Fractures of the

upper limb

Presented by: Vaishnavi

Under the guidance of Dr.Khadijeh Menai
Scapula
Common sites of fracture
• Scapular neck (25% of fractures)
• Glenoid
• Acromion
• Coracoid

Clinical features
• Pain on rest, swelling around scapular region, bruising, inability to lift the
arm, flattened shoulder appearance, pain while breathing.
Mechanism of injury
• Direct/ crushing injury(high energy trauma,RTA)
• Contact sports
• Axial loading on outstretched hand
Type Glenoid(intra Coracoid Acromion
articular)
I # Glenoid rim # proximal to Minimally displaced
coracoclavicular
ligaments (AC
seperartion)
II # through glenoid # distal to Displaced but not
fossa inferior fragment coracoclavicular reducing subacromial
displaced with ligament space
subluxed humerus

III Oblique # through Inferior displacement

glenoid exiting and subacromial
superiorly space
IV Horizontal # exiting
through medial
scapular border
V Type IV # + #
separating the inferior
half of glenoid

VI Severe comminution
of glenoid
Investigation
• X ray(AP,Lat,Axial)
• CT

Intra articular Glenoid #

Medialized
scapular #
 Complications
1.Post-traumatic glenohumeral arthritis
• risk factors
• intra-articular glenoid fracture with residual step-off/displacement
2. Malunion
• risk factors
• higher degree of angulation, translation or medialization
3. Recurrent glenohumeral instability
• risk factors: younger patients
• larger degree of bone loss (anterior or posterior)
 MANAGEMENT

Conservative Surgical management

Undisplaced # managed by Internal fixation by screws
Shoulder immobilization with and plates
sling for 2-3 weeks
PT Rx
Clavicle
Mechanism of injury:
• Direct trauma- RTA
• Indirect trauma- FOOSH
Classification (Allman)
1. Middle 1/3rd of shaft
2. Lateral 1/3rd distal to the attachment of coracoclavicular ligament
Clinical presentation :
• Difficulty in raising arm
• Pain swelling and deformity
Neer classification
• Fractures of the distal clavicle (lateral one third) are further
subclassified into three types by Neer:
• Type I-lateral to the coracoclavicular ligament complex, and thus
stable.
• Type II-medial to the coracoclavicular ligaments, leaving the distal
clavicle and the acromioclavicular joint intact but separate from the
underlying coracoclavicular ligament complex. These are associated
with increased risk of nonunion.
• Type III-involving the articular surface of the distal portion of the
clavicle. These are usually associated with major ligamentous
disruption
Investigation
• X ray : Radiographic analysis requires at least an anteroposterior view
and another taken with a 30 degree cephalic tilt.
• CT : CT scanning with three-dimensional reconstructions may be
needed to determine accurately the degree of shortening or for
diagnosing a sternoclavicular fracture-dislocation, and also to
establish whether a fracture has united.
 Management

Conservative Surgical
• undisplaced #: Simple collar and cuff sling or triangular Open reduction and internal fixation (ORIF) may
bandage(stress sharing) be indicated rarely in cases where sharp spurs of
• Displaced #:Collar and cuff sling, with strapping of the the bone endanger the underlying vessels or
fracture site with adhesive plaster threaten to perforate skin. The clavicle can be
• Fig of 8 bandages: it acts by retracting the shoulder girdle, internally fixed with a nail or a special plate(stress
minimizes the overlap and allows more anatomical healing shielding)
Bosworth screw
 DAYS ROM MUSCLE STRENGTH FUNCTIONAL WB
ACTIVITIES
PT Rx1- 1 WEEK NO SH ROM NO SH C/L SIDE NO WB
ELBOW 90° STRENGTHENING
FULL ROM FOR ELBOW ROM
DISTAL JTS ENCOURAGED ( FOR
BICEPS AND TRICEPS
STRENGTH)

WEEK 2 GENTLE PENDULAR ELBOW ISOMETRICS C/L SIDE NO WB

EXS IN PAIN FREE ISOTONIC EXS OF
RANGE DIGITS
ISOMETRIC DELTOID
EXS

WEEK 4-6 AROM SH END OF 6 WKS CAN BE STARTED NO WB

80° ABD ONLY RC STRENGTHENING
ELBOW FULL ROM EXS
SH ISOMETRICS
GRIP EXS

WK 6-8 MULTIPLANAR RESISTIVE LIGHT ACTIVITIES GRADUAL

AROM STRENGTHEING
WK 8-12 CT ALL ISOMETRIC AND ALL ACTIVITIES FWB
ABD IS ISOTONIC EXS OF SH
ENCOURAGED GIRDLE
 Complications
• Proximal-third clavicle fracture complications include nonunion and
posttraumatic arthritis. Acutely, proximal clavicle fractures displaced
inwardly may result in severe intrathoracic injuries, including brachial
plexus injury, subclavian vessel injury, and pneumothorax.
• Fractures of the distal third of the clavicle have the highest incidence
of nonunion; however, many of these patient's nonunions are
asymptomatic.Degenerative arthritis within the acromioclavicular
joint can be a late complication.
 Acromioclavicular injuries
• Mechanism of injury A fall on the shoulder with the arm adducted may
strain or tear the acromioclavicular ligaments and upward subluxation of
the clavicle may occur; if the force is severe enough, the coracoclavicular
ligaments will also be torn, resulting in complete dislocation of the joint.

