Clavicle Fracture

Allman Classification:
- Group I: # of middle 1/3 (Most common) - Group II: # distal to CCL (Non-union is common) - Group III: # of proximal end clavicle.
Craig Classification: Allman Classification (Modified by Neer)
- Group I: # of middle 1/3 (80%). Most common # in both children & adults; proximal & distal segments are secured by ligamentous & muscular attachments.
- Group II: # of distal 1/3 (15%). Subclassified according to í location of í Coracoclavicular ligaments (CCLs) relative to í #:
Type I: Type II: Type III:
- Minimal displacement: Interligamentous # ( ) í conoid & trapezoid - Displaced: # medial to í CCLs (↑ incidence of nonunion) - Articular surface # of í AC joint é no ligamentous injury (may be
or ( ) í CCLs & Acromioclavicular (AC) lig. (Ligaments still intact) - IIA: Conoid & trapezoid attached to í distal segment. confused é 1st-degree AC joint separation)
- IIB: Conoid torn, trapezoid attached to í distal segment.

- Group III: # of proximal 1/3 (5%). Subclassified include:

- Type I: Minimal displacement - Type II: Displaced - Type III: Intraarticular - Type IV: Epiphyseal separation - Type V: Comminuted
Treatment:
Nonoperative: Operative:
- Most #s can be successfully treated nonoperatively. - Indications:
- Goal of ttt is Comfort & pain relief. - Midshaft clavicle # é substantial displacement & shortening (>1 to 2 cm).
- Immobilization by a sling for 4 to 6 wks. - Type II distal clavicle fractures.
- During immobilization allow active ROM of í elbow, wrist & hand. - Open #. - Skin tenting é potential progression to open #. - Associated NV compromise.
Surgical Options:
Plate & Screw fixation: Intramedullary pin (Hagie pin, Rockwood pin): Type II distal clavicle #:
- Superior or Anteroinferior aspect of clavicle. - Placed in antegrade fashion through í lateral fragment then in retrograde - Coracoclavicular fixation (Mersilene tape, sutures, wires or screws).
- Disadvantage: fashion into í medial fragment. - Fixation across í AC joint.
- More extensive exposure than intramedullary devices. - Disadvantage: - Skin erosion at í hardware insertion.
- Prominent if placed on í superior aspect of í clavicle. - Requires radiographic follow-up for hardware migration.
- Advantage: More secure fixation. - Second procedure for hardware removal.
Complications:
1. Nonunion: 0.1% to 13.0%, with 85% in í middle third. 2. Malunion.
- Risk factors: 3. Posttraumatic arthritis: may occur after intraarticular injuries to í SCJ or ACJ.
- Soft tissue interposition - 1ry ORIF. 4. Neurovascular compromise: uncommon & result from:
- Inadequate immobilization - Displacement - Initial injury
- Refracture - Severity of initial trauma - Compression of callus and/or residual deformity.

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 Acromioclavicular Joint (ACJ)
Rockwood Classification:
Type I: Type II:
- Sprain AC ligament & intact CCLs. - Torn AC ligament & Sprained CCLs é joint disruption.
- AC joint tenderness, minimal pain é arm motion. - Distal clavicle is slightly superior to acromion
- No pain in í Coracoclavicular interspace. - Tenderness is in í Coracoclavicular interspace.
- Radiographs: No abnormality. - Radiographs: Distal clavicle slightly elevated é AC joint widening.
- Stress views: CCLs are sprained but integrity is maintained.
- ttt: Nonoperative é Sling for 7 - 10 days, early ROM as soon as possible. Full ROM after 2 wks. - ttt: Nonoperative é Sling for 1 - 2 wks, early ROM as soon as possible. Full ROM for 6 wks.
- > 50% of ptns remain symptomatic at long-term follow-up. - > 50% of ptns remain symptomatic at long-term follow-up.
Type III: Type IV:
- Torn AC & CCLs é AC joint dislocation (Deltoid & trapezius are detached). - Type III é
- Distal clavicle displaced superiorly & may tent í skin. - Distal clavicle displaced posteriorly into or through í trapezius.
- Tenderness of AC joint & Coracoclavicular interspace. - More pain exists than in type III.
- Radiographs: Distal clavicle superior to í medial border of í acromion - Radiographs: Axillary view or CT: Posterior displacement of í distal clavicle.
- Stress views: Widened Coracoclavicular interspace 25% to 100% > normal side.
- ttt: Active young ptns: OR & surgical repair of CCLs - Inactive old ptns: Nonoperative ttt. - ttt: OR & surgical repair of CCLs.
Type V: Type VI:
- Type III é - Type III é
- Distal clavicle grossly & severely displaced superiorly. - Distal clavicle displaced inferior to í acromion or í coracoid
- Typically associated é tenting of í skin. - Flat shoulder é a prominent acromion + clavicle & rib #s & brachial plexus injuries.
- Radiographs: Distal clavicle superior to í medial border of í acromion - Radiographs: Inferior displacement of í distal clavicle: Subacromial or subcoracoid.
- Widened Coracoclavicular interspace 100% to 300% > normal side. - Decreased Coracoclavicular interspace compared é í normal side.
- ttt: OR & surgical repair of CCLs. - ttt: OR & surgical repair of CCLs.
Complications:

1. Coracoclavicular ossification: not associated é increased disability

2. Distal clavicle osteolysis: associated é chronic dull ache & weakness
3. AC arthritis.

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 Scapula Fractures
Anatomic Classification (Zdravkovic & Damholt Classification): Classification of Acromial Fractures (Kuhn et al.): Classification of Coracoid Fractures (Ogawa et al.):

- Type I: # of í body of í Scapula - Type I: Minimally displaced. - Type I: Proximal to í Coracoclavicular ligament.
- Type II: Apophyseal #s, including acromion & coracoid - Type II: Displaced but does not reduce í subacromial space. - Type II: Distal to í Coracoclavicular ligament.
- Type III: Superolateral angle #s, including scapular neck & glenoid - Type III: Displaced é narrowing of í subacromial space.

Classification of Glenoid fractures (Ideberg classification):

Type I: Avulsion # of í anterior rim. ORIF é screw fixation using an anterior or posterior approach (Especially if > 25% of í glenoid rim).
Type IIA: Transverse # through í glenoid fossa exiting inferiorly.
ORIF é screw fixation using an anterior approach (Especially if >5 mm articular step-off).
Type IIB: Oblique # through í glenoid fossa exiting inferiorly.
Reduction is often difficult: Require Anterior exposure for reduction + Superior exposure for superior to inferior
Type III: Oblique # through í glenoid fossa exiting superiorly & often associated é ACJ injury
screw placement, partial-thickness clavicle removal or distal clavicle resection + SSSC Stabilization if needed.

Type IV: Transverse # exiting through í medial border of í scapula ORIF for displaced #s (Especially if superior glenoid fragment displaces laterally).
Type V: Combination of a type II & type IV pattern. ORIF é screw fixation using an anterior approach (Especially if >5 mm articular step-off).
Type VI: Comminuted glenoid #.
Treatment:
Nonoperative: Most scapula #s → Sling + early ROM as soon as possible.
Operative: is controversial
Scapular body #: If NV compromise is present & exploration is required.
- Indications:
- Displaced intra-articular glenoid # involving >25% of í articular surface. Scapular neck #: If associated é displaced clavicle # → ORIF of í clavicular # results in stabilization for í glenoid #
- Scapular neck # >40° of angulation or >1 cm medial translation. Acromion #: Displaced # causes subacromial impingement → Dorsal tension banding.
- Scapular neck # é associated displaced clavicle # (Floating shoulder). Coracoid #: Complete AC separation accompanied by displaced coracoid # → ORIF of both injuries.
- Acromion # impinges on í subacromial space.
Floating shoulder: Double disruptions of í Superior Shoulder Suspensory Complex (SSSC).
- Coracoid process # that result in a functional AC separation.
Historically, Operative ttt to avoid potential instability & displacement of í glenoid.
- Comminuted # of í scapular spine.
Recently, Nonoperative ttt reported good results.

Complications: N.B.: Superior Shoulder Suspensory Complex (SSSC): is a bone-soft tissue ring ώ includes:
- Glenoid process.
1. Associated injuries: Most serious complications.
- Coracoid process.
2. Malunion: May result in painful scapulothoracic crepitus. - CoracoClavicular Ligaments.
3. Nonunion: Rare, but may require ORIF. - Distal clavicle.
- AC Joint.
4. Suprascapular n. injury: Associated é scapula body, neck or coracoid #s involving í suprascapular notch.
- Acromial process.

