Traumatology of the upper extremity

Object and goal of the seminar

Introduce main patological unitsDiagnosis and therapy

Diseases and injuries of the upper extremity

Shoulder joint- simple ball joint (arthrodia)

cavitas glenoidalis scapulae – caput humeri

Articulating bones:Humerus, scapula, clavicleArticular surface is covered with cartilageShape of the articular surface determines: range of motion, stability

Clinical examination - anamnesis

Complicated joint - articulatio glenohumeralis (acromioclavicularis, sternoclavicularis)

Clinical history – pain and its character(direction, sharp or dull pain, permanent or short-term, mechanism of injury, personal clinical history

Acute pain…bursitis subacromialis, rotator cuff rupture, inflammation, fracture, …

Chronic pain– degenerative disease

Examination of the injured joint – objective status

Aspection – swelling, hematoma, patological shape,damaged skin surface

Palpation– sensitivity, temperature

Examination of stability- dislocation of the joint

Range of the motion

Physiological range of the motion (degree) – shoulder joint

• Flexion…90 • Extension …50• Abduction…90 • Adduction …25 • Elevation…180• External rotation…90 • Internal rotation….90

Examination of the injured joint

X-ray evaluation – AP , lateral, comparative images

CTMRI – soft tissueUltrasound – fluid in (around) the joint, RC,

tendons

Shoulder painfull syndromTenosynovitis capitis longi m. bicipitis brachiiRupture of long tendon of biceps muscleBursitis subacromialisTendinitis m. supraspinatiRupture of rotator cuffImpingement syndrom of shoulderFrozen shoulder syndromArthritis of shoulder jointAC dislocationsInflammation TumorsPains transferred from another place

Transferred pain

C spineThoracic outlet syndromHeart diseasesLung diseasesNeuralgia, herpes zosterStomach tumor

Acromioclavicular dislocation indirect violence classification Allman - Tossy I.-III. rupture of ligaments /CC, AC, CA/

Clinical status

deformation of AC region pain antalgic position of the extremity limitation of motion of the limb

Examination X-ray • AP• comparative view• traction X-ray

Treatment

Conservative I. + II. degree

• Scarf bandage, Desault

• orthesis

Treatment

Surgical - III. degree• suture of ligaments, K-wire osteosynthesis

Rupture of long tendon of biceps muscle

Treatment:

keep extremity immobileanalgesicstill 40 y. - surgerymore than 40 r. - conservatively

Surgery:key hole fixation to humerus shaftsuture to short tendon of biceps muscle

Rupture of rotator cuff

• Pushes humeral head into cavitas glenoidalis• Helps to abduction

Rupture of rotator cuff

Severe painNo abduction

Treatment:ConservativeSurgical• suture• fixation to tuberculum maius using anchor

Dislocation of humerus• very often injury• indirect mechanism

• anterior• posterior• inferior• (superior)

Clinical status

• empty cavitas glenoidalis• joint shape• antalgic position of extremity• limitation of range of motion

Treatment

Conservative • reposition• fixation - orthesis

Surgical … repeated dislocation• repairing joint capsule

Reposition

• Analgesia

• General Anesthesia

• Fixation to 5 weeks

• Surgical solution

Complications

• fractures

• nerve injury

– plexus brachialis

– n. axilaris

• vessels injury

X-ray before reposition!!!

Humeral fractures

1. Proximal humerus2. Shaft3. Distal humerus

Proximal humeral fractures

occurrence at any age 4. the most common fracture (distal radius, proximal femur, ankle) 2. the most common fracture of upper extremity 4 – 5% of all fracture ratio of male – female till 3 : 1 shoulder joint– greatest range of motion

Mechanism of proximal humeral fractures

„Low energy trauma“

short-term and older population predominace of women falls from standing at floor level osteoporosis

direct indirect

„High energy trauma“

younger population sport, traffic, men falls from height open fracture polytrauma

Anatomy greatest range of motion - small stability muscles - important role for the stability joint surface of head is 3-4 times greater than joint surface of cavitas glenoidalis the head forms with the shaft an angle 130 degrees

.