• Clinical features
The patient can usually point to the site of injury and the area may be
bruised. If there is tenderness but no deformity, the injury is probably a
sprain or a subluxation. With dislocation the patient is in severe pain and
a prominent ‘step’ can be seen and felt. Shoulder movements are limited
ROCKWOOD
CLASSIFICATION
X RAY
• anteroposterior, cephalic tilt and axillary views
a stress view is sometimes helpful in distinguishing between a Type II
and Type III injury: this is an anteroposterior x-ray including both
shoulders with the patient standing upright, arms by the side and
holding a 5 kg weight in each hand.
The distance between the coracoid process and the inferior border of
the clavicle is measured on each side; a difference of more than 50 per
cent is diagnostic of acromioclavicular dislocation.
Management
• Nonoperative
• brief sling immobilization, rest, ice, physical therapy
indications
• type I and II
• type III in most individuals
• good results when clavicle displaced < 2cm
 Operative management
• Orif with Bosworth screws
screw placement from distal clavicle to coracoid, superior to inferior
• ORIF with CC suture fixation
suture placed either around or through clavicle and around the base
of the coracoid
can also use suture anchors for coracoid fixation
• ORIF with AC pin fixation (Phemister Technique)
smooth wire or pin fixation directly across AC joint
• CC ligament reconstruction with coracoacromial (CA) ligament
(Modified Weaver-Dunn)
In the modified Weaver–Dunn procedure the lateral end of the clavicle
is excised and the coracoacromial ligament is transferred to the outer
end of the clavicle and attached by trans-osseous sutures.
 Proximal humerus fracture
Mechanism
• Fall on outstretched hands is the classical history.
• Blow on the lateral side of the arm is the other mode of injury.
Four segments are described with respect to proximal humerus:
1. Anatomical neck 2. Greater tuberosity 3. Lesser tuberosity 4. Shaft or surgical neck of the
humerus.
Classification
One-part fracture: The fragments are undisplaced and hence the results are good.
Two-part fracture: One segment is separated from the others. These fractures can usually be
managed by closed manipulation.
Three-part fracture: Two fragments are displaced.
Four-part fracture: All the major fragments are displaced.
Clinical presentation
Pain and swelling around the shoulder are the presenting symptoms. Ecchymosis may develop
within 24–72 h over the shoulder and arm and may extend up to the elbow and chest wall.
Undisplaced #

Displaced #
2 part fracture 3 part fracture 4 part fracture

Greater tuberosity
 Axillary view
Trans scapular
 Management

Surgical
Conservative Stress shielding with plate fixation
Non displaced/minimally displaced# Stress sharing with pin/TBW
Minimally displaced: Triangular sling • Surgical neck#: PHILOS plate,osteosuture,k
Stress sharing device wires,LPHP,closed reduction and percutaneous
fixation(displaces surgical neck#)
Mode of healing: secondary
Comminuted #: Replacement arthroplasty
ORIF:2 and 3 part# with RC repair
Complications
• Malunion or nonunion
• Avascular necrosis incase of 4 part # or anatomical neck fracture
• Rotator cuff tears: due to displacement of tuberosity
DAY ROM MUSCLE STRENGTH FUNCTIONAL WEIGHT
ACTIVITIES BEARING
DAY 1 TO AVOID SH.MOTION - C/L SIDE ONLY -
WEEK 1 NO ROM AT SH AND ELBOW
MILD PENDULAR EXS WITH GRAVITY
ELMINATION(NON DISPLACED AND
HEMIARTHROPLASTY)

2-4 WEEKS SLING- CONT.PENDULAR EXS ISOMETRICS(SLINGS PTS C/L SIDE ONLY -
ACTIVE TO PA EXS ONLY)
NO STRENGHTENING FOR
SxRx
4-6 WEEKS LIM.RANGE DELOTOID EXS TO BE DRESSING AND -
FLEXION ABD 100 -110° AVOIDED IF INCISED DURING GROOMING AS
IR ER LIMITED SX TOLERATED
PEND.EXS AGAINST GRAVITY ELBOW ISOTONIC AND
PROM FOR SX RX ISOMETRIC

6-8 WEEKS NO FORCED ROM SH ISOMETRICS CT ALL AS TOLERATED

MULTIPLANAR AROM FOR SH AND PRE FOR PTS WITH SLING.
ELBOW
8-12 WEEKS MULTIPLANAR ROM ISOKINETIC EXS CT ALL FWB
 Humeral Diaphysis or Midshaft Fractures

• Mechanism of Injury
Humeral fractures are caused by a direct blow,
twisting force, fall onto the arm, or penetrating
trauma and are frequently associated with motor
vehicle accidents.
The arm is painful, bruised and swollen. It is
important to test for radial nerve function before
and after treatment.
• Investigation
AP and LATERAL VIEW OF SHOULDER AND
ELBOW
USG TO RULE OUT ANY RADIAL NERVE
ENTRAPMENT

Complications:
Radial nerve injury manifested with a wrist drop
Non union
Mal union
varus angulation is common but rarely has functional
or cosmetic sequelae
 MANAGEMENT

CONSERVATIVE
• U-slab
• Hanging cast: It is used in some cases of lower-third fractures of the humerus.
• Chest-arm bandage: The arm is strapped to the chest. This much immobilisation is sufficient for fracture of the humerus in
children less than five years of age.
• Coaptation sling: stress sharing devices
• Functional bracing: stress sharing (closed fractures of diaphysis)
• Velpleau: stress sharing devices :Non displaced fracture
 Surgical
Intramedullary nail/rod: Stress shielding device (eg Kirschner rod)
Plate fixation: Stress shielding device, compression achieved by broad plates.
Lag screw fixation of the fragments.
External fixation: Stress sharing device (INDICATED IN OPEN HUMERUS SHAFT
# AND CLOSED SHAFT # WITH SOFT TISSUE TRAUMA, FLOATING
ELBOW,SEGMENTAL HUMERUS #)
Days ROM MUSCLE STRENGTH FUNCTIONAL WB
ACTIVITIES

