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SHOULDER INJURIES

Fractures of the clavicleMechanism :Indirect trauma: more common Fallthe outstretched hand (OSH).

Direct trauma to the clavicle.

Pathologic Anatomy: usually middle third. Thelateral fragment is displaced downward by

gravity. The medial fragment is displacedupwards by the pull of sternomastoid muscle.

Clinically: the patient is lifting the arm bysupporting the elbow. The head is tilted towards

the same side of the fracture.

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SHOULDER INJURIES

Fractures of the clavicleTreatment: Figure of eight bandagefor 3-4weeks.

Complications:a) Malunion with protrusion.

b) Nonunion.

C) rarely injury to subclivian vessels and brachialplexus.

Open reduction with internal fixation (ORIF) isindicated in :

a) painful nonunion

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OPEN FRACTURES

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SHOULDER INJURIES

Fractures of the clavicle

Treatment: Figure of eight bandagefor 3-4weeks.

Complications:

a) Malunion with protrusion.

b) Nonunion.

C) rarely injury to subclivian vessels and brachialplexus.

Open reduction with internal fixation (ORIF) isindicated in :

a) painful nonunion

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SHOULDER INJURIES

JOINT STABILITY:

Joint stability depends upon:

1) shape of the articulating surfaces.

2) Ligament integrity.

3) muscle power.

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SHOULDER INJURIES

Dislocation Shoulder:

This is a common injury due to:

a) A relatively big head in Shallow socket .

b) Wide range of motion.

c) Laxity of capsule and ligaments.

d) Superficial position.

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SHOULDER INJURIES


Mechanism:

Indirect: fall on the OSH.

Direct: Trauma to the point of the abductedshoulder.

Muscle contraction: In epileptic fits.

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SHOULDER INJURIES


Pathological anatomy:

Anterior dislocation:

This is the commonest type.The head of thehumerus is displaced below the coracoid process( subcoracoid) . The capsule is torn. The labriumglenoidale is separated from its bony attachment

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SHOULDER INJURIES

Dislocation Shoulder:Clinical presentation:

A) Flattening of the normal shouldercontour.

b) Limited movements.

c) head of the humerus is felt anteriorly.

Radiologicaly:

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SHOULDER INJURIES


Treatment:Mannipulative reduction under general

anesthesia in the following sequences:

a) Traction . b) Externalrotation.

c)Adduction. d) Internal

rotation.

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SHOULDER INJURIES


Complications:

a) Circunflex nerve injury.

b) Avulsion of supraspinatous muscle.

c) Fracture dislocation.

d) Recurrence.

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SHOULDER INJURIES

Recurrent dislocation Shoulder:

This is due to a defect in the capsule andlabrium glenoidale (Bankarti lesion).

Clinically: Dislocation occurs with less force.

Pain is less.

Easy reduction.

Treatment: Repair of the defect by Bankarti

Operation

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Fractures of the humerusFractures of the proximal end:

Fracture of the greater tuberosity:

This may be:a) Associated with shoulder joint

dislocation.

b) Avulsion fracture of the greater

tuberosity.

Treatment:

Undisplaced Sling or body bandage.

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Fractures of the humerus

Fractures of the proximal end:

Fracture of the humeral neck:

Common in old age because of osteoporosis.

Treatment:

Undisplaced Sling or body bandage.

Displaced closed reduction and wire

fixation.

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Fractures of the humeral shaft:

Mecanism: Is either direct or indirect.

Treatment:

1) Conservative:

Closed reduction : Mannipulation and splintageby:

a) body bandage.b) U- Shaped slab.

c) Cast brace.

2)ORIF with plate and screws or intrameduulary

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Treatment( cont):

3) External Fixator:

Is indicated in:

a) Open fractures.

b) infected fractures.

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Complications:

a) Radial nerve injury. Manifested by

wrist drop .Treated by follow-upobservation or exploration if notimproving within in 3 months.

b) Nonunion: treated by ORIF and bonegrafting.

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Supraconylar Fractures of the humeus:

It is the commonest fracture around the elbow in

children. Two types are described according to the

displacement of the distal fragment:

A) Extension type: Commonest, due to fall on theOSH. Displacement is backward, laterally and

upwards.

B) Flexion type: Rare due to fall on the tip of theelbow.Displacement is backwardsand proximally.

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Fractures of the humerusSupraconylar Fractures of the humeus:

Clinical presentation:

The triangular relationship between the two

humeral condyles and the olecranon remains the same incontrast to dislocation of the elbow.

