conservative management of upper limb fractures

Conservative treatment of upper limb fractures

AssessmentReductionImmobilizationFunctional activity

Basic principles in management of a closed fracture

EconomicalNo operative risksNo displacement – ends together mostly

always unite.

Why conservative?

Reduction – by applying traction – generally in the line of the limb

After reduction, it must be prevented from redisplacing until it has united. -

Plaster slabsPlaster bandages ( casts) – full circumferenceReadymade braces

What is done?

Slab – an example

Plaster splints need 10–12 layers of plaster in upper extremities

Slabs should be dipped, squeezed, when out of water, smoothed then applied with no wrinkles.

Thickness of plaster slab

Shoulder: resting at the side of the bodyElbow: 90° angle between forearm and arm,

neutral pronation/supinationWrist: neutral supination/pronation, 20°–30°

wrist extensionThumb: thumb in 45° abduction, 30° flexionMetacarpals, MCP joint, proximal phalanges:

MCP joint in 90° flexion, DIP and PIP joints in full extension

IP joints, middle/distal phalanx: full extension at IP joints

Positions in splinting

Indications –Elbow fracturesSupracondylar fractures

Above elbow slab

Extends from the middle of the upper arm to the point just proximal to the knuckles in the dorsum of the hand.

patient's forearm is held in mid prone position with the elbow in 900 flexed position.

Above elbow slab

IndicationsNon displaced fractures of the wristSoft tissue injuries to the wrist or forearmColles fracture

Below elbow slab

Extends from a point about 5 cm below the top of the olecranon to the level just proximal to the knuckles in the dorsum of the hand and the distal crease in the palmar aspect.

The forearm is held with the elbow in a 900 flexed and the wrist in the position of function of 250 dorsiflexion.

The fingers should be free to move fully at the metacarpo-phalangeal joints.

Below elbow slab

IndicationsSoft tissue injuries to 4th and 5th fingers4th n 5th metacarpal fractureFractures of 4th n 5th phalanges

Ulnar gutter slab

measure the plaster from the fifth distal interphalangeal joint to the proximal third of the forearm

Apply the wet plaster, over the padding, to the medial or ulnar surface of the forearm. 

The wrist and hand should be in a neutral position. Extend the wrist to 20° and flex the metacarpophalangeal joints to 70°.

Upper limb fractures – conservative management

Clavicle fracture

Group 1 – middle 1/3 (80%)Group 2 – distal 1/3Group 3 – proximal 1/3

Allman classification

More than 90% of clavicle fractures are successfully healed by non-operative treatment.

If the fracture is at the lateral end, the risk of nonunion is greater than if the fracture was of the shaft.

Clavicle fracture

Treatment –Board arm slingRing/quoit methodFigure of 8 bandage

Clavicle fracture

SlingSupport shoulder

girdle, raising lateral fragment upward.

Clavicle - sling

Figure of 8 bandage/brace –

Depress the medial fragment

Elderly patients tolerate clavicular bracing methods poorly

Clavicle - Figure of 8

Why sling or figure of 8?

For 4-6 weeksDuring this period, active range of motion of

the elbow, wrist and hand should be performed.

Immobilization

Acromioclavicular joint injury

Type 1 – sprain of ac ligament2- with coracoclavicular lig sprained3- with joint dislocation4 – clavicle displaced posteriorly5- displaced superiorly6 – inferior displacement

AC joint injury

Type 1-3 – conservative management4-6 – operative

Conservative managementIce packsSling for 2 weeks.

AC - conservative

Sternoclavicular joint injury

Ice for first 24 hrs.

Mild sprain – sling 3-4 daysModerate sprain – sling and swathe/ figure of

8 bandage – 1 week, then sling 4-6 weeksMedial physeal injury – sling n swathe/figure

of 8 bandage for 4-6 weeks

SC joint injury

Scapula fracture

Anatomic Type 1 – scapula bodyType 2 – acromion n coracoidType 3 – scapular neck n glenoid.