1-1 wk NO ROM(splinted) NONE C/L SIDE NONE

ORIF ,EF GENTLE ROM FOR SH
AND ELBOW
GRAVITY ELIMINATED
PENDULAR EXS

WEEK 2 AAROM/AROM SH & ELBOW NONE ORIF OR EF: NONE

WITH SPLINT : NO ABD >60° LIGHT GROOMING, RODDING:
WRITING FEEDING LIGHT WB
ACTIVITIES

WEEK 4-6 AAROM AND AROM ELBOW& FOREARM ISOMETRIC BASIC SELFCARE WITH BRACE AND PLATE:
SH & ISOKINETIC EXS AFF.SIDE LIGHT WB
POST 6W:ISOMETRICS
FOR BICEPS AND
TRICEPS

WEEK 8-12 CT ALL PRE ELBOW &SH ALL ADL’s FWB

LIGHT LIFTING
Distal humerus fractures

• Supracondylar #
Supracondylar fracture of humerus is also called Malgaigne’s fracture.
Commonly occurs in children
• Ligamentous laxity at the elbow leads to hyperextension> Hyperextension
converts linear force into bending force. Olecranon concentrates this force to
the weak supracondylar area >Anterior capsule is taut> Bony architecture of a
supracondylar area disrupted
• Mechanism of Injury Fall on an outstretched hand with hyperextension at
the elbow with abduction or adduction, with hand dorsiflexed.
• The AO-ASIF Group have defined three types of distal humeral fracture:
• Type A – an extra-articular supracondylar fracture
• Type B – an intra-articular unicondylar fracture (one condyle sheared off)
• Type C – bicondylar fractures with varying degrees of comminution.
Type A extra-articular fractures are rare in adults ( displaced and unstable as
there is no tough periosteum to tether the fragments)
Type B & C :High energy injuries with soft tissue trauma
Clinical features
• Arm is short, forearm is normal in length.
• Gross swelling, and tenderness.
• Crepitus is present but should not be elicited for fear of increasing the pain
and damaging the neighboring neurovascular structures.
• S-shaped deformity.
• Dimple sign due to one of the spikes of proximal fragment penetrating the
muscle and tethering the skin.
• Relationship between three bony points is maintained.
• “Soft spots” is an effusion beneath anconeus muscle.
• Movements of the elbow both active and passive are decreased
Investigation x ray
• Baumann’s angle: Angle between the horizontal line of the elbow and the line
drawn through the lateral epiphysis and long axis of the arm.
Lateral view • Tear drop sign: It is disturbed in supracondylar fracture, but it is
seen in the normal radiograph.
• Anterior humeral line: A line drawn along the anterior border or the distal
humeral shaft passes through the middle 1/3rd of capitulum. If it passes through
anterior 1/3rd, it indicates posterior displacement of the distal fragment.
• The coronoid line: A line directed proximally along the anterior border of the
coronoid process of the ulna should just barely touch the anterior portion of the
lateral condyle. Posterior displacement of the lateral condyle will project the
ossification center posterior to this line.
Coronoid line
 Management
• Undisplaced fractures These can be treated by applying a posterior slab with the
elbow flexed almost 90°(stress sharing device)
• Percutaneous Pinning with Cast or Splint Biomechanics: Stress-sharing device.
Closed reduction and percutaneous pin fixation, although commonly used in
children, is used less often in adults and is best reserved for extraarticular distal
humeral fractures.
• Open Reduction and Internal Fixation: Stress-shielding device. Stress sharing may
occur if there is inadequate internal fixation.
Indications: Fixation with lag screws or medial and lateral reconstruction plates is
used for intraarticular injuries with persistent step-off and for extraarticular injures
that do not reduce with closed manipulation.
• External Fixation: Stress-sharing device. Indications: grossly contaminated open
injuries.
Days ROM MUSCLE STRENGTH FUNCTIONAL WB
ACTIVITIES
1-1 wk NO SH ROTATION NONE C/L SIDE NONE
NO ELBOW PROM
ORIF(STABLE):
Gentle elbow rom
NO ROM FOR
OTHER RX
WEEK 2 ORIF(STABLE): NONE C/L SIDE NONE
Gentle elbow rom RODDING:
LIGHT WB
WEEK 4-6 AAROM/ AROM NONE C/L SIDE BRACE AND PLATE:
ELBOW LIGHT WB

WEEK 8-12 CT ALL PRE ELBOW ALL ADL’s FWB BY 12TH WEEK
LIGHT LIFTING
SIDE SWIPE INJURIES Mechanism It is due to the force applied to an elbow
projecting from a car window by a passing vehicle or when it hits a fixed object or
when it overturns.

Shorbe’s Classification
Group I Only soft tissue injury.
Group II Only tip of the elbow is injured and there is fracture olecranon.
Group III Fracture of both radius and ulna.
Group IV Variations of comminuted intercondylar fractures of the humerus.
Group V Severely injured, fracture of all bones around the elbow with considerable
soft tissue injury. Extensive open wounds are not unusual.
CLINICAL FEATURES
Patient complains of extreme pain, gross swelling, broadening of the elbow, loss of
mobility at the elbow joint, crepitus, abnormal mobility, etc. There may be features
suggestive of injuries to the blood vessels and nerves and patient can present with
compartmental syndromes or even gangrene of the hand in extreme cases.
INVESTIGATION
Plain X-ray, MRI, CT scan, arteriogram, Doppler study, etc. are some of the
important investigation methods.
• Radial head fracture is a common injury in adults and is rare in children.
Mechanism of Injury
• Indirect trauma due to fall on an outstretched hand.
• Direct trauma due to RTA, assault, etc. in adults.
• Impaction of the capitellum onto the radial head by a valgus force. Injury is
usually caused by axial loading on a pronated and partially flexed hand`
Mason’s Classification
• Type I: Undisplaced fracture.
• Type II: Marginal fracture with displacement.
• Type III: Comminuted fractures.
• Type IV: Radial head fracture with posterior dislocation of elbow.
Clinical Features The patient with radial head fracture complains of pain on
the lateral side of the elbow, minimal swelling and restriction of elbow
movements and supination, pronation of the forearm. There is tenderness
over the radial head and crepitus can be elicited
• Investigation
X ray
The fracture line is transverse. It is either situated
immediately distal to the physis or there is true
separation of the epiphysis with a triangular
fragment of shaft (a Salter-Harris II injury).
 Special consideration Associated injuries Long term problems

