Lec: 1
Injuries of the upper limb
Fracture of the clavicle:
Is more common in children (usually green stick fracture) causing no trouble, but in adult it can be troublesome.
Mechanism of injury: the injury usually results from;
1. Fall on outstretched hand or on the shoulder.
2. Direct trauma to the clavicle Site of the fracture & displacement; The most common site of the fracture is the mid-shaft fracture, in children the fracture is greenstick & minimally displaced but in adult the fracture is usually complete & displaced in which the outer fragment is pulled down by the effect of the gravity & the weight of the arm while the inner fragment is pulled up by the effect of the sternocleidomastoid muscle.
The other site of clavicle fracture is the fracture of the lateral end of the clavicle, the displacement of this fracture depends on integrity of the coracoclavicular ligaments &weather the fracture is medial or lateral to attachment of the coracoclavicular ligaments. If the fracture is lateral to ligaments & the ligaments are intact the displacement is minimal but if the fracture is lateral to the ligaments with ruptured ligaments or the fracture is medial to the ligaments attachment the displacement will be severe.
Clinical features The patient held the arm against the chest to prevent movement, there may be a subcutaneous lump sometime a sharp fragment threatens the skin, it is important to feel the distal pulses.
Treatment: Accurate reduction is neither possible nor essential. All that is needed is arm sling or figure of 8 bandage for2-3 weeks, then active exercise of the shoulder.
Indications of operative treatment; (1) open fractures (2)fractures threaten to become open(3)established nonunion (4)associated fracture of the scapular neck(5)these fractures associated with neurovascular compromise (6)unstable lateral end fracture with disruption of the coracoclavicular ligament.
Complications: 1- Neurovascular injury (very rare) or skin injury by sharp bone spike. 2- Nonunion (also rare) especially after ORIF. 3- Malunion: is common, but usually harmless. 4- Stiffness of the shoulder (usually temporary). 5- Due to close proximity of the supraclavicular nerve to the clavicle it may involve in callus formation leading to persistent pain at the side of the neck
Fracture of the scapula
The scapula may fracture through its body, neck, acromion, coracoids process or the glenoid
Mechanism of injury The body usually fractured by crushing force against the chest wall which usually fracture the ribs, the neck fractured by blow or fall on the shoulder, the acromion by direct trauma the coracoids process may be avulsed by muscles attached to it and the glenoid may fracture with shoulder dislocation.
Treatment: It is usually conservative; Fracture body may be comminuted, but usually undisplaced because of muscle support. The patient requires no more than arm sling till the pain subside, then active exercise. Some displaced glenoid fracture may need open reduction & internal fixation because they are intraarticular & may affect stability of the shoulder.
Associated injuries: fracture scapula may be associated with other more serious injuries like: ribs fracture lung injury (haemo- pneumo-thorax), brachial plexus injury or shoulder dislocation (with glenoid fracture).
Scapulothoracic dissociation:
It is a high-energy injury in which the scapula & arm are wrenched away from the chest, rupturing the subclavian vessels & brachial plexus.
Clinical features; The limb is flail & ischemic, there is swelling above the clavicle from the expanding haematoma.
Treatment; The patient is resuscitated, the prognosis is poor even with vascular & nerve repair the patient may end with amputation or non functioning limb.
Acromioclavicular (AC) joint injuries:
Mechanism of injury: the injury of 2 types: A. Acute injury caused by fall on the shoulder with the arm adducted. B. Chronic sprains occur in the people engaged in activities like weightlifting or working with jack-hammers & heavy vibrating tools.
Classification:
?- Sprain of AC ligaments (partial tear) with no joint displacement.
II- Tear of AC ligaments with joint subluxation (slight elevation).
III- Tear of AC & CC (coracoclavicular) ligaments with dislocation of AC joint (marked elevation of lateral end of the clavicle).
Clinical features; There may be bruising at the site of the joint, if there is tenderness but no deformity the injury is probably a sprain or subluxation. If the joint is dislocated a step can be seen or felt & the shoulder movements are limited.
X-ray: A stress view may help to differentiate between type II & III: take AP view while the patient is standing upright, holding 5kg in each hand. Then measure the distance between the coracoid & lower border of clavicle; if the difference is >5o%?AC dislocation.
Treatment: For type ? &II, arm sling until the pain subside, for type III also by conservative measures. Operative treatment for type III is indicated with extreme prominence of the clavicle & in active adults with overarm activities. Open reduction and screw fixation through the clavicle into the coracoid with ligaments repair followed by 3weeks arm-sling then exercise.