Classification

Non Surgical Treatment:     - vast majority of scapula fractures may be treated non operatively (extraarticular)     - closed reduction of these frx is usually not possible     - treatment consists of support of a sling and early motion     - most fractures will heal by 6 weeks     

Scapula fracture

A simple sling can be used

Scapula fractures

Glenohumeral dislocation

Shoulder – most commonly dislocated major joint

Anterior dislocation commonRecurrence rate – 50%

Closed reduction – Traction countertractionHippocratic techniqueStimson techniqueMilch techniqueKocher maneuver

Post reduction care – immobilzation for 2-5weeks

Anterior glenohumeral dislocation

Hippocratic technique

Milch technique

20-30min

Stimson maneuver

Subacromial Pt supine, traction appllied to adducted arm

in the line of deformityPostreduction – sling and swathe

immobilization for 3-6weeks.

Posterior glenohumeral dislocation

Luxato erectaSalute fashion – humerus 110-160 degrees

abduction and forward elevation

Reduction – traction countertraction maneuvers. Traction in line with humeral position – superiolaterally.

Immobilized in a sling for 3-6weeks.

Inferior glenohumeral dislocation

Very rareForeshortened arm held in adduction

Closed reductionTraction – inferior direction.

Superior glenohumeral dislocation

Fractures of proximal humerus

Neer classification4 parts –Greater tuberosityLesser tuberosityHumeral shaftHumeral head

Displaced if >1cm displacement/ >45 degrees angulation.

Nondisplaced Fractures<5mm of superior or 10 mm of posterior

greater tuberosity displacement in active people

<10 mm of superior displacement in non dominant arm of sedentary paients

When to put patient on non operative treatment

Nonoperative management of proximal humerus fractures usually begins with maximal support - a sling and swath equivalent worn continuously. If the patient is uncomfortable, a sitting position may be preferred for sleeping.

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.

done with asling that supports the elbow and forearm and counteracts the weight of the arm.

Additional support is provided by a swath which wraps around the humerus and the chest to restrict shoulder motion further, and keep the arm securely in the sling.

Sling and swath

Shoulder immobilizationSling and swath (A)Shoulder

immobilizer (B)Gilchrist bandage

(C)

For surgical neck fracturesWhere

disimpactation is undesirable a board arm sling is preferable

Where the fracture is disimpacted, then a cuff and collar has some potential for gravitational correction.

To reduce the risk of stiffness, immobilization should be discarded as soon as possible. This can be done progressively, beginning with elimination of the swath during the daytime and encouraging pendulum exercises.

The sling may be used on a part-time basis as soon as appropriate.

If formal physical therapy has not been prescribed, it should be considered for any patient whose range of motion is not improving as expected.

Danger - shoulder stiffness

Shaft humerus

90% of shaft fractures heal with nonsurgical management

Hanging castCoaption splintVelpeau dressingShoulder spica castFunctional bracing

Hanging castWeight of limb plus

plaster reduce the fracture and maintain reduction

Patient must remain upright/semiupright position with cast in dependent position for effectiveness.

Utilizes dependency traction and hydrostatic pressure to effect fracture reduction.

Indicated for acute treatment of humeral shaft fractures with minimal shortening.

U shaped coaptation splint/ sugar-tong splint

U shaped coaptation splint/ sugar-tong splintU – slab to the arm

and a cuff and collar to the wrist, arm bandaged to side of body

Exchanged for functional bracing 1-2 weeks after injury.

Thoraco brachial immobilization

Indicated for minimally displaced.

Passive shoulder exercises may be performed.

Velpeau dressing

Applied 1-2weeks after injury (after hanging cast/coaptation splint)

Retained until union occurs(usually 9 weeks)

Cuff and collar may be used to support the forearm.

Functional Brace

Distal humeral fractures

Supracondylar fractures

Type 1 -  undisplaced or minimally displaced fractures - simple immobilization in a plastercast without any manipulation.

Type 2 - partially displaced - manipulation followed by immobilization in a plaster cast

Type 3 - completely displaced - operative

Classification

Lateral displacement- longitudinal traction exerted by griping patient wrist n forearm.

In full extension .. Distal fragment in line with shaft – due to tension from surrounding soft tissues

Posterior displacement – thumb over olecranon.

