Management of common

upper limb fractures in Adults

and Children
Dr Matthew Sherlock
Shoulder and Elbow
Orthopaedic Surgeon

Outline
Immobilisation

choices

Adults
Clavicle

Fractures
Proximal Humeral Fractures
Wrist Fractures
Children
Elbow

Fractures
Forearm Fractures

Immobilising Upper Limb #s

Immobilisation

choices

Slings

triangular, immobiliser
Collar and cuff
Plaster

Backslab, full cast (short arm, long arm), Uslab, hanging cast

Removable

splints

Braces

Choice is determined by forces displacement

Immobilising Upper Limb #s

Clavicle/AC
Weight

joint injuries

of arm displacement

Immobilising Upper Limb #s

Clavicle/AC
Weight

joint injuries

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 #s

Proximal

humerus

Metaphysis
Rotator

cuff balanced
Fracture angulation worsened
Axial load
Shoulder extension

Immobilising Upper Limb #s

Proximal

humerus

Metaphysis
Rotator

cuff balanced
Fracture 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

Arm should hang

Plaster

U-Slab
plaster

maintains alignment
immobilisation possible

Immobilising Upper Limb #s

Humeral Shaft

U-Slab
plaster

U-slab
Uncomfortable, heavy
Temporary

Immobilising Upper Limb #s

Humeral Shaft

Functional
brace

U-slab
Uncomfortable, heavy
Temporary
Change to Sarmiento brace after
1-2 weeks.

Immobilising Upper Limb #s

Elbow Fractures

Adults
Ideally dont 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 fractures
Midshaft

most common

Distal
Medial

- uncommon

Clavicle fractures
Mechanism

of injury

Clavicle fractures
Initial

treatment

Very

painful fracture
Arm immobiliser not
collar and cuff

Figure 8 bandage

Ice

Midshaft Clavicle fractures

All

undisplaced fractures can be

treated conservatively
Immobiliser

sling
Discontinued 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 fractures

How

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 fractures

How

much shortening?

Assessment

Clinical measurement

Midshaft Clavicle fractures

How

much shortening?

Assessment

Clinical measurement
Assess scapular position

Midshaft Clavicle fractures

How

much shortening?

Assessment

Clinical measurement
Assess scapular position
Radiology Xray/CT

Midshaft Clavicle fractures

Surgical
Plate

Options

fixation
Intramedullary screw

Midshaft Clavicle fractures

Plate

fixation

Comminution
Soft

bone/smokers
Less compliant patients

Midshaft Clavicle fractures

Intramedullary
2

screw

part fractures
Young patients (girls)
Avoid above shoulder
ROM first 6 wks

Distal Clavicle Fractures

Beware

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 Fractures

Displaced

fractures require surgery in all

but the elderly (low demand) patient.

Distal Clavicle Fractures

Beware

of inadequate imaging

Distal Clavicle Fractures

Beware

of inadequate imaging

Distal Clavicle Fractures

Beware

of inadequate imaging

Distal Clavicle Fractures

Initial

management
with immobiliser sling

Non-operative

Rx for
undisplaced fractures
with intact CC ligs

Distal Clavicle Fractures

Surgical

management

Distal Clavicle Fractures

Surgical

management

Proximal Humerus Fractures

Third

most common fracture after hip

fracture and Colles fractures
More common in females
Historically 15-20% required surgery
They generally result in some long term
functional disability

Classification Systems
Neer

Classification Systems
AO/ASIF

Surgical decision making

Not bad enough
for surgery

Too bad to fix

Surgical decision making

Not bad enough
for surgery
Sling/ Collar & Cuff

Too bad to fix

Hemi/Reverse TSA

Surgical decision making

Not bad enough
for surgery
Sling/ Collar & Cuff

Too bad to fix

ORIF

Hemi/Reverse TSA

Surgical decision making

Not bad enough
for surgery
Sling/ Collar & Cuff

Too bad to fix

ORIF

Hemi/Reverse TSA

Goal is maximum shoulder function and minimal shoulder pain.

Surgical decision making

Displacement and angulation
Painful Impingement
Significant ROM loss
Risk of non-union

Neer 1cm and or 45

degrees???