Treatment:

Un-displaced: Posterior slab for 3 weeks.Displaced: Closed reduction and Kirschner

wire fixation.

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Supraconylar Fractures of the humeus:

Complications:

Famous for its complications.Malunion: in the form of cubitus varus or

valgus is treared by corrective osteotomy.

Ulnar neuritis: is treated by anteriortransposition of the ulnar nerve.

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Fractures of the condyles:

Is common in children. Mal or nonunionmay affect growth resulting in cubitus varus orvalgus with subsequent ulnar neuritis.

Treatment:

Un-displaced: Posterior slab for 3 weeks.

Displaced: due to pull of the commonextensor origin in lateral condyle fractures orcommon flexor origin in medial condyle fracturesleading to rotation of the feactured

fragment..ORIF with K.wire

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DISLOCATION ELBOW

Types and mechanism:

Posterior: commonest due to fall on the

OSH.Anterior: due to fall on the tip of the

elbow. The olecranon process is fractured.

Medial or lateral: rare

Clinically: the elbow is held in 45 degreesflexion, with restricted active and passivemovements of the elbow.

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DISLOCATION ELBOW

Treatment:Closed reduction under anesthesia followed by

immobilzation in above-the-elbow cast for 4-6

weeks.Complications:

1) Median nerve injury.

2) Brachial artery injury.3) Myositis ossificans.4) Associated fractures of the radial head.

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Forearm fractures

Teaching points:Forearm fractures can be seen with

supracondylar fractures (3-13%).Supracondylar fracture needs to befixed first then the forearm can be

managed.Refracture occurs in about 5%Refracture is more likely after greenstick then complete.

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If malunion, often needosteotomies for correction.Synostosis; rare but can occur

after high velocity trauma,repeated manipulations orfractures associated with headinjuries.Occurs mostly in the middleand proximal third

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Nerve injury: Can occur to themedian, ulnar or posteriorinterosseus nerves.

Nerve injuries usually resolvespontaneously but after 8 weeks ifnot resolved require surgery.Compartment syndrome has beenreported.

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Galeazzi fracture

Fracture of the distal third of theradius with dislocation of the ulna.Occurs more commonly in adults

and teenagers then young children.

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Management:Non-operative management

achieved good results in 90 % ofinjured children.BUT, its operative in adults.

Complications:MalunionNerve injury: ulnar and anterior

intraosseus nerve. Typicallytransitory.Ulnar physis arrest: may occur inup to 60% of patients.

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Monteggias fracture

Fracture of proximal ulnaAny other lesion identified?

Does the radius line up with thecapitellum?No!

Radial Head Dislocation!Ulna fracture + Radial head dislocation =Monteggias fracture.

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Describe first in 1814 by Dr. Giovanni

Battista Monteggia.Comprises 2% of all elbow injuries inchildren.

In general, isolated ulnar fractures arerare, and it is important to haveradiographs of both the forearm and

elbow.If radial head is not reduced it couldlead to permanent joint disability.

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Most common mechanism is

hyperextension of the elbow joint.Results in fracture of the ulna withanterior angulation and anterior

dislocation of the radial head.May also see with hyper-pronationand Fall on out stretched hand as aresult the annular ligament of theradial head is either torn or displacedover the radial head.

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Management:Orthopedic Referral!!First correct the ulnar deformity.

Once the ulnar deformity is corrected theradial head can be re-located much like anurse maids elbow (flexion and supination).

Re-check position with follow upradiographs.

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Complications:Posterior intra-osseous nerve is oftendamaged (innervates deep extensormuscles of hand)Usually self limited and resolvesRecurrent dislocation of radial head,persistent subluxation of radial head

and limitation of elbow joint

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ComplicationsMissed radial head dislocation isoften benign in children.

Adults typically develop early arthritiswith persistent pain, instability of thejoint and restricted motion.Nerve palsies have been reported as

developing secondary to anundiagnosed Monteggias lesion.

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Fracture around the wrist1-extracapsular #a-Pos-displacement (Colles #)

b-Ant-displacement (Smiths #)2-Intrartcular # Bartons #3-Styloid #

4-Epiphysial # in Childern (Salter#)

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Colles Fracture

Fracture of the radius within 2.5CMof the wrist with a characteristic

deformity (dinner fork) (impaction

supination dorsal displacement &angulation with radial displacement

and angulation)

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Thank you

shouder inj 17-11-2007

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