Fractures of Extremities

（Upper Limbs）

Dr. Zhong gang

Department of Orthopaedic Surgery

West China Hospital of Sichuan University

七、上肢骨折和手外伤

（Upper Limbs Fracture and Hand Injury）

一．知识点与教学要求

掌握：

1.肱骨干骨折，肱骨髁上、髁间骨折，桡骨远端骨折，前臂双骨折的临床表现及治疗原则；肱

骨髁上、髁间骨折的常见并发症；

2.开放性手外伤的治疗原则

熟悉：

1.肱骨干骨折，肱骨髁上、髁间骨折，桡骨远端骨折，前臂双骨折的病因、分类及发病机制；

锁骨骨

折，肱骨近端骨折的病因、分类、发病机制及治疗原则；

2.手部骨折的病因、检查、诊断方法；手部周围神经、血管、肌腱损伤的病因和诊断；断肢

（指）的

分类、急救处理及再植的适应症和禁忌症。

了解：手部功能重建的原则，腕骨脱位的诊治原则。

Scapular bone 1

Clavicle bone 1

Humuer 1

Radial 1

Ular 1

Carpals 8

Metacarpals 5

Phalanges 14

Consists of upper limb bone

1、Clavicle bone fracture

Clavicle Fractures

Clinical manifestation and diagnosis•Deformity

•Abnormal movement

•Bone crepitus

The elbow of the injured side is usually held by the other hand and

the head leans to the injured side.

May be complicated by the brachial plexus injury and the injury of

subclavicular vessels.

Clavicle FracturesTreatment

Greenstick fractures in the children and

non-displaced fractures in the adult

Held in branches for 3~6 weeks

Displaced fractures

Closed reduction + Stabilization with

transverse figure “8” bandages

Open reduction and internal fixation could be adopted when necessary

• Intolerant to the bandage stabilization;

• Recurrent displacement after reduction and affect the appearance;

• Complicated by vascular or nervous injury；

• Open fractures；

• Nonunion of the old fractures；

• Distal end fractures of clavicle and accompanied by the disruption of the

coracoclavicular ligament.

1. Standard AP View

2. Standard lateral view

2、Scapular bone fracture

3. Axillary view

CT scan and 3D reconstruction

MRI

Aniography and electromyography

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Type I : acromion (IA), spine (IB), and coracoid (IC) fractures.

Type II : extend to the spinoglenoid notch and suprascapular notch (IIA);

extend superiorly, involving the spine and superior scapular border (IIB);

running horizontally and located just inferior to the spine and glenoid (IIC);

Type III: glenoid fractures

Type IV: scapular body fractures

The Ada-Miller

fracture classification

of scapular fracture

Classification of

the scapular neck fracture

Type I : anatomical neck fracture

Type II: surgical neck fracture

Type III: inferior part fracture

and extend medially

Type I: Anatomical neck fracture

Type II: surgical neck fracture

Type III: inferior part fracture and

extend medially

Ⅰ型——盂缘

Ia-anterior border of glenoid fracture

Ib-posterior border of glenoid fracture

Goss-Ideberg

classification of glenoid fracture

TypeⅡ: Inferior part of glenoid fossa

fracture and extend to the lateral border

Tpye Ⅲ:- Superior part of glenoid fossa

and coracoid fracture

TypeⅣ: Glenoid fracture and extend

mediallay

Va:Ⅳ+ Ⅱ

Vb:Ⅳ+ Ⅲ

Vc:Ⅳ+ Ⅱ+ Ⅲ

TypeⅥ:

Comminuted fracture

of glenoid fossa

Position: lateral decubitus

Incision: transverse, longitudinal、Judet“L”incision

Posterial approach

27

Combined approaches

Female, 37 years, complex fracture of scapular and clavicle bone

2 weeks postoperation

6 months postoperation

9 months postoperation

3、Proximal humeral fracture

NEER classification

Neer type I

NEER type II NEER type III

NEER type IV

Intramedullary nail

Case：male，37 years，traffic accident

1 year postoperation

Special type of proximal humeral frature：

Adolescent

3 months postoperation

Elderly people with osteoporosis

10 months postoperation

Anatomy

Fractures lies between 2cm beneath the surgical neck and

2cm above the epicondyle

Radial groove lies at the junction of the middle and lower 1/3

part of the lateroposterior surface of the humeral shaft。

Etiology and classification

•Direct forces-

transverse or comminuted fractures of the middle shaft

•Indirect forces-

oblique or spiral fractures of the lower part of the shaft

•The displacement of the fracture is determined by

the magnitude, direction of the forces, the location of

fracture and the traction of the muscles

4、Humeral Shaft Fractures

Radial nerve anatomy

Specific clinical manifestation and diagnosis

Radial nerve injury

Drop wrist deformity

Disabled MP joint extension

Disabled extension of thumb

Disabled supination of forearm

Loss of sense or analgesia of the radial part of the hand dorsum

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5、Distal humeral fracture

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Supracondylar Fractures of Humerus

Anatomy

An anteversion of 30~50°lies between the axes of the humeral shaft

and the condyles

Common in the children younger than 10yr

Humeral a. and median n. lie anteriorly to the humeral condyles

Ulnar nerve lies medially

Radial nerve lies laterally

The injury to the epiphyseal plate of children may lead to

the varus or vulgus deformity

Supracondylar Fracture of Humerus

Etiology and classification

Mostly caused by indirect forces

Extension type (palm on land)：Fracture line extend from lower anterior to the upper posterior

Flexion type (elbow on land)：Fracture line extend from lower posterior to the upper anterior

Stable structure

unstable

60

Alonso-Llames(经三头肌内外侧入路)

APPROACHES

61

Campbell(三头肌正中劈开)

62

Campbell(三头肌劈开V-Y入路)

63

Bryan-Morrey(三头肌自内向外翻转)

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Olecranon osteotomy(尺骨鹰嘴截骨)

Alonso-Llames(经三头肌内外侧入路)

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External fixation

73

74

75

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6、Olecroanon fracture

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Schatzker classification

A CB

ED F

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Mayo classification

80

Treatment strategy

Tension band

82

83

84

Plate fixation

85

Intramedullary fixation

Direct forces—transverse or comminuted

fractures of the same level

Indirect forces—higher level radial and lower

level ulnar oblique fractures

Rotation forces—higher level unlnar and lower

level radial spiral fractures

7、Forearm fracture

Bi-fractures of Forearms

Monteggia fracture: fracture of the upper 1/3

ulna shaft with the dislocation of radial head

type I: extension type-anterior dislocation of the radial head and anterior angulation of the ulna;

typeII: flexion type-posterior or posterolateral head dislocation posterior angulation of the ulna;

type III: pediatric Monteggia-fracture of ulnar metaphysis and lateral dislocation of the head;

type IV : anterior dislocation of the radial head - fracture of the proximal radius at the same level with the ulna

Galeazzi fracture: fracture of

the lower 1/3 radius shaft

with the dislocation of ulnar

head

Colles fracture. There is fracture of the distal radius with dorsal

angulation. The articular surface is not involved.

Distal radial fracture

Smiths fracture. The distal radial fracture fragment is angulated and

displaced in a volar direction. The articular surface not involved.

Barton fracture:

A: There is a fracture of the distal radius with extension into the radial articular surface.

B: The distal fracture fragment is angled dorsally, the carpus is subluxed posteriorly.

Reversed Bartons fracture. It is in fact the volar fracture with volar

displacement which occurs more commonly. The fracture fragment varies

in size but may involve up to 50% of the articular surface.