Young patients and Neurovascular injuries to the Heterotrophic ossifiction: seen

players :ORIF should be done post.interosseus nerve or in both internal fixation and
to prevent any valgus median nerve can occur. non operative management
instability High risk of brachial artery
injury +

Older patients: If elbow is Elbow dislocations> causing In case of Radial head

stable, radial head can be disruption of oblique fibers of excisions:
excised and immediate ROM MCL. Proximal migration of the
can be started radius causing ulnar+ wrist
leading to reduced grip
strength and ulnar
impingement of carpus

Silicone synovitis in pts with

silicone radial head
replacement
management

• Aspiration, Early Range of Motion, Sling: Stress-sharing device (sling or

splint). Indications: nondisplaced fractures
• Excision of fracture fragments or Entire Radial Head: Stress-sharing sling
Indications: Comminuted fractures that are not amenable to repair require
excision of articular fragments that restrict the range of motion
• Open Reduction and Internal Fixation: Stress-shielding device.
Indications: This is the treatment of choice for type II radial head fractures
that are displaced 2 to 3 mm, with more than 25% to 30% involvement of the
articular surface. The radial head is reconstructed with mini fragment screws,
Kirschner wires ,T-plate.
DAY ROM MUSCLE STRENGTH FUNC. WB
ACTIVITIES

1 TO NO PROM NO STRENGTHENING FOR C/L SIDE NWB

WEEK 1 Gentle, active range of motion ELBOW
to the elbow in flexion and
pronation.

WEEK 2 NO PROM DELTOID,TRICEPS AND BICEPS C/L SIDE NWB

ACTIVE ELBOW ROM ISOMETRICS

WEEK 4 AROM,AAROM,PROM FOR DELTOID,TRICEPS AND BICEPS C/L SIDE PWB(CAST)

TO 6 ELBOW(CAST) ISOMETRICS AFF.SIDE FOR NWB(FIXATION)
AAROM AROM (FIXATION) ASSISTANCE

WEEK 8- COMPLETE AROM ELBOW Progressive resistive exercises LIGHT ACTIVITIES Weight bearing
12 are given to the elbow flexors, allowed for· self-
extensors, supinators, and care and light-
pronators. duty activities.
Fracture of olecranon
• Mechanism of Injury
Direct: Trauma due to fall on the point of elbow.
Indirect: Due to forcible triceps contraction
Mayo classification
• Type I
type IA: undisplaced non-comminuted
• type IB: undisplaced comminuted
• Type II
type IIA: displaced non-comminuted
type IIB: displaced comminuted
• Type III
type IIIA: unstable non-comminuted
type IIIB: unstable comminuted
• A graze or bruise over the elbow suggests a comminuted fracture; the
triceps is intact and the elbow can be extended against gravity. With
a transverse fracture there may be a palpable gap and the patient is
unable to extend the elbow against resistance
Investigation
Lateral view x ray for fracture and radial head dislocation
Special consideration Associated injuries Long term problems

Elderly pts: Post fracture treatment joint Ulnar nerve neuropraxia: if no recovery Heterotrophic bone formation
stiffness+ is achieved for ulnar nerve , ulnar nerve
K wire fixation and cancellous screws decompression with transposition is
cannot done due to osteoporotic bones. done.
Excision and triceps reattachment are
the Rx of choice
Articular involvement: Articular
congruity should be maintained at the
time of # Rx( 2mm step off acceptable)
• Conservative
Indications: This is indicated for undisplaced fractures and in fractures
with less than 2 mm displacement.(in children)
• Surgical
In adults, repair of triceps is done for avulsion fractures.
Open reduction and internal fixation with figure of ‘8’ wire loop
This method is used for avulsion and transverse fractures of the
olecranon and for fractures which are uncomminuted and proximal to
the coronoid fossa.
Medullary fixation by a single inter fragmentary screw
This is indicated in comminuted fracture of olecranon when its distal
fragment and the head of the radius are dislocated anteriorly. Rigid
fixation is required to prevent recurrence of dislocation.
Day ROM STRENGTH FUNC.A WB
CTIVITIE
S
1 TO No range of motion to the No strengthening exercises to the elbow. C/L SIDE NWB
WEEK elbow or wrist in a cast or 3- 4 days after fracture, isometric
1 splint. Gentle active elbow exercises to the wrist within the cast.
flexion and active range of
motion to the wrist if
treated surgically.

WEEK SAME AS 1ST WEEK No strengthening exercises to the elbow C/L SIDE NWB
2 in extension. Isometric exercises to the
elbow in flexion in a cast. Isometric
exercises to the wrist.

