Management of Fractures - Dr Matthew Sherlock

Management of common upper limb fractures in Adults and Children

Dr Matthew SherlockShoulder and Elbow Orthopaedic Surgeon

Outline Immobilisation choicesAdults

Clavicle FracturesProximal Humeral FracturesWrist Fractures

ChildrenElbow FracturesForearm Fractures

Immobilising Upper Limb #s Immobilisation choices

Slings – triangular, immobiliserCollar and cuffPlaster

Backslab, full cast (short arm, long arm), U-slab, hanging cast

Removable splintsBraces

Choice is determined by forces displacement

Immobilising Upper Limb #sClavicle/AC joint injuries

Weight of arm displacement

Immobilising Upper Limb #sClavicle/AC joint injuries

Weight of arm displacement

Support arm with sling +/-waist strap

Immobilising Upper Limb #s Proximal humerus

Involving tuberosities Pull of rotator cuff displacement Prevent active movement of arm,

Immobilising Upper Limb #s Proximal humerus

Involving tuberosities Pull of rotator cuff displacement Prevent active movement of arm,

waist strap important.

Immobiliser sling

Immobilising Upper Limb #sProximal humerus

MetaphysisRotator cuff balancedFracture angulation worsened

Axial load Shoulder extension

Immobilising Upper Limb #sProximal humerus

MetaphysisRotator cuff balancedFracture angulation worsened

Axial load Shoulder extension

Collar and Cuff

Immobilising Upper Limb #s Humeral Shaft

Muscle pull displacement Pectoralis major/ lat dorsi Deltoid

Immobilising Upper Limb #s Humeral Shaft

Muscle pull displacement Pectoralis major/ lat dorsi Deltoid

Gravity maintains alignment Arm should hang

Plaster immobilisation possible

Immobilising Upper Limb #s Humeral Shaft

Muscle pull displacement Pectoralis major/ lat dorsi Deltoid

Gravity maintains alignment Arm should hang

Plaster immobilisation possible

U-Slab plaster

Immobilising Upper Limb #s Humeral Shaft

U-slab Uncomfortable, heavy Temporary

U-Slab plaster

Immobilising Upper Limb #s Humeral Shaft

U-slab Uncomfortable, heavy Temporary Change to Sarmiento brace after

1-2 weeks.

Functional brace

Immobilising Upper Limb #s Elbow Fractures

Adults Ideally don’t immobilise elbow for

more than 3 weeks! Commonly surgery is indicated to

enable stable fixation and early ROM

Immobilising Upper Limb #s Elbow Fractures

Children Supracondylar #

Stable in flexion

Immobilising Upper Limb #s Elbow Fractures

Children Supracondylar #

Stable in flexion

Positioning arm in flexion is more important than the actual plaster

Immobilising Upper Limb #s Elbow Fractures

Children Supracondylar #

Stable in flexion

Positioning arm in flexion is more important than the actual plaster

Immobilising Upper Limb #s Forearm Fractures

Clavicle fracturesMidshaft – most common

Distal

Medial - uncommon

Clavicle fracturesMechanism of injury

Clavicle fractures Initial treatment

Very painful fractureArm immobiliser not

collar and cuff Figure 8 bandage

Ice

Midshaft Clavicle fracturesAll undisplaced fractures can be

treated conservatively Immobiliser slingDiscontinued once pain subsides (3-5

weeks)Self administered ROM and strengthening

Midshaft Clavicle fractures Indications for surgery

Absolute Open fracture, skin compromise Progressive neurological deficit

Relative Shortening Displacement/comminution Non-union

Midshaft Clavicle fracturesHow much shortening?

Ledger et al. JSES 2004

Biomechanical and anatomical CT study Patients with clavicular malunion >15mm

Reduction of muscular strength of adduction, extension, and internal rotation

Reduced peak abduction velocity

Increased upward angulation of clavicle at SCJ and increased anterior scapular version

Midshaft Clavicle fracturesHow much shortening?

Assessment Clinical measurement

Midshaft Clavicle fracturesHow much shortening?

Assessment Clinical measurement Assess scapular position

Midshaft Clavicle fracturesHow much shortening?

Assessment Clinical measurement Assess scapular position Radiology – Xray/CT

Midshaft Clavicle fracturesSurgical Options

Plate fixation Intramedullary screw

Midshaft Clavicle fracturesPlate fixation

ComminutionSoft bone/smokers Less compliant patients

Midshaft Clavicle fractures Intramedullary screw

2 part fracturesYoung patients (girls)Avoid above shoulder

ROM first 6 wks

Distal Clavicle FracturesBeware of these fractures!