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 Glenohumeral Dislocation
Anterior Glenohumeral Dislocation Posterior Glenohumeral Dislocation
Incidence: - Represent 90% of shoulder dislocations. - Represent 10% of shoulder dislocations. (usually missed on initial examination).
Mechanism of Injury:
- Indirect trauma: Fall on outstretched hand é í shoulder in abduction, extension & ER (Most common). - Indirect trauma: Fall on outstretched hand é í shoulder in adduction, flexion & IR (Most common).
- Direct trauma: anteriorly directed impact to í posterior shoulder. - Direct trauma: posteriorly directed impact to í anterior shoulder (Rare).
- Congenital or acquired laxity or volitional mechanisms: may cause Recurrent anterior instability é - Electric shock or convulsive: due to í greater muscular force of í internal rotators (latissimus dorsi,
minimal trauma. pectoralis major & subscapularis) compared é í external rotators (infraspinatus & teres minor).
Clinical Evaluation:
- Pain, Tenderness é muscular spasm - Pain, Tenderness é muscular spasm
- Shoulder is held in slight abduction & ER. - Shoulder is held in slight adduction & IR (sling position) é limited ER & anterior forward elevation.
- Flattening of í lateral shoulder contour (prominence acromion & hollow beneath it) - Flattening of í anterior shoulder contour (prominence coracoid & hollow beneath it)
- Palpable mass (head) anteriorly. - Palpable mass (head) posteriorly.
- NV examination: Axillary n. & Musculocutaneous n. (sensation on í anterolateral forearm). - NV examination: Axillary n. (sensation over í lower 1/2 of deltoid). (Much less common)
Radiographic Evaluation:
- Trauma series of í affected shoulder: AP, Lateral (Scapular-Y) view & Axillary views. - Trauma series of í affected shoulder: AP, Lateral (Scapular-Y) view & Axillary views.
- Velpeau axillary: If a standard axillary cannot be obtained, í patient leaned obliquely backward 45° - Velpeau axillary: If a standard axillary cannot be obtained, í patient leaned obliquely backward 45°
over í cassette. beam is directed caudally. over í cassette. beam is directed caudally.
- Special views: - On a standard AP view, signs suggestive of a posterior dislocation include:
- West Point axillary: é patient prone í beam directed cephalad to í axilla 25° from í horizontal & 25° - Absence of í normal elliptic overlap of í humeral head on í glenoid.
medial (provides a tangential view of í anteroinferior glenoid rim). - Vacant glenoid sign: glenoid appears partially vacant (space ( ) anterior rim & humeral head >6 mm)
- Hill-Sachs view: AP view is taken é í shoulder in maximal IR to visualize a posterolateral defect. - Trough sign: Reverse Hill-Sachs lesion (Impaction # of í anterior humeral head caused by posterior
- Stryker notch view: é patient supine, í ipsilateral palm on í head & í elbow pointing straight upward í glenoid rim) in 75% of cases.
beam is directed 10° cephalad (visualize 90% of posterolateral humeral head defects). - Loss of profile of neck of humerus: Í humerus is in full internal rotation.
- CT: define humeral head or glenoid impression #s. - CT: define humeral head or glenoid impression #s.
- MRI: identify rotator cuff, capsular & glenoid labral pathology (Bankart lesion). - MRI: identify rotator cuff, capsular & glenoid labral pathology (Bankart lesion).
Classification:
- Etiologic Classification: - Etiologic Classification:
- Traumatic: Subluxation, Dislocation, Recurrent, Locked (fixed) - Traumatic: Subluxation, Dislocation, Recurrent, Locked (fixed)
- Atraumatic: Voluntary, Congenital, Acquired (due to repeated microtrauma) - Atraumatic: Voluntary, Congenital, Acquired (due to repeated microtrauma)
- Anatomic Classification: - Anatomic Classification:
- Subcoracoid - Subglenoid - Intrathoracic. - Subacromial (98%) - Subglenoid (very rare) - Subspinous (very rare).
Nonoperative Treatment: CR after administration of sedation & may require General anathesia.
Techniques include: Techniques include:
- Traction-Countertraction. - Patient is supine, traction should be applied to í adducted arm in í line of deformity é gentle lifting of í
- Hippocratic technique: é one foot placed across í axillary folds & onto í chest wall, é gentle internal & humeral head into í glenoid fossa.
external rotation é axial traction on í affected upper extremity. - If prereduction radiographs demonstrate an impaction # locked on í glenoid rim, axial traction should
- Stimson technique: Patient is prone é í affected upper extremity hanging free. Gentle manual traction be accompanied by lateral traction on í upper arm to unlock í humeral head.
or 5 lb of weight is applied to í wrist, reduction effected over 15 to 20 minutes.

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- Milch technique: Patient is supine é í upper extremity abducted & externally rotated, thumb pressure
is applied to push í humeral head into place.
- Kocher maneuver: humeral head levered on í anterior glenoid to effect reduction (not recommended
because of ↑ risk of #). Postreduction care:
Postreduction care: - Stable: Immobilization for 3 - 6 wks. (old → shorter period to avoid stiffness - Young → longer period)
- Immobilization for 3 - 6 wks. (old → shorter period to avoid stiffness - Young → longer period). - Unstable: Shoulder Spica in Abduction & external rotation for 3 - 4 wks.
- Occupational therapy (active ROM) following immobilization. - Occupational therapy (active ROM) following immobilization.
Operative Treatment:
Indications: Indications:
- Open dislocation. - Open dislocation.
- Large Anterior Glenoid rim # >5 mm. - Large Posterior Glenoid rim #.
- Displaced Greater tuberosity #. - Displaced Lesser tuberosity #.
- Irreducible dislocation (Soft tissue interposition). - Irreducible dislocation (impaction # on í posterior glenoid preventing reduction).
- Hill-Sachs lesion (An posteromedial humeral impaction #) on track of glenoid arch - Reverse Hill-Sachs lesion (An anteromedial humeral impaction #) on track of glenoid arch
- Selective repair in í acute period (in young athletes). - Selective repair in í acute period (in young athletes).

Methods: Open reduction + Methods: Open reduction +

- Bankart repair: of anterior labrum & IGHL (Open/Arthroscopic é Suture Anchor) + Capsular shift.
- Anterior bone block: Coracoid transfer (Bristow-Latarjet procedure) - Iliac Crest Autograft. - Posterior bone block.
- Putti-Platt procedure: Subscapularis advancment. - Reverse Putti-Platt procedure: Infraspinatus advancment.
- Capsulorrhaphy (Open/Arthroscopic). - Capsulorrhaphy (Open/Arthroscopic).
- Hill-Sachs lesion: - Reverse Hill-Sachs lesion:
- 20% to 40% humeral head involvement: Remplissage. - 20% to 40% humeral head involvement: Remplissage.
- > 40% humeral head involvement: hemiarthroplasty. - > 40% humeral head involvement: hemiarthroplasty.

- Voluntary dislocators: Should be treated nonoperatively é counseling & strengthening exercises - Voluntary dislocators: Should be treated nonoperatively é counseling & strengthening exercises
Postoperative: Postoperative:
- Immobilization for 3 - 6 wks. (old → shorter period to avoid stiffness - Young → longer period). - Immobilization for 3 - 6 wks. (old → shorter period to avoid stiffness - Young → longer period).
- Occupational therapy (active ROM) following immobilization. - Occupational therapy (active ROM) following immobilization.
Complications:
1. Recurrent anterior dislocation (most common): Incidence most affected by age of initial dislocation: 1. Recurrent posterior dislocation: incidence ↑ é:
- Age 20 years: 80% to 92% (lower in non-athletes) - Atraumatic dislocations.
- Age 30 years: 60% - Large Posterior glenoid rim #.
- Age 40 years: 10% to 15% - Large Reverse Hill-Sachs lesion.
2. Osseous lesions: 2. Osseous lesions:
- Anterior Glenoid rim # (Bony Bankart lesion) - Posterior Glenoid rim #.
- Humeral head # (Hill-Sachs lesion). - Humeral head # (Reverse Hill-Sachs lesion).
- Greater tuberosity #. - Lesser & Greater tuberosities #.
3. Neurovascular injury: musculocutaneous & axillary nerves, usually neurapraxia. 3. Neurovascular injury: much less common, but it may include injury to í axillary nerve.
4. Rotator cuff or Capsular tear: in old ptns. 4. Rotator cuff or Capsular tear: in old ptns.
5. Post-traumatic degenerative changes 5. Anterior subluxation: result from overtightening of posterior structures.