WEEK Elbow ROM encouraged Isometric exercises to the elbow and LIGHT NWB
4 TO 6 wrist in flexion and extension. SELF
CARE
WEEK Multiplanar AAROM RESISTIVE EXS FOR ELBOW AND WRIST ADL`S AS
6-8 /AROM ELBOW AND CAN BE TOLER
WRIST STARTED ATED
WEEK SAME AS 6TH WEEK SAME AS 6TH WEEK COMPLE FWB
8-12 TE ADL
Coronoid fractures
• MOI: elbow hyperextension with either avulsion of
the brachialis tendon insertion or shearing off by the trochlea.
• Regan and Morrey classification system:
type 1: avulsion of the tip of the coronoid process
type 2: fragment involving <50% of the coronoid process
type 3: fragment involving >50% of the coronoid process
• Coronoid process fractures may be diagnosed on a plain film series of
the elbow, generally on a lateral or a 45° internal oblique view
• CT is commonly necessary for fracture characterization of the
fragment size, the degree of anteromedial involvement, and complex
fracture-dislocation.
• Management
• Non operative
• brief period of immobilization, followed by early range of motion
Indications: Type I, II, and III that are minimally displaced with stable
elbow
• Operative
• ORIF with medial approach
• Indications :Type I, II, and III with persistent elbow instability
posteromedial rotatory instability
• ORIF with posterior approach
Indications: olecranon fracture dislocation, terrible triad of elbow
• hinged external fixation
• Indications: large fragments, poor bone quality, difficult revision cases to
help maintain stability
Fractures of forearm and wrist
• A twisting force (usually a fall on the hand) produces a spiral fracture with
the bones broken at different levels. An angulating force causes a
transverse fracture of both bones at the same level. A direct blow causes a
transverse fracture of just one bone, usually the ulna.

• Types of forearm fracture

A nightstick fracture is an isolated mid shaft (diaphyseal) ulnar fracture
resulting from a direct blow. It is usually amenable to closed reduction and
cast application.
An Essex-Lopresti fracture/dislocation is a fracture of the proximal radius
with complete disruption of the interosseous membrane, usually
associated with fracture of the radial head, and may lead to the proximal
migration of the radius.
Fractures of forearm and wrist
A Galeazzi fracture/dislocation is a distal-third radius fracture with
disruption of the distal radioulnar joint. It is called a fracture of necessity,
because, in this injury, it is necessary to provide surgical intervention
because of loss of correction and loss of bowing of the radius.
A Monteggia fracture/dislocation is a proximal or middle-third ulna
fracture with dislocation of the radial head. The radial head may be
dislocated anteriorly, posteriorly, or laterally, and in some instances both
the radius and ulna are fractured.
Monteggia #
• Mechanism of Injury: Monteggia fractures are caused by direct blow or due to fall on
outstretched hands with forced pronation or hyperextension.
• BADO’S CLASSIFICATION
• I: anterior dislocation of the radial head
• II: posterior dislocation of the radial head
• III: lateral or anterolateral dislocation of the radial head
• IV: anterior radial head dislocation as well as proximal third ulnar and radial shaft
fractures
Clinical presentation
In all four varieties of Monteggia fractures patient complains of severe pain and
tenderness about the elbow. There will be no flexion, extension, pronation and
supination movements at the elbow. Paralysis of posterior interosseous nerve may
occurs.
Management
• Close reduction with above Elbow cast
• ORIF
• For Monteggia fractures, closed reduction of the radial head is carried out,
followed by the plating of the ulnar fracture. Simultaneous reduction of the
radial head occurs as the ulnar shaft fracture is anatomically reduced and
fixed. Depending on the stability of the radial head after reduction,
postoperative immobilization varies from a long arm cast to a functional
brace.
Galezzi fracture
• This is a fracture of radius at the junction of middle and distal third with associated
subluxation or dislocation of the distal radioulnar joint. Subluxation of this joint may
be present initially or occur during treatment
• Mechanism of Injury
1. Fall on an outstretched hand with marked pronation of the forearm.
2. Direct blow on the dorsolateral side of the forearm.
Patient presents with severe pain, swelling, tenderness and loss of forearm and wrist
functions
Treatment
For Galeazzi fractures, the radius is anatomically reduced and fixed with a plate. This
restores the position of the radioulnar joint. A long arm cast or functional brace holds
the forearm in supination for 4 weeks. This is followed by a short arm cast for an
additional 2 weeks.
Special consideration Associated injuries Long term problem
Elderly: elbow and wrist joint Neurovascular injuries: Syntosis in case of high energy
stiffness Post.inerosseus nerve injuries.
(monteggia fracture) Occurs when radial an ulnar # is
at the same level.

Location of #: it determines the Ulnar nerve injury is seen in

forces acting on the proximal and ulnar approach during plae
distal fragments. fixation if subperiosteal elevation
of flexor carpi ulnaris isn’t
performed.
Days ROM Strength Functional activities WB

1 TO 1 WEEK NO PASSIVE ROM Isometric exercises to C/L SIDE NONE

fixation and the the deltoid, biceps, and
forearm is not in a cast, triceps if the fracture is
gentle AROM exercises rigidly fixed. No
to the elbow and wrist, strengthening exercises
including supination to the forearm if
and pronation treated with cast only.
exercises.

WEEK 2 NO PASSIVE ROM Gentle active range of C/L SIDE NONE

motion to the elbow
and wrist if there is
adequate fixation and
the forearm is not in a
cast.

WEEK4-6 Active to active- If fixation is adequate LIGHT ACTIVITIES NONE

assistive range of at end of 6 weeks, start
motion to the elbow gentle isokinetic
and wrist, including exercises to the
supination and forearm muscles with
pronation if the patient less than 5 Ib of
is out of a cast resistance.