Flex the elbow while maintaining traction.

Reduction is then held by cuff and collar in as much flexion as the presence of radial nerve will tolerate and elbow kept inside the clothing.

Correction of displacements

Posterior long arm splint in atleast 90 degrees of elbow flexion with forearm in neutral

Posterior splint immobilization for 1-2 weeks.Then hinged brace for 6 weeks, when

radiographic evidence of healing present.

Supracondylar fracture

Conservative treatmentIndicated for non displacedElderly patients who are debilitated

Transcondylar fracture

Most common distal humeral #

Intercondylar fractures

Type 1 – non displacedType 2 – slight displacement, no rotation of

fragmentsType 3 – with rotationType 4 – comminution of articular surface

Riseborough and radin classification

Indicated for nondisplaced, elderly, with significant comorbid conditions

Options includeCast immobilization Bag of bones – arm placed in cuff and collar

with as much flexion as possible after reduction. The idea is to obtain a pseudarthrosis

Intercondylar fractures

Lateral and medial condylar fractures

Milch classificationType 1 – lateral trochlear ridge left intactType 2 – trochlear ridge part of condylar

fragment

Condylar fractures

Consists of posterior splinting with elbow flexed to 90 degrees with forearm in

supination – for lateral condylar fractures pronation – medial condylar

Condylar fractures

For nondisplaced fracturesImmobilization in posterior splint for 3 weeksFollowed by elbow motion.

Capitellum fractures

Laugier’s fractureExtremely rarePosterior splinting for 3 weeksFollowed by range-of-motion exercises.

Trochlea fractures

A crepe bandage applied over wool to limit swelling and a sling for 3-4weeks is usually adequate.

Lateral – immobilization followed by elbow motion

Medial – immobilization for 10-14 days in posterior splint with forearm pronated, elbow and wrist flexed.

Epicondylar fractures

Immobilization in posterior elbow splint in relative flexion.

Until pain freeFollowed by movement and strengthening

exercises.

Fractures of supracondylar process

Elbow dislocation

Posterior dislocation is most common.

Direction of displacement relative to humerus

PosteriorPosteriolateralPosteriomedialLateralMedialAnterior

Classification

Reduction should be performed with elbow flexed while providing distal traction.

Parvins method and Meyn n Quigleys method

Post reduction x –raysPost-reduction management - Posterior

splint at 90 degrees and elevationRecovery may take 3-6 months.

Proximal forearm fractures

Immobilization of the elbow in a cast or splint is only indicated in undisplaced and stable fractures. A splint may be faster to apply, and easier to remove.

The time of immobilization should be as brief as possible to prevent stiffness of the elbow. Ideally, this would be 2 or 3 weeks.

While the patient is in the cast, finger and shoulder movements are to be encouraged.

Proximal forearm

Above elbow cast with slingAn above elbow cast is

applied with the elbow flexed 90 degrees and the forearm in mid-pronation-supination position. Either fiberglass or plaster cast material may be used.

Avoid constricting the antecubital area.

Trim the cast as needed to protect axilla and around thumb and fingers.

Secure the injured arm with a sling

Olecranon fractures

Type 1 – non displaced Type 2 – displaced – stableType 3 – displaced - unstable

Type 1 managed by non operative

Mayo classification

Long arm cast/splint with elbow in 45-90 degrees of flexion.

Gradual initiation of range of motion after 5-7 days

Cast can be removed after 3 weeks, avoiding active flexion past 90 degrees

Olecranon fracture

Radial head

Classification – mason

Type 1 – nondisplacedType 2 – marginal # with displacementType 3 – comminuted # entire headType 4 – with dislocation of elbow

Radial head fracture

SlingEarly range of motion 24-48hrs after pain

subsides.

Radial head fracture

Nonoperative treatment is indicated in simple transverse fractures with only one bone involved where reduction can be achieved and maintained.

Middle Forearm fractures

Apply a well padded long arm cast in relaxed supination of the forearm.

Apply the cast from the distal palmar crease to the mid-arm with the elbow in 90° flexion, the wrist in slight volar flexion, and the ulna in deviation.