Complications of the AC dislocation; 1. Rotator cuff syndrome; acute strain of the AC joint is sometime followed by supraspinatus tendinitis which may result from the initial trauma or from the inflammation of the AC joint. 2. Unreduced dislocation, it is ugly & may affect function this can be treated by reconstruction of the coracoclavicular ligament using the coracoacromion ligament. 3. Ossification of the ligaments, severe injury may lead to ossification of the coracoclavicular ligament forming a bony spur which may predispose to rotator cuff dysfunction 4. Osteoarthritis of the AC joint; as a late complication of the injury, this can be treated by analgesia, steroid injection & if symptoms persist the surgical excision of the lateral 2cm of the clavicle.
Sternoclavicular joint dislocation
This is an uncommon injury which could be anterior dislocation or posterior dislocation, the anterior one is much more common than posterior.
Mechanism of injury; The injury is usually caused by lateral compression force as in fall on the shoulder or it is caused by direct trauma to the front of the sternoclavicular (resulting in posterior dislocation).
Clinical features;
? Anterior dislocation; the patient presented with considerable pain & prominent bony bump over the sternoclavicular joint, this bump represents the dislocated medial end of the clavicle, there are no cardiothoracic complications.
? Posterior dislocation; there is marked discomfort the posteriorly dislocated medial end of the clavicle may compress the trachea or the large vessel behind the sternum causing venous congestion in the neck & the arm & the arm circulation decreased.
Treatment; ? For the anterior dislocation, it can be easily reduced by direct pressure on the front of the medial end of the clavicle combined with puling on the arm with the shoulder abducted after that the arm rested in arm sling. ? For the posterior dislocation the treatment is urgent because the risk on the neurovascular structures, this is done by pulling on the arm with the shoulder abducted& extended with sandbag between the scapulae if this fail then the medial end of the clavicle can be lifted foreword bone holder forceps if this fail then open surgical reduction of the joint, after reduction the shoulders are braced back with figure eight bandage for 3 weeks.
Shoulder dislocation
Shoulder dislocation is more common than any other joint in the body because the shallow glenoid fossa & the relatively lax ligaments responsible for wide range of movements, all these factors make the shoulder vulnerable for dislocation. There are three types of acute posttraumatic shoulder dislocation; Anterior, Posterior& Inferior.
Anterior shoulder dislocation:
it account for 98% of shoulder Mechanism of injury: fall on the hand with arm forced into abduction, external rotation and extension.
Clinical features (CF): severe pain, the patient support his arm with the opposite hand &prevent any kind of examination, there is flattening of the lateral outline of shoulder. We should examine the neurovascular bundle distally.
X-ray: AP view: the head is below & medial to the glenoid, Lateral view: the head is out of glenoid.
Pathology: when the head is pushed forward, it will tear the capsule or avulse the labrum from glenoid rim (Bankart lesion); sometime there is crushing of the poster lateral part of the head (Hill-Sachs lesion).
Methods of reduction:
1- If the patient has previous dislocations, then simple arm traction may be successful. 2- Stimson s method: Keeps the patient prone with arm dangling from side of Bed for 20 minutes? it may reduce.
3- Hippocratic method: traction to the abducted arm with counter traction in the axilla by an assistant.
4- Kocher s method: hold the elbow close to the body and flex it 90?; then rotate the arm laterally 75?, then lift the elbow & rotate the arm medially. X-ray is taken to confirm reduction & to exclude #. Then arm sling for 3weeks.
Complications;
A. Early: 1- Rotator cuff tears. 2- Nerve injury (axillary n.). 3- Vascular injury (axillary a.). 4- fracture-dislocation: fracture proximal humerus, grater tuberosity or glenoid.
B. Late: 1- Shoulder stiffness. 2- Unreduced dislocation: try closed reduction in the first 6 weeks; after that, open reduction in young patients; if old, ignore the dislocation and concentrate on regaining movement. 3- Recurrent dislocation: is more likely if the 1st time dislocation was associated with detachment of the labrum or stripping of the capsule from front of the neck of glenoid than tear of the capsule. Also, it is more common if there is Hill-Sachs lesion . Clinical features: usually young patient with history of recurrent dislocation. Apprehension test is positive: we do abduction, lateral rotation & extension of the shoulder, the patient feels that the dislocation about to occur & will become anxious & will resist the test.