Upper limb fracture

WOMEN'S BREAKING

Outline

Is kind fracture The most common in the shoulder region, accounting for 35-43% fractures in the shoulder region and about 10% in general fractures. The body has two collarbones located between the ribcage (sternum) and shoulder blades (shoulder blades), connecting the arms to the body. The junction between the middle 1/3 and the outer 1/3 is a transitional area that changes the cross-section, this is the weakest position of the clavicle, which is easy to break. The brachial plexus and subclavian blood vessels are important below and behind the clavicle, however, these structures are rarely injured in clavicle fracture, although the head may be displaced during fracture. The most common causes are falls and traffic accidents. 80% injury mechanism is indirect such as falling on the shoulder, supporting the hand in the shoulder position, the remaining 20% is usually caused directly and usually broken open. This is a very easy fracture bone healing. However, if there is a lot of deviation or there is no collarbone, the shoulder belt will be weak.

Diagnose

clinical

Based on the mechanism of injury: direct or indirect injury to the shoulder area. Three sure signs of a fracture:

• Deformation (ladder type)
• Bone crunch marks
• Abnormal movements.

Palpable sign of discontinuity of the clavicle.

Measure the relative and absolute lengths of change with respect to the healthy side. Three uncertain signs of a fracture:

• Swollen, bruised collarbone
• Loss of ability shoulder same side
• Painful.

Pay attention to vascular and neurological examination to avoid missing lesions.

Subclinical

X-ray The straight plane of the clavicle helps determine the type of fracture and the fracture line.

In some difficult cases, it is necessary to scan the clavicle at a 40-degree angle (the collarbone will not overlap the ribs).

Classify

According to Allman divided into three anatomical regions: the inner third, the middle third, and the outer third. However, displacement, fracture, or injury cannot be predicted.

Craig modified the Allman and Neer classification as follows:

• Group I: fracture of the middle third of the clavicle, the most common account for 80%
• Group II: fracture of the outer third of the clavicle accounts for 12 - 15%. There are four types:
  • Type 1: minimal displacement, fracture line between sacroclavicular ligaments and crow's feet
  • Type 2: Displacement secondary to fracture in the cochlear ligament, divided into:
    • Type 2A: conical ligaments and ladders
    • Type 2B: torn cone ligament, remaining ladder ligament
  • Type 3: facet joint fracture
  • Type 4: fracture in children, ligaments are still attached to the periosteum, distal displacement
• Group III: fracture of one third of the inner third accounts for about 5%
  • Type 1: minimum displacement
  • Type 2: severe displacement (torn ligament)
  • Type 3: intra-articular fracture
  • Type 4: bone fracture in children
  • Type 5: broken.

Treatment, monitoring, re-examination

Conserve:

• Indications: undisplaced or minimally displaced clavicle fracture (< 1/2 body)
• Method: wear the 8 belt for about 4-6 weeks, can be combined with elastic tape to limit the mobility of the collarbone
• Physiotherapy training manual
• Follow-up after 1 week, 3 weeks, 6 weeks, 12 weeks.

Surgery:

• Point:
  • Highly displaced clavicle fracture (≥ 1/2 body)
  • Fracture of the outer clavicle
  • Threat of skin puncture, open fracture, damage to nerve vessels, emergency surgery
  • No bone healing
  • Another factor: the patient wants a quick return to normal activities, aesthetically.
• Method:
  • Open surgery combines the internal bone with a screw brace or an intramedullary nail.
• Monitor:
  • Postoperative wound, suture removed after 10-14 days
  • Guidelines for physical therapy after surgery
  • Follow-up after 1 week, 3 weeks, 6 weeks, 12 weeks.

Symptoms

• Early complications:
  • Skin puncture => open fracture
  • Injury to the brachial plexus: due to tension or pressure, stretching or rupture. Patient loses sensation of total or partial paralysis of upper extremities
  • Injury to subclavian artery and vein: appearance of large hematoma, loss of radial pulse
  • Injury to the top of the lung: causing pneumothorax, hemothorax
  • Postoperative infection.
• Late complications:
  • Misalignment
  • Prosthetic joints: rare, requiring chiropractic surgery, combined with spongy bone graft
  • Shoulder stiffness: do motionless Long time no physical therapy, or tendon damage rotator.

BREAKING BENEFITS OF HANDS

Outline

Là những gãy xương trong vùng giới hạn từ dưới cổ phẫu thuật đến trên hai lồi cầu xương cánh tay. Chiếm khoảng 3% các loại gãy xương, hầu hết là do chấn thương năng lượng cao. Đặc điểm của loại gãy này là có nhiều biến chứng, trong đó có hai biến chứng chính là: liệt thần kinh quay và khớp giả.