High non-union rate when displaced

Displacement often missed

Treatment also determined by relationship to and the integrity of the CC ligs

Distal Clavicle FracturesDisplaced fractures require surgery in all

but the elderly (low demand) patient.

Distal Clavicle FracturesBeware of inadequate imaging

Distal Clavicle FracturesBeware of inadequate imaging

Distal Clavicle FracturesBeware of inadequate imaging

Distal Clavicle Fractures Initial management

with immobiliser sling

Non-operative Rx for undisplaced fractures with intact CC ligs

Distal Clavicle FracturesSurgical management

Distal Clavicle FracturesSurgical management

Proximal Humerus FracturesThird most common fracture after hip

fracture and Colles fracturesMore common in femalesHistorically 15-20% required surgeryThey generally result in some long term

functional disability

Classification SystemsNeer

Classification SystemsAO/ASIF

Surgical decision making

Not bad enough for surgery Too bad to fix

Surgical decision making

Sling/ Collar & Cuff Hemi/Reverse TSA

Not bad enough for surgery Too bad to fix

Surgical decision making

Sling/ Collar & Cuff ORIF Hemi/Reverse TSA

Not bad enough for surgery Too bad to fix

Surgical decision making

Sling/ Collar & Cuff ORIF Hemi/Reverse TSA

Goal is maximum shoulder function and minimal shoulder pain.

Not bad enough for surgery Too bad to fix

Surgical decision makingDisplacement and angulation

Painful Impingement Significant ROM loss Risk of non-union

Neer – 1cm and or 45 degrees???

Surgical decision makingNon-op vs ORIF vs Prosthesis

Determined by risk of AVN age of patient Medical comorbidities Bone quality Functional demands

Surgical decision makingNon-op vs ORIF vs Prosthesis

Determined by risk of AVN age of patient Medical comorbidities Bone quality Functional demands

Greater Tuberosity Fracture Usually displaced

posteriorly (by infraspinatus) and superiorly (by supraspinatus)

>5mm requires reduction previously 1cm shown to have poor

outcomes. Depends on fragment size and

articular involvement Superior displacement – impingment in

abduction

Greater Tuberosity Fracture Undisplaced

Immobiliser sling for 5-6 wks until healed

Elbow ROM Watch closely for displacement

Greater Tuberosity FractureLarge fragment

Screw fixation – open/arthroscopicTension band suturingAnchors

Greater Tuberosity FractureLarge fragment

Screw fixation – open/arthroscopicTension band suturingAnchors

Greater Tuberosity FractureLarge fragment

Screw fixation Tension band suturingAnchors

Advanced Fracture Management Course

Approach:mini deltoid split/ arthroscopic

Greater Tuberosity FractureLarge fragment

Screw fixation – open/arthroscopicTension band suturingAnchors

Small fragmentTreat like a cuff tear

Arthroscopic repair

Greater Tuberosity FractureMy Preference

Large fragment good bone Screw fixation (mini-open or

arthroscopic)

Small fragment or large with soft bone Suture anchor fixation

(Intraosseous equivalent/bridge)

Lesser Tuberosity Fracture Rare If large and displaced block

internal rotation Open reduction and screw

fixation +/- biceps tenodesis.

Surgical Neck FractureAcceptable displacement and

angulation depends on: patients age activity level functional demands

Surgical Neck FractureSkeletally immature

Adults

Patient Age (yr) Allowable Displacement or Angulation

<5 Up to 70 degrees angulation, 100% displacement

5–12 Up to 40–70 degrees angulation

>12 Up to 40 degrees angulation, <50% displacement

2 Part Surgical Neck FractureOptions

Closed reduction + Kwires Intramedullary nailCirclage suturesPlate fixation

2 Part Surgical Neck FractureClosed reduction + Kwires

2 Part Surgical Neck FracturePlate fixation

2 Part Surgical Neck FracturePlate fixation

3 and 4 Part Fractures

3 and 4 Part FracturesSurgical Treatment Options

Open reduction + K wiresCirclage wires/sutures + Rush pins/Enders

rodsCRKW (Resch) Intramedullary nail Locking plate

(hemiarthroplasty/reverse)

3 and 4 Part FracturesSurgical Treatment Options

Open reduction + K wiresCirclage wires/sutures + Rush pins/Enders

rodsCRKW (Resch) Intramedullary nail Locking plate

(hemiarthroplasty/reverse)