WEEK 6-12 FULL AROM WRIST PRE FOR FOREARM ALL ADLS FWB
AND ELBOW.
Colles fracture
• This is also called as Poutteau’s fracture, Colles' fracture is a distal
metaphyseal fracture of the radius, usually occurring 3 to 4 em from
the articular surface with volar angulation of the apex of the fracture
(silver fork deformity), dorsal displacement of the distal fragment, and
a concomitant radial shortening. It mayor may not involve an ulnar
styloid.
• Gosta Frykman classification
• Type I: transverse metaphyseal fracture
• includes both Colles and Smith fractures as angulation is not a feature
• Type II: type I + ulnar styloid fracture
• Type III: fracture involves the radiocarpal joint
• includes both Barton and reverse Barton fractures
• includes Chauffeur fractures
• Type IV: type III + ulnar styloid fracture
• Type V: transverse fracture involves distal radioulnar joint
• Type VI: type V + ulnar styloid fracture
• Type VII: comminuted fracture with the involvement of both the radiocarpal
and radioulnar joints
• Type VIII: type VII + ulnar styloid fracture
Clinical presentation
Dinner Fork Deformity
History of fall on an outstretched hand
Dorsal wrist pain
Swelling of the wrist
Increased angulation of the distal radius
Inability to grasp object
Associated injuries and long term problems

• Tendon rupture: extensor pollicis longus &peritendinous adhesions of

both flexor and extensor compartments may occur.
• nerve injury : median nerve contusion --> acute CTS
• Late CTS may occur due to residual deformity.

• Long term problems:

1. degenerative arthritis incas of intra articular #.
2. Residual deformity
3. Prolonged swelling
Management
• Cast: Stress-sharing device
Indications: Closed reduction and casting provides fracture
management without the need for operative fixation. It is indicated for
patients with nondisplaced or minimally displaced fractures without
much comminution.
• Open Reduction and Internal Fixation (Plates or Percutaneous Pins)
Stress-shielding device for plate fixation and stress-sharing device for
pin fixation.
Indications: This method is primarily indicated for displaced articular
fractures. Postoperative casting is generally recommended for 2 to 6
weeks, depending on stability of fixation.
• External Fixator Biomechanics: Stress-sharing device
Indications: An external fixator is useful for comminuted, displaced, or
open fractures not amenable to closed reduction or internal fixation.
DAYS ROM STRENGTH FUNCTIONAL WB
ACTIVITIES
1-WEEK 1 No supination and Attempt isometric C/L SIDE NO WB
pronation. No wrist exercises to the intrinsic
ROM muscles of the hand.
Full AROM of digits of
metacarpal phalangeal
joint. Full opposition of
thumb.

2 WEEK Attempt gentle wrist Isometric exercises C/L SIDE NO WB

AROM ORIF and fixation given to intrinsic
is rigid. muscles of the hand
and wrist flexor and
extensor.

4-6 WEEKS FULL AROM Gentle resistive The involved extremity NO WB TILL END OF 6TH
ACTIVE UD AND RD exercises given to the may be used as a WEEK
digits of the hand. stabilizer in two-handed
FOCUS MORE ON activities.
POWER GRIP

8 -12 WEEKS ALL JTS FULL AROM Gentle resistive Involved extremity used AS TOLERATED
exercises to digits and for self care and adls
Smith’s #
• It is a fracture of distal one-third of radius with palmar displacement.
Hence, it is called as reverse Colles’ fracture.
• Mechanism of Injury There are three modes of injury like fall on the
back of the dorsum of the hand, fall on the forearm in supination and
a direct blow to the flexed hand.
• Clinical Features The patient complains of pain, swelling, deformity
and loss of wrist functions. The deformity is opposite to that of Colles’
fracture and is called the ‘garden spade’ deformity
• Investigation
Anteroposterior view of the wrist shows the carpus proximally
displaced. There will be anterior displacement of the fragment with
palmar angulation of distal radial articular surface.