Surgical decision making

Non-op

vs ORIF vs Prosthesis

Determined

by

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

Surgical decision making

Non-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 Fracture

Large

fragment

Screw

fixation open/arthroscopic
Tension band suturing
Anchors

Greater Tuberosity Fracture

Large

fragment

Screw

fixation open/arthroscopic
Tension band suturing
Anchors

Greater Tuberosity Fracture

Large

fragment

Approach:
Screw fixation
mini deltoid split/
Tension band suturing arthroscopic
Anchors

Advanced Fracture Management

Course

Greater Tuberosity Fracture

Large

fragment

Screw

fixation open/arthroscopic
Tension band suturing
Anchors
Small

fragment

Treat

like a cuff tear

Arthroscopic repair

Greater Tuberosity Fracture

My

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 Fracture

Acceptable

displacement and
angulation depends on:
patients

age
activity level
functional demands

Surgical Neck Fracture

Skeletally

immature

Patient Age (yr)

Allowable Displacement or Angulation

<5

Up to 70 degrees angulation, 100% displacement

512

Up to 4070 degrees angulation

>12

Up to 40 degrees angulation, <50% displacement

Adults

2 Part Surgical Neck Fracture

Options
Closed

reduction + Kwires
Intramedullary nail
Circlage sutures
Plate fixation

2 Part Surgical Neck Fracture

Closed

reduction + Kwires

2 Part Surgical Neck Fracture

Plate

fixation

2 Part Surgical Neck Fracture

Plate

fixation

3 and 4 Part Fractures

3 and 4 Part Fractures

Surgical

Treatment Options

Open

reduction + K wires
Circlage wires/sutures + Rush pins/Enders
rods
CRKW (Resch)
Intramedullary nail
Locking plate
(hemiarthroplasty/reverse)

3 and 4 Part Fractures

Surgical

Treatment Options

Open

reduction + K wires
l
a
c
i
r
Circlage
Histowires/sutures + Rush pins/Enders
rods
Technically difficult
CRKW (Resch)
Intramedullary nail
Locking plate
(hemiarthroplasty/reverse)

3 and 4 Part Fractures

Approach
Deltopectoral

Mini-deltoid

(Extensile

split Percutaneous plating

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 plates

for increased strength

Distal Humeral Fractures

Supracondylar
Extension

Type COMMON!!
Flexion Type (rare)
Epiphyseal
Epicondylar
Condylar

Supracondylar Fractures
Extension

Type

Grade

1
(Undisplaced)

Grade

2
(Partially)

Grade

3
(Completely)

Supracondylar Fractures
Extension

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

Collar

& Cuff in
flexion for 3/52

+/-

Backslab

Supracondylar Fractures Mx
Grade

Closed

If

Reduction under anaesthetic

unstable (rotationally) add K-wires

Immobilize

in flexion

Supracondylar Fractures Mx
Grade

Usually severely
swollen
delay increases
difficulty of reduction
Vascular compromise
Neurological deficit AIN
Occasionally open
reduction required!

Supracondylar Fractures
Complications
Early

Arterial Injury
Compartment Syndrome
Nerve Palsy

Late

Volkmanns Ischaemic Contracture

Malunion

Complications: Cubitus Varus

Residual Posteromedial
displacement 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

Baumans angle

Lateral Condyle Fractures

15%

of elbow fractures in children

Mechanism:
Avulsion

secondary to FOOSH with

forearm supinated.
Compression injury secondary to FOOSH
with elbow flexed.

Lateral Condyle Fractures:

Milch Classification

Type I

Type II

Lateral Condyle Fractures:

Treatment
Can

be confused sometimes with a

supracondylar fx - cannot make this
mistake.

Lateral Condyle Fractures:

Treatment
Nondisplaced:

Immobilization in simple

backslab
Displaced: 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

Incarcerated

medial epicondyle

Medial epicondyle fractures

Incarcerated
Open

medial epicondyle

reduction internal fixation

Elbow dislocation
Displaced

radial neck fracture

Elbow dislocation
Displaced
Open

radial neck fracture

reduction K-wire fixation

Forearm Fractures
Distal

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 Fractures
Treatment

is determined by:

Age

of patient (remodelling potential)

Displacement

Angulation, translation, rotation, shortening

Cosmetic

appearance
Aim to restore forearm rotation

Forearm Fractures
Plastering

techniques

Maintenance

moulding

of reduction requires 3 point

Forearm Fractures
Plastering

techniques

Maintenance

moulding

of reduction requires 3 point

Distal Third Fractures

Buckle

or Torus Injuries

Minimally

displaced

Stable

3-4/52

in cast short arm

sufficient

Distal Third Fractures

Displaced
?

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 Fractures

Epiphyseal

Injuries

Usually Salter Harris I or

II

Displaced reduction
and short arm cast

Remodel well

Dont manipulate late

Forearm Shaft Fractures

Less remodelling

Accept less than 10 degrees angulation

Closed reduction under GA

Always above elbow moulded cast

Recheck Xray 1 week

Warn parents the cast will look bent!

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

THANK YOU