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 Inferior Glenohumeral Dislocation (Luxatio Erecta) Superior Glenohumeral Dislocation
Incidence: - Very rare. - Very rare.
Mechanism of Injury:
- Sever hyperabduction force: causing impingement of í neck of í humerus on í acromion ώ levers í - FFH onto UL: Extreme anterior & superior directed force applied to í adducted UL forces í humeral
humeral head out inferiorly. head superiorly from í glenoid fossa.
Clinical Evaluation:
- Humerus is locked in 110° to 160° of abduction & forward elevation (salute position). - Shortened UL held in adduction.
- Head is felt in í axilla. - Head is felt above í level of acromion.
Treatment:
- CR after administration of sedation & may require General anathesia. - CR after administration of sedation & may require General anathesia.
- Traction-Countertraction: Axial traction in line abduction é gradual swing of í arm into adduction. - Traction-Countertraction: Axial traction.
- Postoperative: - Postoperative:
- Immobilization for 3 - 6 wks. (old → shorter period to avoid stiffness - Young → longer period). - Immobilization for 3 - 6 wks. (old → shorter period to avoid stiffness - Young → longer period).
- Occupational therapy (active ROM) following immobilization. - Occupational therapy (active ROM) following immobilization.
- OR if irreducible: í head “buttonholes” through í inferior capsule & soft tissue envelope, preventing CR. - OR if irreducible.
Complications: - NV compromise: nearly in all cases but it usually resolves é reduction. - NV compromise: traction injury but it usually resolves é reduction.

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 Proximal Humerus Fractures
Epidemiology: Mechanism of Injury : Clinical Evaluation: Radiological Evaluation:
- Most common humeral #s (45%). - Fall onto outstretched hand in Elderly (Most common). - Pain, swelling, tenderness, painful ROM & crepitus. - AP, Lateral (Scapular-Y) view & Axillary views.
- Female > Male. - High-energy trauma in Younger ptns (MVA). - Upper limb held by í contralateral hand. - Velpeau axillary: If a standard axillary cannot be
- All ages especially Elderly - Less common mechanisms: - Ecchymosis (Shoulde, Chest & flank). obtained, í patient leaned obliquely backward 45°
(Osteoprosis). 1. Excessive shoulder abduction in osteoporotic ptn. - NV examination: Axillary nerve: assessed by í over í cassette. Beam is directed caudally.
2. Direct trauma → GT #. presence of sensation on í lateral aspect of í - CT: Evaluating degree of displacement, articular
3. Electrical shock or seizure. proximal arm overlying í deltoid. involvement & glenoid rim #s.
4. Pathologic #: malignant or benign. - MRI: Only to assess rotator cuff.
Classification & Treatment:
Neer Classification:
- Based on í number of displaced parts. A part is displaced if >1 cm of # displacement or >45° of angulation.
- 4 parts: Greater & lesser tuberosities, humeral shaft & humeral head.
1. One-part # (Up to 85%) 2. Two-part # 3. Three-part #
- No displaced fragments regardless of number of # lines. - Anatomic neck - Surgical neck - Greater tuberosity - Lesser tuberosity. - Surgical neck é greater tuberosity. - Surgical neck é lesser tuberosity.

- Sling immobilization. 1. Anatomic neck #: rare & difficult to treat by CR & requires ORIF: - Unstable due to opposing muscle forces
- Frequent follow X-Ray. - Young: Cancellous lag screw. - Elderly: hemiarthroplasty - CR & maintenance of reduction is difficult.
- Early shoulder motion 7 to 10 days. 2. Surgical neck #: - ORIF except in severely debilitated ptns.
- Passive ROM exercises at 3 wks. - Reducible #: CR + IF percutaneous terminally threaded pins. - Young: Locked plate
- Active ROM exercises at 6 wks. - Irreducible # or osteopenic bone: ORIF é pins, IMN or plate & screws - Elderly: hemiarthroplasty.
- Resistive exercises at 12 wks. 3. Greater tuberosity #:
- Displaced > 5 mm superior translation: ORIF é or éout RC repair
- Associated é anterior dislocation: may reduce on CR of í GHJ.
4. Lesser tuberosity #: CR unless blocks internal rotation.
4. Four-part #
- Classic - Valgus-Impacted - Fracture-dislocation - Articular surface # (Impression # - Head split)

1. Classic: ↑ rate of AVN 3. Fracture-dislocations: ↑ risk of Myosi s ossificans due to ↑ trials of CR.
- Young: ORIF by multiple K- wires, screw - 2 part fracture-dislocations: CR unless fragments remain displaced.
fixation, suture or plate & screws - 3 or 4 part fracture-dislocations: ORIF in younger ptns & hemiarthroplasty in elderly.
- Elderly: hemiarthroplasty - Anatomical neck fracture-dislocations: Hemiarthroplasty ↑ incidence of AVN.
2. Valgus impacted: ↓ rate of AVN → ORIF. 4. Articular surface #: according to humeral head involvement.
- <20 %: CR - 20% - 40%: Remplissage - >40%: hemiarthroplasty.

Complications:
1. Vascular injury: Axillary artery is í most common especially in elderly. 5. Shoulder stiffness: minimized é aggressive physical therapy & may require open lysis of adhesions.
2. Nerve injury: Brachial plexus injury & Axillary nerve injury. 6. Osteonecrosis: ↑ incidence é 3-part & 4-part #s and anatomic neck #s.
3. Chest injury: Intrathoracic fracture-dislocations may cause pneumothorax or hemothorax. 7. Nonunion: in displaced 2-part surgical neck #s é soft tissue interposition & other causes of Nonunion.
4. Myositis ossificans: in chronic unreduced fracture-dislocations & repeated attempts at CR. 8. Malunion: due to inadequate CR or failed ORIF.

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 Distal Humerus Fracture
Descriptive Classification: AO Classification:
- Supracondylar #s: Type A: Type B: Type C:
- Extension-type - Extraarticular #s: - Partial articular #s: - Complete articular #s:
- Flexion-type - 13-A1: Apophyseal avulsion - 13-B1: Sagittal lateral condyle - 13-C1: Articular simple, metaphyseal simple
- Transcondylar #s - 13-A2: Metaphyseal simple - 13-B2: Sagittal medial condyle - 13-C2: Articular simple, metaphyseal comminuted
- Intercondylar #s - 13-A3: Metaphyseal comminuted - 13-B3: Frontal - 13-C3: Articular, comminuted
- Condylar #s
- Capitellum #s
- Trochlea #s
- Lateral epicondylar #s
- Medial epicondylar #s
- #s of í supracondylar process
Intercondylar Fracture Condylar Fracture
Riseborough & Radin Classification: Milch Classification: Two types for medial & lateral condylar #s; í key is í lateral trochlear ridge.
- Type I: Non-displaced. - Type I: Lateral trochlear ridge left intact
- Type II: Slight displacement é no rotation ( ) í condylar fragments. - Type II: Lateral trochlear ridge part of í condylar fragment (medial or lateral)
- Type III: Displacement é rotation of í fragments.
- Type IV: Severe comminution of í articular surface.

Treatment: Nonoperative: Operative:

General Princeples: - Nondisplaced or minimally displaced #s, - ORIF: Displaced reconstructible #s.
- Anatomic articular reduction. - Elderly inactive ptns é severely comminuted # & severe osteopenia - Interfragmentary screws
- Stable IF of í articular surface. - Ptns é significant comorbid conditions not fit for operative management. - Dual plate fixation: one plate medially & another plate placed
- Restoration of articular axial alignment. posterolaterally, 90° from í medial plate
- Extension-type: Posterior splint in 90° of elbow flexion é forearm in neutral for 4 wks. - Total elbow arthroplasty: in elderly active ptns é unreconstructable
- Early ROM of í elbow is essential. - Flexion-type: Posterior splint in relative extension (flexion may cause # displacement). comminuted #s or osteoporotic bone.
- Lateral condylar #: Posterior splint in 90° of elbow flexion é forearm in supination. - Condylar #: Screw fixation é or éout collateral ligament repair if
- Medial condylar #: Posterior splint in 90° of elbow flexion é forearm in pronation. necessary, é attention to restoration of í rotational axes.

