MANAGEMENT OF

COMMON UPPER LIMB

FRACTURES IN ADULTS
Suharni C014182206
Andi Siti Bani Fitriasih C014182015
Ade Nusraya C014182153

dr. Mirza Ariandi | dr. Luky Tandio Putra

dr. DEWI KURNIATI, M.Kes, Sp.OT

Skinner E, Conboy V. Management of
common upper limb fractures in adults.
Surgery. 2019; 37(5): 258-64.
 ABSTRACT
• Upper limb fractures are common and can be disabling. We give an
account of upper limb fractures in adults commonly encountered in the
emergency department or fracture clinic, with an overview of
classification, operative and non-operative management.

• Keywords: Classification; management; upper limb fractures

 OVERVIEW
Clavicle fractures

Proximal humerus fractures

Shaft humerus fractures

Distal humerus fractures

Forearm fractures

Distal radius fractures

 00

INTRODUCTION
EPIDEMIOLOGY OF FRACTURES
Lifetime prevalence: ~40%
Annual incidence: 3.6%
Upper limb fractures: 51% of all fractures
 GENERAL TREATMENT PRINCIPLES OF
FRACTURES

INITIAL INITIAL
EXAMINATION MANAGEMENT
• Signs of fracture DETAILED • Stabilization with splint,
• Rule out open fracture cast, or sling
HISTORY TAKING • Further investigation:
• Neurovascular injury • Mechanism of injury
• Compartment syndrome Radiography
• Current social and ONGOING
mobility requirements
STABILIZATION MANAGEMENT
• Airway • Further imaging
• Breathing • Definitive
• Circulation stabilization
• Rehabilitation
 01

CLAVICLE
FRACTURES
 EPIDEMIOLOGY
Most clavicle fractures result from a fall onto the affected
shoulder, an outstretched hand/arm or a direct blow
Fractures are the most common overall at mid-shaft (65.4%), followed by
lateral fractures at 29.7% and medial fractures at 4.5%
 INITIAL ASSESSMENT
• General appearance
– Integrity of skin
– Skin tenting
• Neurovascular status
– Brachial plexus and subclavian vessels are in close proximity
• Imaging
– Simple radiographs  normally adequate. An anteroposterior (AP) and AP cephalic-
angled 15-30 cephalic
 AP view

AP cephalic view (15-30o)

 CLASSIFICATION

Medial Middle thirds

thirds (mid-shaft)
ALLMAN or NEER classification

Distal
thirds
 MANAGEMENT
• Initial management
– Sling supporting the elbow  Reduce the effect of gravity pulling down the shoulder and
the attached half of the clavicle
• Non-Operative
– Gentle ROM exercise  Start around 2 weeks
– Active ROM exercise  Start around 6 weeks
– Strengthening exercise
 MANAGEMENT
• Operative
– Absolute indications
• Open fracture
• Multiple fractures resulting in a floating shoulder
• Symptomatic mal/nonunion
• Vascular compromise (in conjunction with vascular
– Relative indications
• Brachial plexus dysfunction
• More than 2 cm of shortening
• High energy mechanism
• The poly=trauma patient
• Joint and ligament involvement
 MANAGEMENT
• Recently published randomized trials indicate that non-union rates are
likely to be higher with non-operative management
• Operative fixation tends to allow earlier return to unrestricted activity
• For very distal fractures  an acromioclavicular dislocation and manage
accordingly
• Rehabilitation  Hook plates require removal at 12 weeks
 Clavicle bridging plate

Clavicle hook plate

 02

PROXIMAL
HUMERUS
FRACTURES
 INITIAL ASSESSMENT
• Neurovascular
– Axillary nerve
• Radiography
– AP + lateral scapular ‘Y’ view
– Axillary view  if the patient is able to tolerate the examination.
– CT scan
CLASSIFICATIO
N
 MANAGEMENT
• Initial management
– Reduction
– Sedation/anaesthetic
• Non-Operative
– For elderly patients: Collar and cuff  2-3 weeks  Active rehabilitation
• Operative
– For high-demand patient with 100% displacement or comminuted fracture
– Severe soft tissue compromise
– Neurovascular injuries
– Pathological fractures
– Multiple injuries
 MANAGEMENT
• Operative
– Plate fixation
– Screw fixation
– Intramedullary nail
– joint replacement
• Post-Operative Rehabilitation
– Post-fixation: 2-3 weeks  reduced range movement in sling  gentle active-assisted
mobilization  active mobilization (6 weeks)
 03