Historical

Technically difficult

3 and 4 Part FracturesApproach

Deltopectoral

Mini-deltoid split – Percutaneous plating

(Extensile lateral)

Percutaneous Plating Beach chair Spider arm holder

Percutaneous Plating Beach chair Spider arm holder II – opposite side

Percutaneous Plating Beach chair Spider arm holder II – opposite side

Lateral deltoid split

Percutaneous Plating Get control of

tuberosities LT + biceps tenodesis GT

Percutaneous Plating Get control of

tuberosities LT + biceps tenodesis GT Elevate head if

impacted

Percutaneous Plating Get control of

tuberosities LT + biceps tenodesis GT Elevate head if

impacted

Percutaneous Plating Insert plate under

deltoid/axillary nerve

Percutaneous Plating Lock proximally and

distally

Percutaneous Plating Lock proximally and

distally

Percutaneous Plating Final images

AP Lateral Axillary view

Percutaneous Plating Final images

AP Lateral Axillary view

Percutaneous Plating

Percutaneous Plating Bone grafting

Elevation of valgus impacted fracture

Cancellous bone defect ?possible cause of late

failure and collapse

Injectible bone graft Ca PO4 Sets hard – support

head, fixation for screws

Deltopectoral Approach I use DP approach

when: Extensive medial

calcar/shaft extension Excessive rotation of

head fragment Head split (access

through rotator interval)

Deltopectoral Approach

Deltopectoral Approach Fracture reduction techniques

Double plating method

Some fractures are too comminuted to get stable fixation with 1 plate

Deltopectoral Approach Fracture reduction techniques

Double plating method

Some fractures are too comminuted to get stable fixation with 1 plate

Use orthogonal platesfor increased strength

Distal Humeral FracturesSupracondylar

Extension Type – COMMON!!Flexion Type (rare)

EpiphysealEpicondylarCondylar

Supracondylar FracturesExtension Type

Grade 1 (Undisplaced)

Grade 2 (Partially)

Grade 3 (Completely)

Supracondylar FracturesExtension Type

Unstable in extension

Reduction is maintained with elbow held FLEXED!!!

FLEXION IS MORE IMPORTANT THAN PLASTER IMMOBILISATION

Supracondylar Fractures This treatment is worse

than nothing at all!

Plaster is dead weight on fracture!!

Supracondylar Fractures This treatment is worse

than nothing at all!

Plaster is dead weight on fracture!!

Apply collar and cuff in flexion.

Leave on until fracture union (3-4 wks)

Shirts over the top!

Supracondylar Fractures Mx

Grade 1

Collar & Cuff in flexion for 3/52

+/- Backslab

Supracondylar Fractures MxGrade 2

Closed Reduction under anaesthetic

If unstable (rotationally) – add K-wires

Immobilize in flexion

Supracondylar Fractures MxGrade 3

Usually severely swollen

delay increases difficulty of reduction

Vascular compromise Neurological deficit -

AIN

Occasionally open reduction required!

Supracondylar FracturesComplications

Early Arterial Injury Compartment Syndrome Nerve Palsy

Late Volkmann’s Ischaemic Contracture Malunion

Complications: Cubitus Varus

Residual Posteromedialdisplacement results in internal rotation and varus deformity of the distal fragment.

This results in loss of the normal carrying angle, the so-called “gunstock” deformity.

Complications: Cubitus Varus

Bauman’s angle

Lateral Condyle Fractures15% of elbow fractures in childrenMechanism:

Avulsion secondary to FOOSH with forearm supinated.

Compression injury secondary to FOOSH with elbow flexed.

Lateral Condyle Fractures:Milch Classification

Type IType II

Lateral Condyle Fractures:Treatment

Can be confused sometimes with a supracondylar fx - cannot make this mistake.

Lateral Condyle Fractures:TreatmentNondisplaced: Immobilization in simple

backslabDisplaced: Reduce and pin.

Why reduce? Congruent joint surface Prevent nonunion Prevent growth arrest

Usually Open Reduction, then 2 pins Immobilize 6 weeks, then remove pins.

Lateral Condyle Fracture

Lateral Condyle Fracture

Lateral Condyle Fracture

Elbow Dislocations

Reduce Immobilise in backslab

for 3 weeks

Elbow Dislocations

Reduce Immobilise in backslab

for 3 weeks

Make sure radial head reduced

Elbow Dislocations

Reduce Immobilise in backslab

for 3 weeks

Make sure radial head reduced

and medial epicondyle is not in joint!