Complications:
1. Volkmann ischemic contracture: result from unrecognized compartment syndrome é subsequent neurovascular compromise. 4. Posttraumatic arthritis 7. Nonunion
2. Joint Stiffness: Up to a 20° decrease in í condylar-shaft angle may be tolerated owing to compensatory motion of í shoulder. 5. Ulnar n. neuropathy 8. Malunion
3. Heterotopic ossification. 6. Cubitus Valgus/Varus

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 Capitellum Fracture Trochlea Fractures (Laugier’s Fracture)
<1% of elbow #s. Displacement of í articular # into í coronoid or radial fossae may result in a block to flexion. Extremely rare. It is associated with elbow dislocation.
Nonoperative: Nondisplaced #s, Posterior splint in 90° of flexion é forearm in neutral for 3 wks. Nonoperative: Nondisplaced #s, Posterior splint in 90° of flexion é forearm in neutral for 3 wks.
Operative: Operative:
- Goal: anatomic restoration. - Goal: anatomic restoration.
- ORIF: for displaced type I #s. - ORIF: for displaced #s é K-wire or screw fixation.
- Via a posterolateral or posterior approach, screws may be placed from a posterior to anterior direction - Excision: for fragments not amenable to internal fixation.
- Alternatively, headless screws may be placed from anterior to posterior.
- Fixation should be stable enough to allow early range of elbow motion.
- Excision: for severely comminuted type I #s, most type II #s & Chronic missed #s é limited ROM of elbow.
- Relatively CI in í presence of associated elbow # owing to compromise of elbow stability.
Capitellum Classification (Modified by McKee):

- Type I: Complete osteochondral # of í capitellum, sometimes é trochlear involvement (Hahn-Steinthal #)

- Type II: Anterior osteochondral # é minimal subchondral bone: “uncapping of condyle” (Kocher-Lorenz #)
- Type III: Comminuted/Compression # of í capitellum (Grantham #)
- Type IV: Coronal shear # involving í capitellum & a section of í trochlea (McKee #)

Olecranon Fractures
Mayo Classification: Based on amount of comminution, degree of displacement & Ulnohumeral stability
Type IA: Noncomminuted
Type I: Nondisplaced or minimally displaced Nonoperative: immobilization in 30° of flexion for at least 6 wks.
Type IB: Comminuted

Displaced proximal fragment éout Type IIA: Noncomminuted Tension band wiring or cancellous screw technique.
Type II:
elbow instability Type IIB: Comminuted Plate fixation or Fragment excision & triceps advancement.

Displaced proximal fragment é Type IIIA: Noncomminuted Rigid plate technique.

Type III:
elbow instability Type IIIB: Comminuted Plating or External Fixator.

Schatzker Classification: Based on Fracture Pattern

Transverse: Avulsion # at í apex of í sigmoid notch from a sudden violent pull of both triceps & brachialis.

Transverse-impacted: A direct force leads to comminution & depression of í articular surface.

Oblique: Hyperextension injury begins at midpoint of í sigmoid notch & runs distally.

Comminuted é associated injuries: Result from direct high-energy trauma; fractures of í coronoid process may lead to instability.

Oblique-distal: Fractures extend distal to í coronoid & may lead to instability.

Fracture-dislocation: It is usually associated é severe trauma.

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 Pediatric Supracondylar Humerus Fractures
Epidemiology: Mechanism of Injury : Clinical Evaluation:
- Most common pediatric #s. - Extension type (98%): Fall onto outstretched hand → - Swollen, tender elbow é painful ROM.
- 55% - 75% of all elbow #s. Hyperextension é or éout varus/valgus force: - S-shaped angulation at í elbow: Complete displacement (Gartland Type III #).
- Male > female. - If hand Pronated → Posteromedial displacement (MC). - Pucker sign: dimpling of í skin anteriorly 2ry to penetration of í proximal fragment into í brachialis (difficult CR).
- 5 - 8 years. - If hand Supinated → Posterolateral displacement. - Preserved equilateral triangle ( ) Olecranon, medial & lateral epicondyle.
- Left > Right - Flexion type (2%): Fall onto flexed elbow. - NV examination: Median, Radial & Ulnar nerves, Capillary refill & Distal pulses & Repeated after manipulation.
Radiological Evaluation: AP view True lateral view Special views (Comparison views é contralateral elbow)

1. Baumann angle: angle ( ) í lateral condylar physeal line & a 1. Teardrop: Radiographic shadow formed by posterior margin of í 1. Jones view: When pain limits í AP view of í elbow in extension;
line perpendicular í long axis of í humerus (Normally: 15° - 20°) coronoid fossa, anterior margin of í olecranon fossa & superior Elbow is hyperflexed & í arm flat on í cassette in neutral rotation; í
2. Humeral-ulnar angle: angle ( ) í diaphyseal bisectors of í margin of í capitellar ossification center. beam directed at í elbow through í overlying forearm.
humerus & ulna (true carrying angle). 2. Diaphyseal-condylar angle: ( ) bisector of í humeral shaft & lateral 2. Internal & external rotation (Column) views: if # is suspected but
3. Metaphyseal-diaphyseal angle: angle ( ) í bisector of í humeral condyle (30° to 45°). not clearly demonstrated on routine views.
shaft & a line at í widest points of í distal humeral metaphysis. 3. Anterior humeral line: When extended distally it should intersect í 3. Fat pad signs: 3 fat pads at í elbow: Translucency in X-Ray due to
middle third of í capitellar ossification center. intraarticular effusion causing displacement of í fat pad.
4. Coronoid line: When extended proximally along í anterior border of í Anterior (Coronoid), Posterior (Olecranon) & Supinator fat pad.
coronoid process it tangent to í anterior aspect of lateral condyle.

Classification: Gartland Classification: based on í degree of displacement.

Extension Type: 98% Flexion Type: 2%
- Type I: Nondisplaced - Type I: Nondisplaced
- Type II: Displaced é intact posterior cortex; may be angulated or rotated - Type II: Displaced é intact anterior cortex
- Type III: Complete displacement; posteromedial or posterolateral - Type III: Complete displacement; usually anterolateral

Treatment:
Type I: - Immobilization in a long arm cast or splint in 60° to 90° of flexion for 2-3 wks Type I: - Immobilization in a long arm cast in near extension for 2-3 wks
Type II: - CR followed by casting; it may require percutaneous pinning if unstable é 2 lateral pins or crossed pins Type II: - CR followed by percutaneous pinning é 2 lateral pins or crossed pins
- Attempt CR & pinning; traction may be needed for comminuted #s é marked swelling - ORIF é 2 lateral pins or crossed pins (difficult CR) followed by long arm cast in 90°
Type III: Type III:
- ORIF for rotational unstable #s, open #s& those é neurovascular injury é 2 lateral pins or crossed pins of flexion for 2-3 wks then pins removed & a sling is applied for 4-6 wks
Complications:
1. Nerve injury (up to 10%): 2. Vascular injury: caused by direct injury to í brachial artery or 2ry to antecubital swelling.
- Causes: Traction injury - Volkmann ischemic contracture - Angular deformity - Incorporation into í callus. 3. Loss of motion: >5° loss of elbow motion in 5% of ptns 2ry to poor reduction or contracture.
- Mostly neurapraxia requiring no ttt (Motor recovery after 2-3 wks & Sensory recovery after 6 ms). 4. Angular deformity: Varus > Valgus.
- Median nerve/anterior interosseous nerve: most common 5. Myositis ossificans: Rare & is seen after vigorous manipulation.
- Ulnar nerve: most common in flexion-type & iatrogenic in extension-type following medial pinning. 6. Compartment syndrome: Rare.

