
  • Unable to straight leg raise
slide56

Tibial Plateau Fractures

  • MVA, fall from height, sporting injuries
  • Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with medial plateau injuries)
  • Be aware of compartment syndrome
  • Check for knee ligamentous instability
slide59

TibialShaft Fractures

  • Can occur in lower energy, torsion type injury
  • Open fractures of the tibia are more common than in any other long bone
pilon fractures
Pilon Fractures
  • Fractures involving distal tibia metaphysis and into the ankle joint
  • Soft tissue management is key!
  • “Excellent” results are rare
  • Multiple potential complications: Mal or Non-union (Varus), infections, soft tissue complications, et. al
initial evaluation
Initial Evaluation
  • Plain films, CT scan
  • Spanning External Fixator
  • Delayed Definitive Care to protect soft tissues and allow for soft tissue swelling to resolve
slide63

Treatments

  • Restore Articular Surface
  • Minimize Soft Tissue Injury
  • Establish Length
  • Avoid VarusCollapse
ad