Pathology

Displacement of the fracture involves the muscles attaching to the bone and pulling. Fracture of the upper third is divided:

• Fractures above the attachment of pectoralis major muscle: proximal fractures are outward due to contraction of supraspinatus muscle, distal fractures are displaced into the axillary cavity by contraction of pectoralis major muscle.
• Fractures below the attachment of the pectoralis major: the proximal fracture is displaced inward by the contraction of the pectoralis major, the distal fracture is displaced outward and upward by the deltoid muscle contraction.
• Middle 1/3 fracture: the proximal fracture is displaced by contraction of the deltoid muscle and anteriorly by the pectoralis major, the distal fracture is displaced upward inward due to the contraction of the brachiocephalic muscle.

clinical

• Three sure signs of a fracture:
  • Deformation
  • Abnormal movements
  • Bone crunching sound.
• Three uncertain signs of a fracture:
  • Sharp pain at the fracture
  • Swollen bruises
  • Loss of ability.

If the fracture does not move, look for signs of pain from a distance.

Vascular and neurological examination is required to avoid missing lesions (pay attention to the radial nerve).

Subclinical

X-ray of the humerus straight, paying attention to the two joints at the two ends of the broken bone: helps determine the fracture location, fracture line and displacement.

Treatment

Conserve

- Point:

Short husband < 3 cm

Fold angle < 20 degrees

Rotate < 30 degrees.

- Method:

Immobilize with suspension powder, Velpeau powder, forearm arm and shoulder powder for 6-8 weeks

Surgery

• Point:
  • Break type:
    • Short husband ≥ 3 cm
    • Fold angle 20 degrees
    • Rotate 30 degrees
    • Broken in many pieces
    • Pathological fracture
    • Fracture with injury to the shoulder joint, elbow joint.
  • Combined damage:
    • Open fracture
    • Damage to blood vessels and nerves
    • There is a fracture of the forearm on the same side
    • Broken two arm bones.
• Method:
  • Open surgery, internal bone fusion with screw braces, intramedullary nailing with dowels
• Monitor:
  • Postoperative wound, suture removed after 10-14 days
  • Do physical therapy after surgery soon
  • Re-examination after 1 month, 3 months, 6 months, 12 months,...

Symptoms

Liệt thần kinh quay: chiếm tỉ lệ 10 – 18% trong gãy xương cánh tay.

• Liệt vận động: mất duỗi cổ tay, mất duỗi bàn ngón tay, mất duỗi ngón cái
• Sensory paralysis: loss of sensation in the back of the hand between fingers I and II
• Hand pose with stork neck
• If necessary, emergency surgery should be indicated to decompress decompression or nerve suture if broken.

Prosthetic joints: often due to dislocation, or software inserted into the fracture.

BREAKING BOTTOM LINES WITH HANDS

Outline

Bilateral forearm fractures account for 15–20% fractures in the forearm region. Seen in all ages. This is a type of fracture with relatively complicated displacement, especially the upper third fracture, difficult to correct.

Cause and Mechanism

Usually due to falls, fights, traffic accidents.

• Direct mechanism: fall hitting the forearm on the hard ground, raising your hand to block the blow, ...

The bone often breaks across both bones in the same position.

• Indirect mechanism: Falling against the elbow and elbow bends and bends the two bones, causing cross fracture, torsion, and ladder fracture. Two bones often break in two different places. The ulna fracture is low, the radial bone is high.
• Mixed mechanism: both direct and indirect, causing complex fracture types: two-stage fracture, third fragment fracture, etc.

Classify

• According to the fracture location on the radial bone divided:
  • Fracture of the upper third: fracture above the pronation round muscle attachment
  • Fractures of the middle and lower thirds: fractures below the attachment of the pronation round and the quadriceps
• The meaning of this classification is to assess the possibility of more or less deviation
  • Fracture of the upper third: proximal segment in full supine position due to short suprapubic and biceps pulls, distal proximal segment due to circular pronation and square pronation
  • Lower 2/3 fracture: the proximal segment is slightly supine because in addition to the two supraclavicular muscles, there is also the opposite involvement of the circular pronation, the distal proximal segment because of the square pronation
• Clinical forms
  • By location: as above
  • By age: fractures in adults
  • Bone fractures in children: morphological fracture, the radial bone is bent without the fracture line and in the fresh branch fracture, only one side of the cortical bone is broken, the other is only bent
  • Closed fracture or open fracture.

Diagnose

• Medical history
• Cause and Mechanism
• Clinical signs and symptoms
• Includes sure and uncertain signs.

Sure sign

• Deformation: angled, short, ladder deformation
• Cracking sound: detected when looking for sharp pain or unusual movement
• Abnormal movements.