Dr. A. Samy TAG Upper Limb | 10

 Lateral Condylar Physeal Fractures
Epidemiology: Mechanism of Injury: Clinical Evaluation: Radiographic Evaluation:
- 17% of distal humerus #s. - 5 to 10 years. - Pull-off theory: Avulsion injury of í common extensor - Pain, swelling, tenderness & LOM - AP, lateral & oblique views of í elbow.
- Often result in less satisfactory outcomes due to: origin due to a varus stress to í extended elbow. - Pain on resisted wrist extension. - Varus stress views.
- Difficult diagnosis (may be missed). - Push-off theory: Fall onto outstretched hand → axial load - Crepitus associated é supination- - Arthrogram: distinguish ( ) í lateral condylar
- LOM is more severe due to intraarticular nature. causing í radial head to impinge on í lateral condyle. pronation motion. physeal # & complete distal humeral physeal #.
- ↑ Incidence of growth disturbance. - MRI: help to appreciate # pattern.
Classification:
Milch Classification: Jakob Classification: Based on í degree of displacement.
Type I: Type II:
- Less common. - More common. - Stage I: Nondisplaced é an intact articular surface (<2 mm).
- # line courses lateral to í trochlea & into í - # line extends into í apex of í trochlea. - Stage II: Moderate displacement (2-4 mm).
capitulotrochlear groove. - Stage III: Complete displacement & rotation é elbow instability.
- It represents a Salter-Harris Type IV # - It represents a Salter-Harris Type II #
- Elbow is stable because í trochlea is intact. - Elbow is unstable because í trochlea is disrupted.
Treatment:

Jakob stage I (40%): Stable Jakob stage II: Unstable Jakobs stage II & stage III (60%):
- Immobilization in a posterior splint or long - CR é elbow extended & í forearm supinated. - ORIF é 2 crossed smooth pins diverging in í metaphysis.
arm cast é í forearm in neutral position & - Í fragment may be secured percutaneously é 2 crossed smooth pins. - Passage of smooth pins through í physis does not result in growth disturbance.
elbow flexed to 90° for 3-4 wks then ROM. - CR is unsuccessful in 50% owing to rotation (Late displacement is a - Postoperatively í elbow is maintained in a long arm cast at 60° to 90° of flexion é í
frequent complication). forearm in neutral position for 3-4 wks then pin removal & Active ROM exercises.

- If ttt is delayed (>3 wks), CR should be strongly considered, regardless of displacement due to ↑ incidence of osteonecrosis of í condylar fragment é late ORIF.

Complications:

1. Lateral condylar overgrowth é spur formation: It represents a cosmetic problem (Cubitus Pseudovarus) but not a functional problem.
2. Delayed union or nonunion (> 12 wks): most commonly in ptns treated nonoperatively.
3. Angular deformity: Cubitus Valgus > Varus due to lateral physeal arrest.
4. Tardy ulnar nerve palsy: due to cubitus valgus, Rare in acute setting, ttt by anterior transposition.
5. Osteonecrosis: Iatrogenic due to delayed surgical intervention. It results in Fishtail deformity (Persistent gap ( ) í lateral & medial ossification centers).

Dr. A. Samy TAG Upper Limb | 11

 Coronoid Fractures Radial Head Fractures
Regan & Morrey Classification: Mason Classification:
Type I: # avulsion just í tip of í coronoid Type I: Nondisplaced # of í radial head or neck.
Displaced (>2 mm) # of í head or neck
Type II: < 50% of coronoid (single # or multiple fragments) Type II:
involving >30 % of í radial head but <50 %.
Type III: >50% of coronoid Type III: Comminuted # of í radial head & neck.
Subdivided into those éout (A) & é elbow dislocation (B) Type IV: Radial head # associated é dislocation of elbow.

Radial Shaft Fractures

Galeazzi Fractures
Definition: Fracture of í radial diaphysis at í junction of í middle & distal thirds é associated disruption of í DRUJ (AKA Piedmont # or fracture of necessity because it requires ORIF to achieve a good result) .
Mechanism of Injury: Result from direct trauma to í wrist, typically on í dorsolateral aspect or a fall onto an outstretched hand é forearm pronation.
Clinical Evaluation: Radiographic Evaluation: Four major deforming forces result in loss of CR:
- Pain, swelling & tenderness over í # site. - AP & lateral radiographs of í forearm, elbow & wrist. 1. Weight of í hand: Results in dorsal angulation of í # & subluxation of í DRUJ.
- Wrist pain exacerbated by stressing of í DRUJ. - Radiographic signs of DRUJ injury are: 2. Pronator quadratus insertion: It tends to cause proximal & volar displacement.
- Neurovascular injury is rare. 1. Fracture at base of í ulnar styloid. 3. Brachioradialis: It tends to cause proximal displacement & shortening.
- Elbow ROM should be assessed (Rarely radial 2. Widened DRUJ on AP X-Ray. 4. Thumb extensors & abductors: They result in shortening & relaxation of í radial collateral
head dislocation associated é diaphyseal #). 3. Subluxed ulna on lateral X-Ray. ligament, allowing displacement of í fracture despite immobilization of í wrist in ulnar deviation.
4. > 5 mm radial shortening.

Treatment: ORIF é Plate & screw is í treatment of choice.

- Anterior Henry approach (Interval ( ) Flexor carpi radialis & Brachioradialis) provides adequate exposure of í radius # é plate fixation on í flat volar surface of í radius.
- Dorsal capsulotomy to gain access to í DRUJ if it remains dislocated after fixation of í radius:
- If DRUJ is stable: Plaster immobilization may suffice.
- If DRUJ is unstable: K-wire fixation to maintain reduction for 6-8 wks.
- Postoperativly:
- If DRUJ is stable: Early motion is recommended.
- If DRUJ is unstable: Immobilize í forearm in supination for 4-6 wks in a long arm splint or cast.

Complications:
1. Malunion: Nonanatomic reduction of í radius # é a failure to restore rotational alignment or lateral bow may 6. Radioulnar synostosis: Uncommon.
result in painful ROM & loss of supination & pronation. It may require osteotomy. - Worst prognosis is é distal synostosis & í best is é diaphyseal synostosis.
2. Nonunion: Uncommon é stable fixation, but it may require bone grafting. - Risk factors include:
3. Compartment syndrome: Clinical suspicion should be followed by compartment pressure monitoring é 1. Fracture of both bones at í same level.
emergency fasciotomy if a compartment syndrome is diagnosed. 2. Single incision for fixation of both bone forearm #s.
4. Neurovascular injury: It is usually iatrogenic. If no recovery occurs after 3 months explore í nerve. 3. Penetration of í interosseous membrane.
- Superficial radial nerve injury (beneath í brachioradialis) is at risk é anterior radius approaches. 4. Surgical delay >2 wks.
- Posterior interosseous nerve injury (in í supinator) is at risk é proximal radius approaches. 5. Crush injury.
5. Recurrent dislocation: Result from radial malreduction. 6. Infection.

Dr. A. Samy TAG Upper Limb | 12

 Ulnar Shaft Fractures
- These include Nightstick, Monteggia #s & stress #s in athletes.
Nightstick Fractures
Mechanism of Injury: Result from direct trauma to í ulna along its subcutaneous border, classically as a victim attempts to protect í head from assault.
Clinical Evaluation: Typically present é focal swelling, pain, tenderness & variable abrasions at í site of trauma.
Treatment:
- Nondisplaced or minimally displaced #s: Immobilization in a sugar-tong splint for 7-10 days followed by functional bracing for 8 wks é active ROM exercises for í elbow, wrist & hand.
- Displaced #s (>10° angulation in any plane or >50% displacement): ORIF using a 3.5-mm dynamic compression plate.
Monteggia Fractures
Definition: Fracture of í proximal ulna accompanied by radial head dislocation.
Mechanism of Injury: According to Bado classification: Clinical Evaluation: Radiographic Evaluation:
Type I: - Forced pronation of í forearm - Elbow swelling, deformity, crepitus & painful ROM - AP & lateral views of í elbow & forearm including í wrist.
Type II: - Axial loading of í forearm é a flexed elbow especially supination & pronation. - Normal findings:
- Neurovascular examination is essential, because nerve - A line drawn through í radial head & shaft should line up é í capitellum.
Type III: - Forced abduction of í elbow injury is common, especially radial or posterior - Supinated lateral: Lines drawn tangential to í radial head anteriorly &
Type IV: - Type I mechanism in which í radial shaft additionally fails interosseous nerves. especially é Type II Bado #s. posteriorly should enclose í capitellum.
Bado Classification:
Type I: - Anterior dislocation of í radial head é # of ulnar diaphysis é anterior angulation (Extension type) 60%
Type II: - Posterior/posterolateral dislocation of í radial head é # of ulnar diaphysis é posterior angulation (Flexion type) 15%
Type III: - Lateral/anterolateral dislocation of í radial head é # of ulnar metaphysis. (Unique to í pediatric) 20%
Type IV: - Anterior dislocation of í radial head é #s of both radius & ulna éin proximal third at í same level 5%
Treatment:
- CR & casting of Monteggia #s should be reserved only for í pediatric population.
- Monteggia #s require operative treatment: CR of í radial head é í ptn under anesthesia & ORIF of í ulna shaft é a 3.5-mm dynamic compression plate or reconstruction plate.
- After fixation of í ulna, í radial head is usually stable (>90%).
- Failure of í radial head to reduce é ulna reduction & stabilization is usually í result of an interposed annular ligament or rarely í radial nerve.
- If open reduction is required for í radial head, í annular ligament should be repaired.
- Associated radial head #s may require fixation.
- Postoperatively: í ptn is placed in a posterior elbow splint for 5-7 days.
- If fixation is stable, physical therapy can be started é active flexion-extension & supination-pronation exercises.
- If fixation or radial head stability is questionable, í ptn may be placed in a long arm cast é serial radiographic evaluation to determine healing, followed by physical therapy.
Complications:

1. Nerve injury: most commonly associated é Bado Type II & III injuries involving í radial &/or median nerves, as well as their respective terminal branches í posterior & anterior interosseous nerves. Surgical
exploration is indicated for failure of nerve palsy recovery after a 3 month period of observation.
2. Radial head instability: uncommon following anatomic reduction of í ulna. If redislocation occurs < 6 wks postoperatively é a nonanatomic reduction of í ulnar, repeat reduction & fixation of í ulna é an open
reduction of í radial head may be considered. Dislocation of í radial head > 6 wks postoperatively is best managed by radial head excision.

Dr. A. Samy TAG Upper Limb | 13

 Distal Radius Fractures
Epidemiology: Mechanism of Injury : Clinical Evaluation:
- Most common # of í upper limb.
- In younger ptns: FFH, MVA or sports injuries. - Swollen wrist é ecchymosis, tenderness & painful ROM.
- 1/6 of all #s treated in í ER.
- In elderly ptns: Low-energy mechanisms as a Simple fall from a standing height. - Ptns present é Variable wrist deformity & displacement of í hand in relation to í
- In elderly it correlates é osteopenia.
- Most common mechanism is fall onto outstretched hand é í wrist in dorsiflexion. wrist (Dorsal in Colles or dorsal Barton #s & Volar in Smith-type #s).
- Risk factors in í elderly:
- The radius initially fails in tension on í volar aspect é í # propagating dorsally, whereas - Ipsilateral elbow & shoulder should be examined for associated injuries.
- ↓ bone mineral density
bending moment forces induce compression stresses resulting in dorsal comminution. - NV examination should be performed é particular attention to median nerve.
- Family history
- Cancellous impaction of í metaphysis further compromises dorsal stability. - Carpal tunnel compression symptoms are common (25%) owing to traction
- White race
- Additionally, shearing forces influence í injury pattern, often resulting in articular during forced hyperextension of í wrist, direct trauma from fracture fragments,
- Female sex
surface involvement. hematoma formation or increased compartment pressure.
- Early menopause
Radiological Evaluation:
- PA, Lateral & Oblique views of í wrist should be obtained.
- Contralateral wrist views may help to assess í ptn’s normal ulnar variance & scapholunate angle.
- CT scan may help to demonstrate í extent of intraarticular involvement.
- Normal radiographic relationships:
- Radial inclination: averages 23° (13° to 30°)
- Radial length: averages 12 mm (8 to 18 mm)
- Palmar (Volar) tilt: averages 12° (0 to 28°)

Classification:
Frykman Classification of Colles #s: Based on í pattern of intraarticular involvement
Type I: Extra-articular Type II: Type I é ulnar styloid #
Type III: Involvement of í radio-carpal joint Type IV: Type III é ulnar styloid #
Type V: Involvement of í distal radio-ulnar joint Type VI: Type V é ulnar styloid #
Type VII: Involvement of í radio-carpal & radio-ulnar joints Type VIII: Type VII é ulnar styloid #
Fernandez Classification: Based on mechanism of injury
Type I: Metaphyseal bending # é í inherent problems of loss of palmar tilt & radial shortening relative to í ulna (DRUJ injury)
Type II: Shearing # requiring reduction & often buttressing of í articular segment
Type III: Compression of í articular surface éout í characteristic fragmentation; also í potential for significant interosseous ligament injury
Type IV: Avulsion # or radiocarpal #-dislocation
Type V: Combined injury é significant soft tissue involvement owing to high- nergy injury
Melone Classification of Intraarticular #s: Based on mechanism of injury (Lunate impaction injury)
Type I: Stable éout comminution
Type II: Unstable die-punch, dorsal or volar: - IIA: Reducible. - IIB: Irreducible
Type III: Spike #; contused volar structures
Type IV: Split #; medial complex # é dorsal & palmar fragments displaced separately
Type V: Explosion #; severe comminution é major soft tissue injury

Dr. A. Samy TAG Upper Limb | 14

Eponymic Classification:
- # é dorsal angulation (apex volar) of í distal radius é dorsal displacement, radial shift & radial shortening (Dinner fork deformity).
Colles #: - Mechanism of injury: Fall onto a hyperextended, radially deviated wrist é í forearm in pronation.
- Represents > 90% of distal radius #s.
- # é volar angulation (apex dorsal) of í distal radius é volar displacement of í hand & distal radius (Garden spade deformity)
Smith #: - Mechanism of injury: Fall onto a flexed wrist é í forearm in supination.
(Reverse Colles)
- Most #s are unstable & require ORIF because of difficulty in maintaining adequate CR.
- #-dislocation or subluxation of í wrist in ώ í dorsal or volar rim of í distal radius is displaced é í hand & carpus.
Barton #: - Mechanism of injury: Fall onto a dorsiflexed wrist é í forearm in pronation.
- Most #s are unstable & require ORIF é a buttress plate to achieve stable anatomic reduction.
- Avulsion # é extrinsic ligaments remaining attached to í styloid fragment.
Radial styloid #: - Mechanism of injury: Compression of í scaphoid against í styloid é í wrist in dorsiflexion & ulnar deviation.
(Chauffeur’s) - Often associated é intercarpal ligamentous injuries (Scapholunate dissociation, Perilunate dislocation).
- Most #s are unstable & require ORIF.
Treatment:
Factors affecting treatment include: Nonoperative:
1. Fracture pattern. - All #s should undergo CR, even if it needs surgical management.
2. Local factors: bone quality, soft tissue injury, # comminution, # displacement & energy of injury. - CR helps to limit postinjury swelling, pain relief & relieves median nerve compression.
3. Patient factors: age, occupation, hand dominance, medical conditions, associated injuries. Cast immobilization is indicated for:
Acceptable radiographic parameters for a healed radius in active ptn include: 1. Nondisplaced or minimally displaced #s.
2. Displaced #s é a stable # pattern ώ can be expected to unite éin acceptable radiographic parameters.
1. Carpal alignment: measured by í intersection of 2 lines on í lateral view:
3. Low-demand elderly ptns.
one along í long axis of í radial shaft & í other along í long axis of í
capitate. If í 2 lines intersect éin í carpus then í carpus is aligned. If í 2 Technique of CR (Dorsally tilted #):
lines intersect out í carpus then í carpus is malaligned. - The distal fragment is hyperextended.
2. Radial inclination: <5° loss. - Traction is applied to reduce í distal to í proximal fragment é pressure
3. Radial length: éin 2-3 mm of í contralateral wrist. applied to í distal radius.
4. Palmar tilt: neutral tilt (0°). - A well-molded long arm (sugar-tong) splint is applied é í wrist in neutral
5. Intraarticular step-off: <2 mm. to slight flexion.
- One must avoid extreme positions of í wrist & hand.
Factors associated é redisplacement after CR of a distal radius #: - The cast should leave í metacarpophalangeal joints free.
- Once swelling has subsided, a well-molded cast is applied.
1. Initial displacement of í #: ↑é í degree of displacement (particularly radial shortening). - The ideal forearm position, duration of immobilization & need for long arm cast remain controversial.
2. Age of í patient: Elderly patients é osteopenic bones tend to displace. - Extreme wrist flexion should be avoided, because it ↑ carpal canal pressure (median nerve
3. Extent of metaphyseal comminution (metaphyseal defect). compression) as well as digital stiffness.
- Displacement following CR is a predictor of instability & repeat manipulation is unlikely to result in a - Fractures that require extreme wrist flexion to maintain reduction may require operative fixation.
successful outcome. - The cast should be worn for 6 wks or until radiographic evidence of union has occurred.
- Frequent radiographic examination is necessary to detect loss of reduction.