Flatten the volar and dorsal surfaces of the forearm.

Long arm cast

Radius and ulna shaft

nondisplaced – rareLong arm cast in neutral rotation with elbow

flexed to 90 degrees.

Both radius and ulna

Where displacement is slight, conservative treatment may be used.

A long arm plaster should be applied with the hand in mid pronation.

The plaster is retained until the union is advancing(usually about 8 weeks)

Plaster

Ulna fractures

Fracture of proximal ulna accompanied by radial head dislocation.

Monteggia fracture

Type 1 – ant dislocation radial head, #ulna diaphysis

Type 2 – post/postlat dislocation radial head , # ulna diaphysis

Type 3 – lat/antlat dislocation radial head, # ulna metaphysis

Type 4 – ant dislocation radial head with # both radius n ulna within proximal 3rd at the same level.

Closed reduction and casting should be reserved only for pediatric population.

Bado classification

Isolated ulna fracturePlaster immobilization in sugar tong splint for

7-10daysFollowed by functional bracing for 8 weeksOr immobilzation in a sling with compression

wrap.

Nightstick fractures

Suitable for isolated ulnar fractures.

Timing of the change from cast to brace should be after 10 days.

The sleeve should be molded firmly into the interosseous space.

The brace should not limit elbow or wrist flexion or extension and only slightly limit pronation and supination.

The brace should be adjusted following decreasing swelling and may be removed for hygienic purposes.

Ulnar sleeve

Galeazzi # - # of radial diaphysis at junction middle n distal 1/3rd with disruption of distal radioulnar joint.

Fracture of necessity

Closed treatment associated with high failure rate.

Radial shaft

Distal forearm fractures

Distal radius fractures

Gartland and werleyFrykman - based on pattern of intraarticular

involvementFernandez – mechanism based classificationAOMayoMeloneEponymic

Classification

CollesSmithBartonChauffer’s fracture

Distal radius fractures - eponyms

Length – within 2-3mm of other wristPalmar tilt -0, dorsal angulation upto 10

degreesRadial inclination - <5 degree loss

Radiographic parameters for acceptable reduction

Colle’s fracture

A  Colles fracture, is a distal fracture of the radius in the forearm with dorsal (posterior) displacement of the wrist and hand. ( at cortico-cancellus junction)

Dinner fork deformity

Colles

Manual reductionAs a principle, the first

step in reduction is to disimpact the distal fragment by increasing the dorsal angulation.

Then, with traction applied, the distal fragment is pushed distally, and flexed, in order to reduce the palmar cortex and to restore palmar inclination. Any traction is then released.

Change the grip to allow free application of the plaster.One hand holds the thumb fully extended.The other holds three fingers (avoiding cupping of the hand) maintaining slight traction.The limb should be in full pronation, full ulnar deviation at the wrist and slight palmar flexion.

Plaster application

Colle’s cast

Smith’s fracture

The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles' fracture which the fragment is displaced dorsally. 

Garden spade deformity

Smith’s fracture

As a principle, the first step in reduction is to disimpact the distal fragment of a Smith’s fracture by increasing the palmar angulation. Then, with traction applied, the distal fragment is pushed distally, and extended, in order to reduce the dorsal cortex and restore normal inclination. Any traction is then released.

Smiths fracture

an above elbow cast is retained for 6-8 weeks. It may be changed, with careful maintenance of position, at 2-3 weeks.X-rays are taken at 5 days, 10 days and 3 weeks to check fracture reduction.

Casting above elbow

Bartons fracture

A Barton's fracture is an intra-articular fracture of the distal radius with dislocation of radiocarpeljoint.

Barton’s fracture

Bartons fracture Manual reduction With traction applied, the

distal fragment is pushed distally, and flexed in order to reduce the palmar cortex and restore palmar inclination. Any traction is then released.

The heel of one hand is used as a fulcrum. Firm pressure, directed anteriorly corrects remaining posterior displacement or anterior angulation, visible in lateral x-rays.

