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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

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


  • 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%)


  • Type I Middle Third (80%)

  • Type II Distal Third (15%)

  • Type III Medial Third (5%)

Clinical Evaluations

  • Pain

  • Local deformity/abnormal motion

  • Radiography


  • Conservative Treatment:

    Eight bandage immobilization for 4 weeks.


  • 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


  • Clinical Evaluation

    • Lose of a round shape of the shoulder

    • Dysfunction

    • Dugas sign (+)


  • Radiographic Evaluation


  • Closed Reduction

  • Hippocratic technique: effective for one person

  • Appropriate sedation

  • 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

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;

Proximal Humerus Fractures

  • Minimally displaced fractures- Sling immobilization, early motion

  • Complicated fractures: Open reduction and internal fixation (ORIF)

Humeral Shaft Fractures

  • Commonly resulted from indirect injury

  • Indirect injury results in Spiral or Oblique fractures

  • Complications : - Radial nerve injury

    - Delayed union & non-union

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


  • 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


  • 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

Supra-condylar Fracture of Humerus

  • More common in Children

  • Indirect injury

Typical treatment surgery
Typical treatment: Surgery

K wires fixation

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


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

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

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


  • 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

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


  • Hip Fractures / Dislocations

  • Femur Fractures

  • Patella Fractures

  • Tibia Fractures

Hip Dislocations

  • Significant trauma, usually MVA

  • Posterior: Hip flexion, inner rotation, adduct


  • Anterior: rare

Closed Reduction: Emergency

  • Emergency is necessary for reducing risk of DVT and AVN, under anesthesia

  • Need a team!

  • Allis Maneuver

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


  • Garden Classification

    • I Valgus impacted

    • II Non-displaced

    • III Complete: Partially Displaced

    • IV Complete: Fully Displaced

  • Functional Classification

    • Stable (I/II)

    • Unstable (III/IV)






  • 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


  • Typically surgery: DHS, DCP, PFN

Femoral Shaft Fractures

  • Intra-madullary nail

  • ORIFwith plate and screws

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

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

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


  • Restore Articular Surface

  • Minimize Soft Tissue Injury

  • Establish Length

  • Avoid VarusCollapse