Dr. A. Samy TAG Upper Limb | 15

Operative:
Indications:
1. High-energy injury 4. Metaphyseal comminution or bone loss
2. 2ry loss of reduction 5. Loss of volar buttress é displacement
3. Articular comminution, step-off or gap 6. DRUJ incongruity
Operative Techniques:
1. Percutaneous pinning: 2. Kapandji “Intrafocal” pinning:
- This is primarily used for extraarticular #s or 2 part intraarticular #s. - This is a technique of trapping í distal fragment by buttressing to prevent
- It may be accomplished using 2 or 3 K-wires placed across í # site, displacement.
generally from í radial styloid, directed proximally & from í dorsoulnar - The wires are inserted both radially & dorsally directly into í # site. í
side of í distal radial fragment directed proximally. wires are then levered up & then directed into í proximal intact opposite
- Transulnar pinning é multiple pins has also been described. cortex.
- Percutaneous pinning is generally used to supplement short arm casting - The fragments are thus buttressed from displacing dorsally or proximally
or external fixation. í pins may be removed 3-4 wks postoperatively, é í - This technique is simple, inexpensive & very effective particularly in
cast maintained for an additional 2-3 wks. elderly ptns.
3. External fixation: Its use has grown é low complication rates.
a. Spanning external fixation: b. Nonspanning external fixation:
- Ligamentotaxis is used to restore radial length & radial inclination, - A nonspanning fixator is one that stabilizes í distal
but it rarely restores palmar tilt. radius # by securing pins in í radius alone,
- External fixation alone may not be sufficiently stable to prevent proximal to & distal to í # site.
some degree of collapse & loss of palmar tilt during healing. - It requires a sufficiently large intact segment of
- Overdistraction should be avoided because it may result in finger intact distal radius.
stiffness & may be recognized by increased intercarpal distance on - It has better results in preserving volar tilt &
intraoperative fluoroscopy. preventing carpal malalignment & gave better grip
- It may be supplemented é percutaneous pinning of comminuted or strength & hand function than spanning external
articular fragments. fixation.
- Pins may be removed at 3-4 wks, although most recommend 6-8 wks
of external fixation.

4. ORIF:
a. Dorsal plating: b. Volar plating:
- Advantages: - Volar nonlocked plating:
- It is technically familiar to most surgeons - Its 1ry indication is shear # of í volar lip.
- Its approach avoids neurovascular structures on í palmar side. - It is unable to stabilize distal radius #s é dorsal comminution.
- The fixation is on í compression side of í # & provides a buttress against collapse. - Volar locked plating:
- Successful outcomes é earlier return of function - It is able to stabilize distal radius #s é dorsal comminution.
- Better restoration of radial anatomy than seen é external fixation. - The interval is ( ) í flexor carpi radialis & í radial artery.
- Disadvantages: It has been associated é extensor tendon complications.

Dr. A. Samy TAG Upper Limb | 16

5. Arthroscopically assisted intraarticular # reduction:
- Fractures that may benefit most from adjunctive arthroscopy are:
- Complex articular #s éout metaphyseal comminution, particularly those é central impaction fragments
- Fractures é evidence of substantial interosseous ligament or TFCC injury éout large ulnar styloid base #.
6. Adjunctive fixation: 7. Ulna styloid fractures:
- Supplemental graft may be autograft, allograft or synthetic graft. - Indications for fixation of ulna styloid are controversial.
- Adjunctive K-wire fixation may be helpful é smaller fragments. - Some authors have advocated fixation for displaced #s at í base of í ulna styloid.
Complications:
1. Median nerve dysfunction: Management is controversial: 3. External fixation Complications: reflex sympathetic dystrophy, pin tract infection, wrist & finger
- A complete median n. lesion é no improvement following # reduction requires surgical exploration. stiffness, pin site # & radial sensory neuritis.
- Median nerve dysfunction after reduction requires release of í splint & positioning of í wrist in 4. Posttraumatic osteoarthritis: results from radiocarpal & radioulnar articular injury.
neutral position; if there is no improvement, exploration & carpal tunnel release should be 5. Finger, wrist & elbow stiffness: results é prolonged immobilization in a cast or é external fixation; it
considered. requires aggressive occupational therapy to mobilize í digits & elbow while wrist is immobilized.
- An incomplete lesion in a # requiring ORIF is a relative indication for carpal tunnel release. 6. Tendon rupture: most commonly Extensor pollicis longus, even é minimally displaced injuries.
2. Malunion or nonunion: results from inadequate # reduction or stabilization; it may require ORIF é or 7. Midcarpal instability (Dorsal or volar intercalated segmental instability): may result from radiocarpal
éout osteotomy é bone graft. ligamentous injury or a dorsal or volar rim distal radius disruption.

Dr. A. Samy TAG Upper Limb | 17

 Carpal Fractures
Scaphoid Fractures Lunate Fractures
th
Incidence: Most common carpal bone (50% to 80% of carpal injuries). - 4 most carpal bone after scaphoid, triquetrum & trapezium.
Anatomy:
- Scaphoid is divided into proximal & distal poles, a tubercle & a waist - Lunate # often unrecognized until Osteonecrosis "Kienboeck disease".
- 80% of í scaphoid is covered é articular cartilage. - Lunate is í Carpal keystone because:
- Ligamentous attachments: - It rests in well-protected concavity of lunate fossa of í distal radius
- Radioscaphocapitate ligament: attaches to í ulnar aspect of í scaphoid waist. - Anchored by interosseous ligaments to í scaphoid & triquetrum
- Dorsal intercarpal ligament: provides í primary vascular supply to í scaphoid. - Distally is congruent é í convex head of í capitate.
- Major vascular supply (80% including proximal pole): Scaphoid branches of í radial artery. - Vascular supply: Proximal carpal arcade dorsally & volarly é 3 variable intralunate anastomoses.
Mechanism of Action:
- Fall onto outstretched h& é wrist in dorsiflexion, ulnar deviation & intercarpal supination (MC). - Fall onto outstretched h& é í wrist in hyperextension or a strong push é í wrist in extension.
Clinical Evaluation:
- Tenderness to palpation on í anatomic snuffbox é wrist pain & swelling. - Tenderness to palpation on í volar wrist overlying í distal radius & lunate é painful ROM.
- Provocative tests of Scaphoid #s:
- Scaphoid lift test: Reproduction of pain é dorsal-volar shifting of í scaphoid.
- Watson test: Painful dorsal scaphoid displacement as í wrist is moved from ulnar to radial deviation
é compression of í tuberosity.
Radiographic Evaluation:
- PA, Lateral, Clenched fist PA: to extend í scaphoid. - PA, Lateral, Clenched fist PA views of í wrist are often inadequate to establish í diagnosis of lunate #
- Radial oblique (Supinated AP) & Ulnar oblique views. because osseous details are frequently obscured by overlapping densities.
- Initial films are nondiagnostic up to 25% of cases. - Radial oblique (Supinated AP) & Ulnar oblique views: may be helpful
- If í clinical examination suggests # but radiographs are not diagnostic, a trial of immobilization é - CT, MRI & Technetium bone scanning best demonstrate #.
follow-up radiographs 1 to 2 weeks after injury may demonstrate í #. - MRI has been used é increasing frequency to appreciate í vascular changes associated í injury &
- Ct, MRI, Technetium bone scan & ultrasound evaluation may be used to diagnose occult Scaphoid #s. healing & is í imaging of choice for evaluation of Kienboeck disease.
Classification:
Based on # pattern (Russe) Based on displacement (Herbert) Based on location Acute #s of í lunate can be classified into 5 groups:
- Stable Acute: nondisplaced #s é no 1. Frontal #s of í palmar pole é involvement of í palmar nutrient arteries
- Waist: 70%
- Horizontal oblique step-off in any plane 2. Osteochondral # s of í proximal articular surface éout substantial damage to í nutrient vessels
- Tuberosity: 20%
- Transverse - Unstable Acute: displacement é 1 3. Frontal #s of í dorsal pole
- Distal pole: 10%
- Vertical oblique mm or more step-off scapholunate 4. Transverse #s of í body
- Proximal pole: 5%
angulation >60° or radiolunate 5. Transarticular frontal #s of í body of í lunate
- Transverse: 45%
angulation >15° Treatment:
- Horizontal oblique: 15%
- Delayed union - Nondisplaced #s: Immobilization in Short or Long arm cast or splint é follow-up to evaluate healing.
- Vertical oblique: 10%
- Established Non-union - Displaced or Angulated #s: ORIF to allow adequate formation of vascular anastomoses.
Complications:
- Delayed union, nonunion & malunion: Frequent é short arm cast compared é long arm cast, as well - Osteonecrosis " Kienboeck disease": May require operative ttt for pain relief: radial shortening, radial
as é proximal scaphoid #s. Requires Operative fixation é bone grafting. wedge osteotomy, ulnar lengthining or salvage procedures such as proximal row carpectomy, wrist
- Osteonecrosis: é #s of í proximal pole owing to í tenuous vascular supply. denervation or arthrodesis.