HUMERAL
SHAFT
FRACTURES
 EPIDEMIOLOGY
3-5% of all fractures
Bimodal distribution
(younger men + high energy trauma; older women + low energy trauma)
 INITIAL ASSESSMENT
• Radial nerve assessment
– Occur in 16% of all humeral shaft fractures
– Particularly prevalent in Holstein-Lewis fracture (fractures at the junction of
the middle and distal thirds of the humerus)

• Imaging: AP-lateral radiograph

CLASSIFICATIO
N
 MANAGEMENT
• Non-operative • Laceration or ongoing compression
• Polytrauma
– Casting • Floating elbow (fracture of humerus
– Bracing with an ipsilateral forearm fracture)
– Simple sling • Progressive radial nerve deficit
• Skin/soft tissue not amenable to
• Operative bracing
– Indications • Pathological fractures
• Open fractures • Failed non-operative management.
• Vascular injury
• Neurological injury with high index
of suspicion for
 MANAGEMENT
• Operative
– Plate fixation
– Intramedullary nail
Pros on cons to both plate fixation and intramedullary nailing:

NAILI PLATE
FIXATIO
S maller in cis ion s
Lo wer inf ection r ate
NG
U s ed in p ath olo g ical f ractu res w hen the w ho le bo n e n eeds to be stab ilized
●
N
Higher union rates  where two incisions are made either side of the fracture and the plate passed between them
Intramedullary
nailing
 MANAGEMENT
• Operative
– Proximal third fractures extended into the humeral head  need to be taking
an imaging and implant selection
– Distal third fractures (Holstein-Lewis)  managed with plate fixation,
especially fracture extends into the elbow
 04

DISTAL
HUMERUS
FRACTURES
 EPIDEMIOLOGY
Fractures around the elbow account for 7% of all adult fractures  distal
humerus fractures account for 30% of that number
Bimodal distribution
(younger men + high energy trauma; older women + low energy trauma)
 INITIAL ASSESSMENT
• Should include a particularly careful assessment of neurovascular status:
– Brachial artery
– Radial, ulnar, and median nerves
• Imaging
– AP + lateral radiographs of the humerus, elbow, and forearm
– CT scans  preoperative planning
CLASSIFICATION
 MANAGEMENT
• Initial Management
– Reduction and stabilization in an above elbow plaster or brace
• Non-operative
– Holding the elbow in flexion using brace or sling 2 to 3 weeks followed by
progressive mobilization
– Very elderly patients with undisplaced two-part fractures  close watching if
managed non-operatively
 MANAGEMENT
• Operative
– Considered planning of fixation  important for comminuted type C fractures
– Open reduction/internal fixation (ORIF)
– Total elbow arthroplasty (TEA)
– Fixation of intercondylar fractures is achieved using perpendicular or parallel
double plating
 05

FOREARM
FRACTURES
 INITIAL ASSESSMENT
• Assessment and clear documentations of neurological and vascular status
• Compartment syndrome should be considered in high energy trauma
• AP and lateral radiographs
 CLASSIFICATION
• There are three main fractures in the forearm:

Isolated single Both bone

bone fracture fracture
Fracture dislocation
(Monteggia/Galeaz
zi)
Lateral view of a Lateral views of a
Monteggia fracture Galeazzi fracture
 MANAGEMENT
• Open reduction and internal fixation (ORIF)
• Deformed or displaced bone, Galeazzi and Monteggia fracture should all
be treated operatively
• Simple fracture compression plating will be feasible to achieve anatomical
reduction and subsequent primary bone healing.
 06

DISTAL
RADIUS
FRACTURES
 INITIAL ASSESSMENT/MANAGEMENT
• Neurological status
• Initial immobilization requires a padded splint, backslap or cast
• AP and lateral radiograph are sufficient for initial diagnosis and
management
• CT may be required for preoperative planning in complex cases
 CLASSIFICATION

Colles’ Fracture

Smith’s Fracture

A volar Barton’s fracture

Barton’s Fracture

A Colles’
fracture
 MANAGEMENT
• Splint, casts, Kirschner wires (K-wires) and fixation with buttress of
locking plates
• Stable and simple fracture: treated conservatively with a cast following
manipulation to reduction under regional or general anaesthesia
• Unstable fractures: K-wire or plate fixation
• Volar Barton type fractures, as unstable join injuries: operative fixation
Thank
You