Uncertain sign

• Sharp pain point: if there is a fracture, it indicates the fracture location
• Swelling, loss of function: this is a warning sign, an indicator, need to check other signs
• Painful remote percussion: difficult to perform, only if there is no definitive sign of fracture.

Subclinical

• X-ray: take two planes of the face and side. Both put the forearms in the supine position and take the joints at both ends. X-ray film shows the exact location of fracture, fracture line and displacement. Based on that, we have a treatment plan.

Treatment

There are two main methods of conservative treatment and surgical treatment:

Conservative treatment

Điều trị bảo tổn bằng cách nắn kín và cast cánh – bàn tay.

1. Should be placed in the appropriate forearm position depending on the fracture location: if the upper 1/3 of the forearm is broken, let it be completely supine, and the lower 2/3 of the forearm should be slightly supine.
2. Immobilization: wing – leg – elbow flexed 90^o
3. Conservative treatment usually has good results in low displacement fractures, lower 2/3 fractures, and pediatric fractures.

Surgical treatment

Surgery is aimed at precise reshaping and using bone fusion instruments (such as nails, splints, screws) to immobilize the broken bone.

• Advantage:
  • Correction of bones, restoring the original anatomical shape
  • It is possible to fix broken bones firmly (using AO braces) to avoid immobilization of joints, helping patients to exercise early and quickly. Rehabilitation.
• Weakness:
  • Possible infection, inflammation of the bone
  • Possible further anatomical damage and scarring of the hand
  • There may be complications from anesthesia, anesthesia, etc.
• Commonly used bone fusion surgery is:
  • Screw braces for radial and ulnar bones
  • Screw brace for radial bone, Rush nail for ulna
  • Rush nail or intramedullary nail of both bones
  • Nails are usually not fixed firmly, so a 1-month strengthening cast is needed
  • In these open fracture, surgical attention is to cut the wound, fix the broken bone, usually using a cast, fix it outside or only minimal bone should be combined to keep the bone shaft and strengthen the cast. Limit the use of complex bone combinations inside.

Symptoms

• Early complications:
  • Traumatic shock and fatty vascular occlusion are uncommon unless multiple other injuries are associated. Common complications are:
    • Cavity compression: four-compartment forearm, usually anterior compartment compression (Volkmann syndrome)
    • Compression of blood vessels, nerves
    • Perforation of the skin leads to an open fracture.
• Late complications:
  • Displacement: common due to incomplete displacement or secondary displacement in the cast without detection, dislocation can be: short overlap, angle flexion, rotation or two bones together (interstitial cantilever, cantilever. letters X, K, …), this deviation causes loss of head function.
  • Prosthetic joints: less common, usually due to:
    • Compression of soft tissue on both ends of broken bones
    • Multiple fractures, far deviated fragments
    • Loss of bone (open fracture)
    • Combination of unstable bones but for early exercise
    • Poor nutrition, eg fracture of the lower third of the ulna.
• Volkmann's syndrome: due to poorly treated compartment compression.
• Malnutrition syndrome: due to long-term immobility and lack of exercise, leading to muscle atrophy, osteoporosis restricts joint movement.

Follow-up, functional recovery after treatment

If it is well shaped and immobile, the bone will heal after two months. Regular exercise during immobilization helps to restore good function. Pay attention to correct forearm pronation.

Time of immobilization with powder: 8-12 weeks, children: 4-6 weeks.

If after this time the bone has not yet healed, you can be immobilized for another 2-4 weeks. If it still does not heal, there may be delayed healing or prosthetic joints.

In the type of fresh branch fracture in children, it is necessary to straighten the remaining cortical bone, then cast as other forearm fractures.

Clinical forms of forearm fractures

Simple fracture of a radial or ulnar bone

Fractures of one radial or ulnar bone are less common than fractures of both bones. Maybe because the force of impact is not strong enough to break the remaining bone. However, it is necessary to carefully examine the superior and inferior radial joints to avoid missing injuries in these two places.

Fractures of the middle third of the radial bone or the lower third of the ulna are common.

Clinically, patients have incomplete functional loss, rarely see visual distortions, can see deformities to the touch (such as stairs), swelling, sharp pain in the fracture area and sometimes a crunching sound. Longitudinal compression of the remaining bone and joints should be painless. X-ray of the entire forearm should be taken, transverse or diagonal fractures may be seen, usually with little displacement (if the fracture is highly displaced, it is difficult to straighten).

Treatment: conservative treatment with a cast of the arm - forearm - hand. If that fails, surgery must be performed to combine bones, using Rush nails or screw braces.

The prognosis is usually good if the correction is good.