Dr. A. Samy TAG Upper Limb | 18

Treatment of Scaphoid Fracture:
Nonoperative: Operative:
- Indications: - Indications:
- Nondisplaced distal 1/3 & Tuberosity #s - # displacement >1 mm
- Methods: - Radiolunate angle >15°
- Immobilization in Long arm thumb spica in slight flexion & slight radial deviation for 6 wks - Scapholunate angle >60°
- Replacement é short arm thumb spica cast at 6 wks until united
- Humpback deformity
- Expected time to union: - Healing Rates: - Nonunion
- Distal 1/3: 6 to 8 wks - Distal 1/3 & Tuberosity: 100% - Methods:
- Middle 1/3: 8 to 12 wks - Waist: 80% to 90% - Screw fixation (Controversy exists about open Vs percutaneous techniques).
- Proximal 1/3: 12 to 24 wks - Proximal pole: 60% to 70% - Open techniques: Nonunions & #s é unacceptable displacement.
- Proximal #s are prone to Nonunion & Osteonecrosis - Closed techniques: Acute #s é minimal displacement.
- Management of suspected scaphoid #s: - Volar approach ( ) í flexor carpi radialis & í radial artery:
- In ptns é an injury & positive examination findings but normal X-Rays, immobilization for 1 to 2 wks - Provides good exposure for ORIF & repair of í Radioscapholunate ligament
(thumb spica) is indicated. Repeat x-rays if í patient is still symptomatic. - Least damaging to í vascular supply of í vulnerable proximal pole.
- If pain is still present but x-rays continue to be normal, consider MRI (or bone scan). Postoperative:
- If an acute diagnosis is necessary, consider MRI or CT immediately. - Immobilization in a long arm thumb spica cast for 6 wks.
Differential diagnoses:
1. Scapholunate instability. 3. Radial styloid #. 5. Carpometacarpal (basal) joint arthrosis. 7. De Quervain disease.
2. Lunate dislocation. 4. Trapezium #. 6. Flexor carpus radialis tendon rupture.

ScaphoLunate Dissociation
Incidence: Most common & significant ligamentous disruption of í wrist. It is í ligamentous analog of a scaphoid #.
Mechanism of Action: Loading of í extended carpus in ulnar deviation causing disruption of í RadioScaphoLunate & í Interosseous ScaphoLunate ligaments.
Clinical Evaluation: Radiographic Evaluation:
- Ecchymosis & tenderness on í volar wrist. - PA, Lateral, Clenched fist PA & Radial & Ulnar deviation views.
- Painful flexion-extension or ulnar-radial deviation of í wrist. - Signs on í PA view:
- Proximal pole of í scaphoid is prominent dorsally. - Terry Thomas sign: widening of í scapholunate space (Normal <3 mm).
- Vigorous grasp induces pain, decreasing repetitive grip strength - Cortical Ring sign: caused by í abnormally flexed scaphoid.
- Watson test: Painful dorsal scaphoid displacement as í wrist is moved from ulnar to radial deviation é - Signs on í Lateral view:
compression of í tuberosity. - ScaphoLunate angle: >70°.
Treatment:
- CR: Scaphoid can often be reduced é audible & palpable click, followed by immobilization for 8 wks in a long arm thumb spica cast.
- Arthroscopic reduction é percutaneous pin fixation: described é good results.
- ORIF: Combined dorsal & volar approach é reduction & stabilization dorsally using K-wires & repair of í ligaments volarly.
- Indication: Inability to obtain or maintain reduction.
Complications:
- Recurrent instability: Failure of CR or ORIF é ligament repair
- It may require ligament augmentation, intercarpal fusion, proximal row carpectomy or wrist fusion.
- It may progress to a DISI pattern or a scaphoid-lunate advanced collapse of the wrist.

Dr. A. Samy TAG Upper Limb | 19

 Perilunate Dislocation & Fracture-Dislocation
Anatomy: Mechanism of Action:
- Perilunate injuries: Load is applied to í thenar eminence, forcing í wrist into extension.
- Lunate is í Carpal keystone because it is securely attached to í distal radius by lig. attachments.
- Injury progresses through several stages (Mayfield progression):
- Greater arc injury: This passes through í scaphoid, capitate, & triquetrum & results in transscaphoid or
- It usually begins radially through í body of scaphoid (#) or thru scapholunate interval (dissociation).
transscaphoid transcapitate perilunate fracture-dislocations.
- Scaphoid bridges í proximal & distal carpal rows.
- Lesser arc injury: This passes through í radial styloid, midcarpal joint & lunatotriquetral space & results
- Dislocation ( ) í 2 rows, í scaphoid must rotate or #.
in perilunate & lunate dislocations.
- Force is transmitted ulnarly through í space of Poirier ( ) í lunate & capitate.
- Most common injury: is transscaphoid perilunate fracture-dislocation (De Quervain injury).
- Finally, force transmission disrupts í lunotriquetral articulation.
Clinical Evaluation:
- Tenderness just distal to Lister tubercle. - Wrist swelling é variable dorsal prominence of í entire carpus in cases of frank perilunate dislocation.
Radiographic Evaluation:
- Diagnosis can often be made éout accompanying radiographs, but PA & lateral views should be obtained to confirm í diagnosis & rule out associated injuries.
- PA view: Dislocated lunate appears to be wedge-shaped é an elongated volar lip.
- Loss of normal carpal greater & lesser arcs & abnormal widening of í scapholunate interval are noted.
- Lateral view: “spilled teacup sign” occurs é volar tilt of í lunate.
- Clenched-fist PA view: obtained after CR of í midcarpal joint is useful for checking residual scapholunate or lunotriquetral dissociation as well as #s.
- CT, MRI & Arthrography: are generally unnecessary but may be useful in defining injury pattern.
Classification:
- A sequence of progressive perilunate instability is seen as í injury spreads:
- From í ScaphoLunate joint (RadioScaphoLunate ligament) → Midcarpal joint (RadioScaphoCarpal ligament) → LunoTriquetral joint (Distal limb of
RadioLunoTriquetral ligament) → Dorsal RadioLunoTriquetral ligament → Volar dislocation of í lunate.
- Stage I: Disruption of ScaphoLunate joint: RadioScaphoLunate & Interosseous ScaphoLunate ligaments are disrupted.
- Stage II: Disruption of Midcarpal (CapitoLunate) joint: RadioScaphoCapitate ligament is disrupted.
- Stage III: Disruption of LunoTriquetral joint: Distal limb of RadioLunoTriquetral ligament is disrupted.
- Stage IV: Disruption of RadioLunate joint: Dorsal RadioLunoTriquetral ligament is disrupted, ultimately causing Volar dislocation of í Lunate.
Treatment:
- CR: should be performed é adequate sedation. - CR & Pinning:
- Technique: - Lunate is reduced & pinned to í radius in neutral alignment.
- Longitudinal traction is applied for 5 to 10 minutes. - Triquetrum or scaphoid can then be pinned to í lunate.
- For dorsal perilunate injuries: Volar pressure is applied to carpus while counterpressure to lunate. - Transscaphoid perilunate dislocation:
- Palmar flexion then reduces í capitate into í concavity of í lunate. - This requires reduction & stabilization of í fractured scaphoid.
- Early surgical reconstruction: if swelling allows. Immediate surgery if median n. compromise. - Most of injuries are best treated by open volar & dorsal reduction & repair of injured structures.
- Delayed surgical reconstruction: if early intervention is not feasible. - Open repair may be supplemented by pin fixation.
Complications:

1. Chronic Perilunate injury: May result from untreated or inadequately treated dislocation or Fracture- 2. Median neuropathy: May result from carpal tunnel compression, Require surgical release.
dislocation resulting in chronic pain, instability & wrist deformity. 3. Posttraumatic arthritis: May result from initial injury or secondarily from retained osseous
ttt: Salvage procedure such as proximal row carpectomy or radiocarpal fusion. fragments.

Dr. A. Samy TAG Upper Limb | 20