Medial epicondyle fractures Incarcerated medial epicondyle

Incarcerated

Medial epicondyle fractures Incarcerated medial epicondyle

Open reduction internal fixation

Elbow dislocationDisplaced radial neck fracture

Elbow dislocationDisplaced radial neck fracture

Open reduction K-wire fixation

Forearm FracturesDistal radius fractures most common

upper limb paediatric fracture > supracondylar fractures >shaft fractures

Forearm fracture most commonly associated with the trampoline!

Treatment more difficult the more proximal the fracture

Forearm FracturesTreatment is determined by:

Age of patient (remodelling potential)Displacement

Angulation, translation, rotation, shorteningCosmetic appearanceAim to restore forearm rotation

Forearm FracturesPlastering techniques

Maintenance of reduction requires 3 point moulding

Forearm FracturesPlastering techniques

Maintenance of reduction requires 3 point moulding

Distal Third FracturesBuckle or Torus Injuries

Minimally displaced

Stable

3-4/52 in cast – short arm sufficient

Distal Third FracturesDisplaced Greenstick Fractures

? Reduce

If 20 Degrees of tilt or

If clinically deformed

Distal Third Fractures Complete Fractures

CR & POP +/- wires Above elbow cast

Redisplacement common

Careful FU

Remodel well

Distal Third Fractures

Distal Third Fractures

Distal Third Fractures

Distal Third Fractures

Distal Third FracturesEpiphyseal

Injuries

Usually Salter Harris I or II

Displaced – reduction and short arm cast

Remodel well

Don’t manipulate late

Forearm Shaft Fractures

Less remodelling Accept less than 10 degrees angulation

Closed reduction under GA Always above elbow moulded cast

Warn parents the cast will look bent!

Recheck Xray 1 week 5% redisplacement rate

Plaster for upto 6 weeks

Forearm Shaft Fractures

Isolated radius fracture

Forearm Shaft Fractures

Isolated radius fracture

Forearm Shaft Fractures

Both bones shaft fracture

Forearm Shaft Fractures

Both bones shaft fracture

Forearm Shaft Fractures

Both bones shaft fracture

Forearm Shaft Fractures

Both bones shaft fracture

Monteggia Fracture Dislocation Ulna fracture mid to

proximal 1/3 Radial head dislocation

Line through radial shaft and head BISECTS capitellum in ANY VIEW

Never accept ISOLATED ulna fracture

Examine & X-ray joint above and below

Monteggia Fracture Dislocation Ulna fracture mid to

proximal 1/3 Radial head dislocation

Line through radial shaft and head BISECTS capitellum in ANY VIEW

Never accept ISOLATED ulna fracture

Examine & X-ray joint above and below

Adult Distal Radius Fractures Most common adult fracture Usually in elderly due to

osteopenia/porosis Usually associated with high energy

trauma in young adults

Adult Distal Radius Fractures Types:

Colles Smiths Bartons Chauffeurs Intraarticular

Generally plain Xray adequate CT scan if intraarticular involvement

Adult Distal Radius Fractures Surgical Indications:

Loss radial length 3mm or more

Adult Distal Radius Fractures Surgical Indications:

Loss radial length 3mm or more Decreased radial inclination

Adult Distal Radius Fractures Surgical Indications:

Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees

Adult Distal Radius Fractures Surgical Indications:

Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees Step in articular surface 2mm or more

Adult Distal Radius Fractures Surgical Indications:

Loss radial length 3mm or more Decreased radial inclination Dorsal tilt >20 degrees Step in articular surface 2mm or more

Other indications: open #, progressive neurological deficit.

If redisplacement outside these limits can be avoided with plaster best outcomes.

Adult Distal Radius Fractures Factors that make failure of

conservative management more likely: Dorsal comminution Osteopenia High energy injury

Adult Distal Radius Fractures Conservative management:

Plaster for 6 week Short arm cast only Physiotherapy

Adult Distal Radius Fractures Locking plate fixation

New locking plates have dramatically improved surgical outcomes

Early therapy has improved patients return in range of motion and function

Adult Distal Radius Fractures Locking plate fixation

New locking plates have dramatically improved surgical outcomes

Early therapy has improved patients return in range of motion and function

Recommended treatment for displaced unstable fractures in adults is: Locking plate fixation Early range of motion, with removable splint

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