The above elbow cast is maintained for 6-8 weeks, but may be changed at 2-3 weeks, with careful maintenance of position. Check x-rays must be taken at 4 and 12 days to monitor fracture 

Casting above elbow

Fracture of scaphoid

Scaphoid fracture

A scaphoid cast. it goes above the patient's elbow, that it ends just proximal to his distal palmar crease and the interphalangeal joint of his thumb, and that his thumb is able to touch his index finger. 

Scaphoid cast

Tuberosity fractures: 6 weeks. At that time, check x-rays and start physiotherapy.

Undisplaced waist fractures: 8-12 weeks. If union is not achieved by this time, continue with immobilization for an extra 4 weeks.

Duration of immobilization

Fractures of hand

Stable fractures – buddy taping or splinting, with repeat radiographs in 1 week.

Unstable fractures – reduced. - immobilization with cast, cast with outtrigger splint, gutter splint or anterio-posterior splints.

Buddy strapingAdjacent non injured finger is used as a

splint.

General considerations

Fracture of metacarpels

Stable reductions - splinted in position – metacarpal-phalangeal flexion >70 degrees to minimize joint stiffness.

Metacarpal head

Fracture of metacarpelsDisplacement

usually occurs as a flexion deformity that can be reduced by exerting pressure on the metacarpal head from the palmar aspect, either directly, or using the proximal phalanx as a piston.

A splint may be applied with the hand in an intrinsic plus (Edinburgh) position and the wrist in slight extension of 20-30 degrees.

Immobilization with palmar splint

A standard forearm cast is applied, including the wrist joint in 30 degrees of extension, and the aluminium splint is incorporated in the cast.

This aluminium splint must be pre-bent to 90 degrees proximal to the level of the MCP joint of the injured finger. The finger is taped to this splint in an intrinsic plus position. Correct rotational alignment must be checked. The other fingers are not immobilized.

Immobilization with a forearm cast and finger splint

Attelle fonctionelleThis technique

allows immediate mobilization of the interphalangeal joints of all fingers. Its application, however, is difficult, and correct exercising must be supervised by a hand therapist.

Bennet’s fracture

Bennet’s fractureBennett’s injury is a

fracture subluxation of the first carpo-metacarpal joint.

During the application of the plaster, it is important to exert pressure from the dorsal aspect onto the first metacarpal base, and from the palmar aspect over the first metacarpal head.

Immobilize the wrist in a well-padded below-elbow cast with the wrist slightly extended, and the thumb immobilized in a position of slight abduction, with appropriate moulding of the cast.

Rolando’s fracture

Rolando’s fracture is a 3-part intraarticular fracture of the base of the thumb metacarpal. A T- or Y-shaped fracture, a comminuted bennett fracture or a fracture with dorsal and palmar fragments.

Rolandos fracture

Rolando’s fractureImmobilize the

wrist in a well-padded below-elbow plaster with the wrist slightly extended, and the thumb immobilized in a position of slight abduction

Finger fractures

Fractures of proximal phalynx

Reduction is achieved by applying longitudinal traction to the finger and flexing the MCP joint.Rotational malalignment is also corrected

Fracture of proximal phalynx

Immobilization with palmar splintImmobilization with a forearm cast and finger

splintAttelle fonctionelle

Proximal phalynx

Fractures of distal phalynx

Using a dorsal splint has the advantage of leaving the patient with the ability to pinch while the digit is immobilized.

Do not immobilize the PIP joint.

Fractures of distal phalynx

Baseball finger/dropped fingerFracture of dorsal lip with disruption of

extensor tendon.

Full time extension splinting for 6-8 weeks.

Mallet finger

Conservative treatment -

Mostly for undisplaced or minimally displaced fractures

Slab thickness for upper limb – 10-12 layers of plaster

Joints not included in cast/slab must be exercised.

Regular checkup x-rays to see for union.Generally immobilization for around 6 weeks.

Summary

Fracture Time for it to HealCollar bone (clavicle) 3-8 weeks

Shoulder blade (scapula)

6 weeks

Upper arm (humerus)

4-10 weeks

Lower arm (radius,ulna)

6 weeks

Wrist 4-12 weeksFingers 4-6 weeks

Time to heal

The endPresentation by Pendurthi Suneel