MANAGEMENT
The treatment of choice is closed reduction
and immobilization in a long arm cast with
forearm in supination and wrist in extension.
For unstable fractures, fixation with
percutaneous K-wire or ORIF
Injuries of wrist
• Scaphoid fracture
Mechanism of Injury: A scaphoid fracture occurs during a fall on an
outstretched hand with the wrist dorsiflexed and radially deviated. In
95 to 100 degrees of wrist extension, the proximal pole of the scaphoid
remains fixed while the distal pole moves dorsally, leading to a waist
fracture.
Clinical Features Patient complains of pain and swelling of the wrist.
Tenderness in the anatomical snuff box is a characteristic finding. The
movements of the wrist may be painful.
Proximal pressure along the axis of the thumb may be painful.
 investigation
• Xray
• neutral rotation PA
• lateral
• semi-pronated (45°) oblique
• wrist in 20 degrees of ulnar deviation,waist fractures seen best
• CT scan with 1mm cuts along scaphoid axis
Indications:best modality to evaluate fracture location, angulation,
displacement, fragment size, extent of collapse, and progression of
nonunion or union after surgery.
Special consideration Associated injuries Long term problems
The precarious blood There may be concomitant Malunion with humpback
supply to the scaphoid radial styloid or distal deformity results in
accounts for the variability radius fractures or carpal decreased extension and
in healing time. ligament injuries. grip strength; however,
Approximately 80% of the Concomitant lunate or this clinical outcome
blood supply to the perilunate dislocations,· should be accepted and no
scaphoid is via branches of capitate fractures, and further surgical treatment
the radial artery. distal radius fractures undertaken. Obtaining
should be aggressively union is the best way to
sought because they result avoid instability and
from a higher-energy resulting painful arthritis.
trauma.
• Conservative management
Cast: Stress-sharing device.
Indications: Thumb spica cast immobilization is the treatment of choice for
nondisplaced or minimally displaced scaphoid fractures. The inclusion of
the thumb reduces motion at the scaphoid waist. The wrist should be
maintained in neutral flexion/extension and neutral to radial deviation
• A short-term thumb spica This is indicated for tuberosity fracture which
has a high union rate.
• A long-term thumb spica This is indicated for all other fractures. The
duration of immobilization is for 6 weeks, followed by 6 weeks of short cast
• Open Reduction and Internal Fixation Stress-shielding device.
Indications: Operative treatment is used for new displaced fractures
as well as delayed unions or nonunions.
Cast immobilization is required postoperatively. Herbert screw fixation
provides compression at the fracture site, which may shorten the
postoperative period of cast immobilization.
 ACTIVITIES
1 TO WEEK 1 FOR DISTAL JTS FOR DISTAL JTS C/L SIDE NONE
ISOMETRICS
WEEK 2 SAME AS SAME AS C/L SIDE NONE
ABOVE+DIGITS ABOVE
AROM OR
PROM+ELBOW
AROM(SHORT
CAST)
WEEK4 -6 Wrist and Elbow-Isotonic C/L SIDE NONE
thumb- (open exercises in
reduction and flexion
internal SHOULDER
fixation), STRENGTHENI
gentle wrist NG
arom and
thumb in
flexion,
extension, and
thumb
opposition.
WEEK 8 -12 Gentle arom Resistive Light activities Fwb post 12th
wrist mcp ip jts exercises to week
long flexors
and extensors
of thumb and
wrist.(post 12
w)
 Hamate #
MOI
typically caused by a direct blow to the volar proximal palm
• grounding a golf club
• checking a baseball bat
• falling on outstretched hand
Symptoms
• ulnar-sided wrist pain
• hypothenar pain
• pain with activities requiring tight grip
• INVESTIGATION
XRAY
• PA and lateral of wrist(10% sensitivity )
• carpal tunnel view
• best radiograph to see hook of hamate fracture(40%
sensitivity)
CT if xray diagnosis cannot be established
 MANAGEMENT
• Nonoperative
• immobilization 6 weeks: nondisplaced acute hook of hamate fractures
short arm ulnar gutter cast

• Operative
1.excision
• indications
• symptomatic chronic hook of hamate fractures with non-union
• hook of hamate fractures with ulnar neuritis
• high-level athletes
 MANAGEMENT
• ORIF
• indications
• acute and significantly displaced fractures in
patient's unable to tolerate reduction in grip
strength
• small-fragment headless compression or
countersunk screws
screws need to be countersunk to prevent
irritation of the deep motor branch of the
ulnar nerve
• in cases of ulnar neuritis
• neurolysis of deep motor branch of ulnar
nerve is recommended.
Metacarpal fractures
• mechanism of injury
direct blow to hand or rotational injury with axial load
high energy injuries may result in multiple fracture
• Two-part intraarticular fractures of the base of the first metacarpal
are known as Bennett's fractures
• Three-part intraarticular fractures of the base of the first metacarpal
are known as Rolando's fractures
• Three-part intraarticular fractures of the base of the fifth metacarpal
are known as reverse-Rolando's fractures .
• Fractures of the fifth metacarpal neck are known as boxer's fractures
• Cast/Splint: Stress-sharing device.
Indications: A cast or splint is the treatment of choice for stable fractures,
including metacarpal shaft and neck fractures. It is also used for
extraarticular basal metacarpal fractures, intraarticular basal fractures of
the second through fourth metacarpals, and severely comminuted
metacarpal head fractures.
• Closed Reduction and Percutaneous Pinning
indications: This is the treatment of choice for unstable metacarpal neck
fractures, unstable metacarpal shaft fractures, and most intraarticular basal
fractures of the first and fifth metacarpals. Different methods of
percutaneous pinning include intramedullary pin fixation, transfixation to
adjacent metacarpals, and crossed Kirschner wires.
• Open Reduction and Internal Fixation
Indications: This treatment is used for metacarpal shaft fractures and
intraarticular basal metacarpal fractures in which the reduction cannot be
maintained by closed means and for metacarpal head fractures in which
there is minimal comminution and the articular surface can be restored.
• Closed Reduction and Functional Bracing Stress-sharing device
Indications: These braces are placed after closed reduction in stable
fractures, usually of the metacarpal shaft, to provide three-point fixation of
the fracture while allowing motion of the metacarpophalangeal and
proximal and distal interphalangeal joints.
• External Fixation Stress-sharing device.
Indications: External fixation is used for open fractures or severely
comminuted fractures not amenable to closed reduction or internal
fixation.
Special consideration Associated injuries Long term consideration
Elderly patients are at greater risk for Collateral Ligament Injury This may occur secondary The patient needs to be
development of joint stiffness secondary to the primary injury or, most often, to treatment. warned of possible future
to the fracture and its treatment. External plaster immobilization of the degenerative joint disease
metacarpophalangeal joints must be maintained in (which is an increased risk
60 to 90 degrees of flexion to keep the collateral with any intraarticular
ligaments elongated. If flexion is not maintained, the fracture), decreased range of
collateral ligaments shorten during immobilization, motion, residual deformity,
causing the patient difficulty in flexing the decreased grip strength, and
metacarpophalangeal joint adequately after the prolonged swelling
immobilization device is removed. secondary to the injury.

Fractures involving the articular surface Soft-Tissue Injury Many fractures involving the
require an anatomic reduction to metacarpals are due to crushing injuries or
minimize the risk of decreased range of penetrating trauma, which can be associated with
motion and the development of soft-tissue injury and edema.
degenerative changes.