Fractures of the lower third of the ulnar bone have a risk of prosthetic joints or delayed healing because of poor nutrition.

The time of immobility is like breaking two bones of the forearm.

Fracture of Monteggia

Characteristic

• Fracture of the upper third of the ulna with rotator cuff dislocation (due to rupture of the annular ligament), was first introduced by Monteggia in Milan in 1814. In treatment, if it is late, it is often difficult to straighten. Long-term casts often cause stiffness of the elbow joint, if the fixation is not stable, early exercise is easy to dislocate and there is a high risk of pseudo-ulnar joint.

Cause and Mechanism

• Monteggia dislocations have both direct and indirect mechanisms. The ulna fracture is caused by direct force, and the radial bone is dislocated by indirect force. The most common cause is the patient being hit directly on the forearm and raising the hand to support it. The same can also be caused by a fall hitting the forearm on hard ground in the elbow flexion position.

Classify

• There are four types of Bado degrees:
  • The radial head was dislocated anteriorly, the ulna fracture was angled forward, accounting for 60% cases
  • The radial head is dislocated posteriorly or posteriorly, the ulnar fracture is angled anteriorly, accounting for 15%
  • The radial head is displaced externally or anteriorly, fracture of the medulla oblongata at the upper end of the ulnar bone accounts for 20%
  • The radial head is dislocated anteriorly with fracture of both the radial and ulnar bones.
• Or it is possible to divide the Monteggia fracture into two bodies:
  • Curvature: radial head dislocated anteriorly, ulnar fracture flexes posteriorly (common)
  • Folded form: the radial head is dislocated posteriorly, the broken ulna is anteriorly angled (uncommon).

Diagnose

• Mechanism of injury
• Clinical symptoms:
  • Look for symptoms that indicate ulnar fracture and superior radial dislocation
  • Signs of ulnar fracture:
    • Painful swelling of the upper third of the ulna
    • Anterior flexor (flexor) or anterior (flexor) flexion deformity is sometimes seen only when palpated along the upper third of the ulna.
    • Signs of radial-ulnar dislocation: manifested by brachial-rotator cuff dislocation or rotator cuff dislocation: the radial head is no longer in its normal position (in front of the superior condylar process when the elbow is flexed and below it when the elbow is extended). . The patient has limited forearm pronation.
  • X-ray: X-ray film confirmed the fracture of the upper third of the ulnar bone and dislocation of the radial head (loss of the brachio-radial joint space, the dot i (of the condyle) is not located at the apex of the i (cap) turn).

Treatment

Can be treated conservatively or surgically:

Conserve: cast cast on arm - leg - elbow flexed 90 degrees, forearm supine. Keep the dough for 3 weeks, if the rotator cuff is not dislocated, keep the dough for another 3-5 weeks in neutral forearm position.

Surgery:

• If manipulation does not come in, surgery should be done early to reposition the joint and fuse the ulna. The broken ulna will be fixed with a Rush nail (if it has a horizontal fracture) or a screw brace (if it has a cross or multiple fracture).
• If the rotator cuff is easily dislocated, it is necessary to reconstruct the annular ligament
• In case of late arrival, the rotator cuff is difficult to straighten (if it is pressed, it is easy to cause stiffness later), it is recommended to remove the radial head.
• If the rotator cuff is not easily dislocated, the patient should be exercised early after surgery to avoid pronation.

Prognosis and complications

• With good manipulation, the patient will regain motor function. However, there are also many early complications:
• Displacement, ulnar prosthetic joint
• The radial head is still displaced, the patient has lost the pronation function of the forearm and cannot reach the elbow maximally.
• Stiffness of the elbow joint; due to many causes of ossification around the joint such as rough manipulation, drug application, ...

Galéazzi dislocation

This is a fracture of the lower third of the radial bone with a dislocation of the lower ulnar. Cause and mechanism: Usually due to falls against extended wrists. Anatomical damage: include:

• Fracture of the lower third of the radial bone, tear of the interosseous membrane, dislocation of the lower ulnar radial, rupture of the triangular ligament, or fracture of the ulnar process.

Diagnose

Based on clinical symptoms and radiographs.

• Clinical symptoms: swelling, pain and deformity of the lower third of the radial bone. The deformity is very typical: forearm flexed outward, wrist pronation toward radial bone. The brooch turned up higher than the cylindrical apex.
• X-ray: confirm the diagnosis of the above lesions.

Treatment

There are two main methods:

• Conservative treatment: closed compression and cast of the arm - forearm - hand is indicated in cases of nondisplaced fracture.
• Surgical treatment: surgery aimed at correcting and using bone fusion instruments (such as nails, splints, screws) to fix broken bones. Indicated in cases of fracture with displacement.