© Springer-Verlag France 2015
Cyril Mauffrey and David J. Hak (eds.)Passport for the Orthopedic Boards and FRCS Examination10.1007/978-2-8178-0475-0_10Upper Extremity Trauma
(1)
Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA
1 Sternoclavicular Dislocations
Take-Home Message
Joint stability depends on the integrity of ligamentous structures.
Anterior dislocation most common; majority remain unstable but asymptomatic.
Posterior dislocation may present with dyspnea, dysphagia, tachypnea, or stridor.
Assess for associated pneumothorax and injury to the trachea, esophagus, or major vascular structures.
Imaging studies: serendipity view and CT scan.
Thoracic surgery should be available prior to undertaking any closed or open reduction procedures.
General
High-energy chest wall injury (MVA, contact sports).
Associated injuries: pneumothorax, nerve injury, injury to the trachea, esophagus, or major vascular structures.
Joint stability depends on the integrity of ligamentous structures.
Posterior capsular ligament: anterior/posterior stability
Anterior sternoclavicular ligament: primary restraint to superior displacement of the medial clavicle
Costoclavicular ligaments: resist superior/inferior rotation and medial-lateral displacement
Intra-articular disk ligament: prevents medial clavicle displacement, secondary restraint to superior clavicle displacement
Imaging Studies
Serendipity view x-ray (40° cephalic tilt)
Anterior dislocation: affected clavicle above contralateral clavicle
Posterior dislocation: affected clavicle below contralateral clavicle
CT scan
Study of choice
Allows assessment of mediastinal structures
Classification
Anterior dislocation
Deformity with palpable bump, prominence increases with abduction and elevation
Posterior dislocation
May compress mediastinal structures and present with dyspnea, tachypnea, dysphagia, stridor, or venous congestion or diminished pulse of the affected upper extremity
Chronic dislocation
Anterior or posterior sternoclavicular joint dislocations >3 weeks old
Treatment
Nonoperative
Consider in atraumatic and chronic dislocations.
Accept deformity, local symptomatic treatment, sling for comfort, and return to unrestricted activity in 3 months.
Closed reduction under general anesthesia
Thoracic surgery should be available prior to any manipulation.
Acute anterior dislocations
Reduction maneuver: abduction, extension, and direct pressure over the medial clavicle.
Stable reduction: sling and swath for 6 weeks; return to activities at 3 months.
Unstable reduction: accept deformity (preferable) vs resect medial clavicle.
Acute posterior dislocations
Reduction maneuver: abduction, extension, and anterior traction on the medial clavicle with towel clip.
Stable reduction: sling and swath for 6 weeks, consider figure of eight brace, and return to activities in 3 months.
Unstable reduction: resect medial clavicle (preferable) vs surgical stabilization.
Operative
Thoracic surgery should be available prior to any open procedure.
Open reduction with soft tissue reconstruction vs surgical fixation
Consider in unstable posterior dislocations with compromise of mediastinal structures.
Smooth wires should not be used to stabilize the joint because of the risk of migration into the thorax.
Complications
Recurrent instability of the SC joint: consider tendon graft reconstruction.
SC joint arthrosis: treat with medial clavicle excision.
Bibliography
1.
Bicos J, Nicholson GP. Treatment and results of sternoclavicular joint injuries. Clin Sports Med. 2003;22(2):359–70. Review.
2.
Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009. p. 1757–8.
3.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 705.
4.
Wirth MA, Rockwood Jr CA. Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg. 1996;4(5):268–78.
2 Clavicle Fractures
Take-Home Message
Clavicle fractures are common injuries that most often occur in the middle third.
Open clavicle fractures have high rates of associated pulmonary and closed head injuries.
Treatment is controversial. The majority of clavicle fractures can be managed nonoperatively.
Increased risk of nonunion in females, elderly, and fractures >100 % displacement or >2 cm shortening.
Improved shoulder function and union rates for significantly displaced and shortened clavicle fractures.
General
Clavicle fractures are common injuries, comprising 5–10 % of all fractures.
High-energy mechanisms may have associated ipsilateral scapula fractures, scapulothoracic dissociation, rib fracture, and pneumothorax and neurovascular injury.
Open clavicle fractures associated with high rates of pulmonary injury and closed head injuries
Imaging
Clavicle fractures are often first identified on trauma series CXR.
AP view and 15° cephalad-oblique views: assess fracture location, configuration, and displacement.
CT scan: consider in medial third fractures; additionally may help evaluate displacement, comminution, and nonunion.
Classification
Medial third (5 %)
Majority can be managed nonoperatively and are rarely symptomatic.
Assess for posterior displacement, and treat according to the principles for posterior sternoclavicular joint dislocation if present.
Middle third (80 %)
Majority can be managed nonoperatively.
Deforming forces in displaced fractures.
Medial fragment: the sternocleidomastoid and trapezius pull the medial fragment posterosuperiorly.