Muscles around shoulder

Superficial level: m. deltoideus Deep level: muscles of RC– m. supraspinatus m.infraspinatus m. teres minor m.subscapularis

Peripheral muscles: m.pectoralis maior (crista tuberculi maioris)m. latissimus dorsi, m. teres maior (crista tuberculi minoris)m. corachobrachialis, m. bicipitis brachii- caput breve (proc coracoideus)

Retroversion of the hole– 9 degrees dorsallybody of the scapula is placed 30 degrees from frontal

levelhole facing ventrolaterally

Surgical anatomy

Collum anatomicum humeri - inclination - 115-130 degrees - retroversion of the head - 15-30 degrees dorsallyCollum chirurgicum humeri

Morfology of proximal humeral fractures

Anatomy – blood supplay a. circumflexa humeri anterior – a. arcuata (Laing artery) metafyseal-epifyseal supplay (injured in dislocated fractures of surgical neck) Branches of ACHP – postero-inferior part of the head via RC in tubercles

Clinical examinationswellinghematoma (elbow, forearm, chest wall)damage to the skin cover, open fracturepaincrepitationfunctional deficitvascular and neurological deficit!!! (suspicion for vascular injury - angiography)

Examination of the whole limb – current forearm and hand injuries

                                  

AP

Lateral

Axillar

(thoracal)

X - ray3 standard projection(Neer)

CT scan

more than two fragments dislocation of fragments – particullary of the humeral head assessment of the size of fragments articular fractures fractures of cavitas glenoidalis postoperative complications

Indication criteria for treatment of proximal humeral

fractures

Objective examination: age, the internal status, the ability of active rehabilitationSkin condition of injured extremityType of the fracture: X-ray examinationPersonal and technical equipment

Treatment of proximal humeral fractures

Conservative

Surgical

Conservative treatment - indication

Individual approache Internal complications

75 – 80% small dislocation – conservative treatment15 – 20% great dislocation- surgical treatment

Indications for surgical treatment

Instable fractures with dislocation Intraarticular fractures with joint dislocations Failure of conservative treatment Neurovascular injuries Open fractures Patological fractures Polytrauma

Surgical or conservative?

4-frg lux.

3-frg2-frg

patol.

2-frg

4-frg

Fracture of proximal humerus

Osteosynthesis or primary replacement?

Surgical methods

1) Conventional implants

Percutaneous stabilization - K-wires

Osteosynthesis – screw and wires

Osteosynthesis -T-plates

Conventional implants

Disadvantages:

Problematic bone fixation in porotic bone -

instability Frequent failure of osteosynthesis Sometimes the need for accessory fixation (brace, orthesis)

2) Modern surgical methods:

angle stable implants

Failure prevention( osteoporotic bone, comminuted) Head of the screw – locked in the hole

Principle of angular stable implant

Surgical technique-position of the patient- beach chair position

Surgical approache - deltoideopectoral

Surgical approache - transdeltoideal

Surgical technique - reduction K wires – joystick bone hook

Surgical technique – entry point

Two X-ray projections Entry point

Nail insertion

Angle stable plate

ArthroplastyCCEP

Surface replacement

TSA

Reverse replacement

Rehabilitation

long term phase of the exercise

• passive

• assisted

• active and physical

exercise

Complications of surgical treatment

General

Impaired wound healing. HematomaInflammation

SpecificRestriction of motionHead necrosisFailure of OSNonunionFracturesHeterotopic ossificationNerv and vessels injuries

Nail cutting

Screw cutting

Periimplants fracture

Nonunion

Fractures of scapula

infrequent mostly direct mechanism

fr. of body fr. of neck fr. of glenoid fr. of acromion fr. of coracoid process fr. of spine

Treatment

Conservative• hinge• Desault• orthesis

Surgical• Intraarticular fractures

Clavicle fracture

Nonunion

Humeral shaft fractures

direct mechanism dislocation depend on fracture level

Humeral shaft fractures

Humeral shaft fractures account for approximately 1–3% of all fractures

High and low energy trauma

Fracture displacement is the result of muscular forces

Fracture patterns of the humeral shaft

Examination

X - ray• AP • lateral view

TreatmentNon-operative: Operative:

• Compression plating

• IM nailing

Antegrade

Retrograde

• External fixation

• MIPO technique

• Nondislocated fxt

• Hanging Arm Cast

• Velpeau

• Abduction Brace

• Functional Brace

Anterolateral approach

Be careful about traction of the nerve

• Open fractures with extensivesoft tissue injuries

• Severe contamination

External Fixation

OS by plating

HackethalHackethal

Nailing

Complication of humeral fractures

Radial nerve injury from accident or iatrogenic –distal third of humerus

Delayed union and nonunion

Failure of internal fixation

Distal humeral fractures2% of all fractures1/3 of the humeral fracturesMostly intraarticular

MechanismLow energy trauma – middle aged and elderly

(ground-level falls), associated with osteoporosisHigh energy trauma – younger patients (sports,

vehicle accidents), open injuries

Anatomy – triangular structure• MEDIAL & LATERAL column and connecting arch distally

Distally – intraarticular portion• Laterally: capitellum humeri• Medially: medial epicondyle with trochlea (tie arch)• Forward angulation 30-45°• Trochlea valgus angle 4-8°• Trochlea externally rotated 3-8°2-3cm proximally to the

olecranon fossa – termination of the intramedullary canal

Functional anatomy

Trochlea is center of the joint

Hinged joint with single axis of rotation (trochlear axis)

45°

• Physical examination• Soft-tissue envelope• Vascular status

– Radial and ulnar pulses

Evaluation• Neurovascular status

– Radial nerve (most commonly injured, 14cm prox. to lat. epicondyle)

– Ulnar and Median nerves (rarely injured)

X -ray- AP and lateral view- CT

Principles of treatment

- Restoration of axial alignment

- Anatomical reduction of the articular surfaces

- Stable fixation of the articular segment to the

metaphysis and diaphysis

- Goal: early range of motion of the elbow

- Prevention of posttraumatic arthritis

New implants - LCP

Posterior approache

Isolate and gently retract the ulnar nerve

Olecranon intraarticular osteotomy (if needed)

Open reduction and internal fixation

Surgical approach—skin incision

Ulnar nerve identification and mobilization

Olecranon osteotomy

Reduction and fixation

Early rehabilitation

Elbow joint- Composed joint- Humeroulnar……..hinge- Humeroradial……..ball- Prox.radioulnar…..cylindrical

Range of motion in elbow

Flexion – 140-160 extension-10Pronation 80-90 supination 80-90SFTR: S 10-0-160 R 90-0-90

EnthesopathyPathological changes in the tendons, ligaments,insertions to the bone

Causes:• Acute or chronic overload• Repeated small injury• Repetitive movements

Epicondylitis radialis humeriSyndrome of tennis elbow

• Pain when extensors are functional• Palpation pain on the radial epicondyle• Painfull supination of the forearm• Handgrip pain

Epicondylitis radialisConservative treatment:• Not burdening, NSAD locally and generally• Stretching, special orthesis• Corticoids locally• Rehabilitation• Immobilization

Surgical treatment:• Op. sec. Hohman• Op. sec. Boyd- Mc Leod

Epicondylitis ulnaris humeri

• Enthezopathy of common flexor insertion• Pain on the ulnar epicondyle• Pain when flexors are functional

Dislocation of the elbow

Fracture of the radial head

• small abruption• large abruption• comminuted fractures• fractures of the neck

Fracture of the radial head - OS

Olecranon fracture

Olecranon + proc. coronoideus

Fractures of the both forearm bones

Galeazzi fracture

Monteggia fracture

Fractures of distal radius

Introduction

1/6 of all the fractures

most cases between 6 – 10 year a 60 – 69 year

75 % of the forearm fractures

ratio of women and men 4 : 1 (osteoporosis)

children: ratio of boys and girls 3 : 1 (physical activity)