Metacarpal shaft fractures involving the Open #:Any lacerations associated with metacarpal
first, fourth, and fifth digits can heal with head or neck fractures should be considered open
moderate angulation without undue fractures, especially when a human bite injury is
effects because of the hypermobility of suspected.
these digits. The more proximal the
fracture is along the shaft, the less
angular deformity can be accepted
days rom strength Functional wb
activities
1 –week1 Active range of Muscle Strength C/L SIDE NWB
motion to Isometric exercises
nonsplinted digits. prescribed within
the cast of the
nonsplinted fingers
WEEK 2 RIGID ISOMETRICS TO C/L SIDE NWB
FIXATION=AROM INTRINSICS OF
TO AFF.DIGIT NON SPLINTED
DIGITS

WEEK 4-6 FULL AROM Gentle ball- Bimanual activities NWB

ACTIE PRONATION squeezing and Silly from 6th week
SUPINATION Putty exercises,
adduction and
abduction resistive
exercises of the
digits.
WEEK 6 TO 8 SAME AS ABV SAME AS ABV USE OF AFF.SIDE FWB AS TOLERATED
WEEK 8 TO 12 SAME AS ABV PRE TO DIGITS AND ADLS IN FWB
WRIST TOLERANCE
 Fracture of phalanges
• Phalangeal fractures include proximal, middle, and distal phalanx fractures and
are classified as intraarticular or extraarticular and as stable or unstable.
• Articular fractures involve the base or the condyles of the phalanx and are
subdivided into the following types: avulsion fractures with attached collateral
ligaments, shaft fractures that extend into the joint, and fractures secondary to
compressive loads. Extraarticular fractures are diaphyseal or involve the neck of
the phalanx.
Mechanism of Injury
Most phalangeal fractures are caused by direct trauma to the hand.
 Fracture of phalanges
terminal
proximal middle
tuft fractures
head fractures mechanism is usually crush injury
type I - stable with no displacement head fractures usually stable due to nail plate dorsally
type II - unstable unicondylar type I - stable with no displacement and pulp volarly
type III - unstable bicondylar or type II - unstable unicondylar often associated with laceration of nail
comminuted type III - unstable bicondylar or matrix or pulp
neck/shaft fractures comminuted shaft fractures
short oblique neck fractures transverse
long oblique apex volar angulation longitudinal base fractures
spiral shaft fractures usually unstable
transverse transverse Mechanism:
base fractures short oblique shearing due to axial load, leading to
extra-articular long oblique fracture involving > 20% of articular
intra-articular spiral surface
lateral base avulsion due tensile force of terminal
tendon or FDP, leading to small avulsion
fracture
Symptoms
Tenderness, Swelling, Bruising, crepitus, Deformity, Restricted motion
and instability
X Ray
• PA
• lateral
• Oblique: The oblique view can help diagnose fractures of the heads.
CT scan
• assess articular involvement
• amount of articular displacement
• degree of comminution
frontal oblique lateral
Tuft fracture caused due to hammer blow
 MANAGEMENT
Buddy Taping :The treatment of choice for stable fractures, including non
displaced and impacted fractures and distal phalanx tuft fractures. Splintage is
retained for 2–3 weeks, but during this time it is wise to check the position by x-
ray in case displacement has occurred.

Closed Reduction and Application of Cast or Splint This is the treatment of

choice for displaced transverse fractures that are stable after closed reduction,
as well as for stable dorsal fracture/dislocations of the proximal interphalanges.

Open Reduction and Internal Fixation: This treatment is recommended for

comminuted articular fractures or highly unstable oblique or spiral fractures.
(pin fixation,Kwire,lag screws)
Eaton-Belsky pinning through metacarpal head
Special considerations Associated injuries Long term consideration

A Elderly patients are at greater risk for Mallet fractures are distal interphalangeal The patient needs to be warned about
development of joint stiffness secondary joint flexion deformities secondary to loss possible future degenerative joint disease
to the fracture and its treatment. of the extensor mechanism of the distal (an increased risk with intraarticular
phalanx, due to either soft-tissue or bony fractures), decreased range of motion,
injury. residual deformity, decreased grip
strength, and prolonged swelling
secondary to injury.

Articular Involvement Fractures involving Many distal phalanx fractures, especially

the articular surface require anatomic tuft crush injuries, are associated with
reduction to minimize subsequent nail bed lacerations. If a subungual
decreased range of motion and hematoma involves more than 25% of
degenerative changes. the nail bed, the nail should be removed
and the hematoma evacuated.

Diaphyseal proximal phalanx fractures Boutonniere Deformity This deformity

usually have an apex that is palmer results from disruption of the extensor
angulated secondary to an imbalance of mechanism, specifically from rupture of
muscle pull. the central slip dorsally or a dorsal
avulsion fracture from the base of the
middle phalanx.
Day ROM STRENGTH FUNCTIONAL ACTIVITIES WB

Day 1-week1 AROM to the unaffected digits Isometric exercises to CL SIDE NWB
and to the fractured digit if the the intrinsic muscles of
fracture is stable the non splinted
fingers.

Week 2 Same as 1st week

Week 4 to 6 Full active and active-assistive Isometric and isotonic Bimanual activities using AS TOLERATED
range of motion to all digits. exercises to the flexors, the involved extremity are
extensors, abductors, encouraged for self-care.
and adductors of the
digit.

Week 6 to 8 Arom,aarom,prom to all digits Gentle resistive Light activities FWB

exercises to all digits.

Week 8 to 12 Full active and passive range of PRE to all digits Self care and light activities FWB
motion to all digits.
References
• Apleys system of orthopaedics and fractures 9th edition
• Stanley Hoppenfield
• Orthobullets.com