History

Abraham Colles - 1814: clinical description of this fracture in English speaking countries - described it before discovery of X-ray (1898) - extraarticular fracture with dorsal dislocation - „Colles fracture“ – incorrectly used name for all fractures of distal radius

R.W. Smith - 1847 volar dislocation of distal fragment

Anatomy

JOINTS: radio-carpal medio-karpal carpo-metacarpal distal radio-ulnar

Mechanism of injury

Dorsal angulation – wrist in extension, pronation, ulnar duction - 90 % of fractures (Colles type)Volar angulation - wrist in volar flection - 10 % of fractures (Smith type)

Clinical picture

swelling hematoma typical dislocation restriction of range of

motion blisters, visible

fragments under skin vessels, nerves

Distal radius fractures

Distal radius fractures

X – ray evaluationNormal Anatomy 1. Volar Angulation 11º (1 – 21)2. Radial Inclination 22º(13 – 30)3. Radial Length 11º4. Ulnar Variance 0±2mm(comparison with intact side)

CT

Associated Injuries

Another diagnostics method

MRI - diagnosis of post-traumatic and chronic states - displaying of soft tissue(tendon, capsule, muscles) - patological states(osteomyelitis, AVN)

Artroscopy – optical evaluation of articular structures

Treatment goals

• Non-operative treatment

• Short arm cast

• Check X-ray at week

Undisplaced fractures

Displaced fractures

• Dorsal Comminution beyond midaxial plane of the radius

• Intra-articular Involvement• Associated Ulnar Fracture• Volar

Angulation/Displacement

Closed reduction- Anaesthesia – Haematoma/Bier’s block, GA

- X - ray control

- Manipulation technique

- Longitudinal traction- Pronation or neutral position of hand- Ulnar tilt- No big wrist flexion - Plaster cast

Unstable extra-articular Supplementary fixation with exfix

• 1.6mm K-wires• X - ray control• Additional cast

immobilisation• Removal in 5-6 weeks• Poor wire fixation in

osteoporotic bone

Percutaneous K-wiring

Bridging external fixation

Non-bridging external fixator• Comminuted extra-articular

• Limited indications

• Allows early mobilisation

Surgical treatment – transfixation with K - wires

Surgical treatment – external fixation

Surgical treatment – plate and screws

Locked volar plate

Surgical procedure

Surgical treatment– nailing

Surgical treatment– combination of methods

Volar approache

Dorsal approache

Malunion DRUJ problems CRPS – overdistraction Tendon rupture Carpal Tunnel syndrome Arthritis Failure of osteosynthesis

Complications

Scaphoid fractures

swelling pain - (fossa tabatiére) limitation of motion

Diagnostics• X-ray - AP

- lateral view- ulnar duction

• CT

Treatment Conservative

• reduction, plaster cast (12-16 weeks!)

Surgical • osteosynthesis (Herbert screw), • tranfixation

Herbert screw

Complications

nonunion – bone grafting carpal instability necrosis

Luxatio perilunatis

Hand

Open or closed fracture skin damage and fracture in the same place of limb a wide range of local findings o

!!! Decision affects treatment!!!

Clinical status

skin damage, swelling of soft tissue, hematoma bleeding (artery, vein, capillary) pathological movement, crepitations, changed shape prominence of bone fragments from the wound oppression skin with impending perforation contamination of the wound neurovascular lesion

General Principles

• Protecting open wounds• Positioning the limb• Immobilizing the injury• Checking neurovascular function

• Pulse• Palpate• Utilize pulse oximetry

• Motor• Sensation

Treatment at operating room

mechanical cleaning of the wound with steril brush removing dirt, foreign bodies, devitalized tissue repeated washings with disinfectans cultivation debridement osteosynthesis antibiotics

External fixation Advantages

• No foreign body in the wound

• Fracture site vascularity not compromised

• Applied distant to injury

• Overbridging joints

Disadvantages• Pin tract infections• Fracture malalignment• Patient tolerence• Adjacent joint stiffness• Transfixation of muscles• Interfere with flap

design and vascular acces