Lateral fragment: pectoralis major and weight of the arm pull the lateral fragment inferomedially.
Improved outcomes with ORIF for middle third clavicle fractures with 100 % displacement and >2 cm shortening.
Improved function with less pain and improved shoulder strength and endurance, increased union rates with faster time to union
Nonoperative management of fractures with 100 % displacement: 5–10 % nonunion
Lateral third (15 %)
Coracoclavicular ligaments provide superior/inferior stability.
Trapezoid ligament: 3 cm from the end of the clavicle
Conoid ligament: 4.5 cm from the end of the clavicle
Higher rates of nonunion compared to middle third clavicle fractures.
Treatment
Treatment is controversial.
Nonoperative
Most clavicle fractures can be successfully treated nonoperatively.
Sling immobilization and figure-of-eight bandage have no difference in outcomes.
Begin range of motion exercises at 2–4 weeks.
Operative
Indications for surgical treatment continue to evolve.
Absolute indications: open fractures, associated vascular injury, skin tenting, floating shoulder, symptomatic nonunion, some significantly displaced fractures.
Relative indications: polytrauma patient, closed head injury, seizure disorder, brachial plexus injury.
Plate fixation
Superior plating: improved biomechanical strength, more symptomatic hardware, increased risk of neurovascular injury with drilling
Anterior plating: less symptomatic hardware
Hook plate: AC joint spanning fixation, indicated in lateral third clavicle fractures, requires plate removal
Intramedullary rod and screw
Percutaneous insertion possible, symptomatic hardware still possible
Increased complication rate, including migration
Avoid Steinmann pins for risk of migration into the thorax.
Coracoclavicular ligament repair/reconstruction
Consider in lateral third clavicle fractures.
Primary repair, suture supplementation.
Rehabilitation
Early active motion, strengthening at 6 weeks, return to activities at 3 months
Hook plate range of motion restriction: no forward flexion >90° or abduction >90° until plate is removed
Complications
Hardware complications
Symptomatic hardware
30 % of patients request hardware removal.
Superior plates associated with increased irritation.
Failure of fixation: 1.5 %
Nonunion
Nonoperative management: 1–5 % overall
Asymptomatic: no treatment indicated
Symptomatic: consider nonunion take down and ORIF +/− bone graft (atrophic nonunions)
Risk factors: female, elderly, smoking, ≥100 % displacement, or ≥2 cm shortening
Adhesive capsulitis
4 % of patients who undergo surgical fixation
Neurovascular injury
3 %, increased risk with superior plating.
Acute neurovascular complications are rare, typically associated with scapulothoracic dissociation.
Pneumothorax
A concern with operative fixation but actual case reports are rare
Bibliography
1.
Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009. p. 1765–77.
2.
Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1–10.
3.
Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009;91(2):447–60.
4.
Kim W, McKee MD. Management of acute clavicle fractures. Orthop Clin North Am. 2008;39(4):491–505.
5.
McKee MD, et al. Deficits following nonoperative treatment of displaced midshaftclavicular fractures. J Bone Joint Surg Am. 2006;88(1):35–40.
6.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 705–7.
7.
Oh JH, et al. Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures. Arch Orthop Trauma Surg. 2011;131(4):525–33.
8.
Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO, Foster CJ, Clark K, Brooksbank AJ, Arthur A, Crowther MA, Packham I, Chesser TJ. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicle fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am. 2013;95:1576–84.
3 Acromioclavicular Injuries
Take-Home Message
Acromioclavicular ligaments provide anterior/posterior stability.
Coracoclavicular ligaments provide superior/inferior stability.
Bilateral AP radiographs for comparison to contralateral side and zanca view.
Nonoperative management: type I, II +/− III.
Operative management: type IV, V, VI.
AC joint arthrosis best treated with distal clavicle excision.
General
Common injuries, comprise 9 % of shoulder girdle injuries
More common in males
Acromioclavicular ligament: provides anterior/posterior stability
Coracoclavicular ligaments: provide superior/inferior stability
Imaging
Bilateral AP radiograph: compare distance from the top of the coracoid to the bottom of the clavicle to the contralateral side
Zanca view: 10° cephalic tilt and 50 % penetration, improved visualization of AC joint by eliminating overlying structures
Axillary view: assess for posterior clavicle displacement (type IV)
Classification
Type I: AC ligament sprain, no displacement
Type II: AC ligament rupture, CC ligament sprain, vertical displacement with <25 % increase of CC interspace
Type III: AC and CC ligament ruptures, vertical displacement with 25–100 % increase of CC interspace
Type IV: AC and CC ligament ruptures, lateral clavicle buttonholed through trapezius posteriorly
Type V: AC and CC ligament ruptures, vertical displacement with >100 % increase of CC interspace and rupture of deltotrapezial fascia
Type VI: AC and CC ligament ruptures, distal clavicle translocated inferior to the coracoid
Treatment
Nonoperative
Indicated in type I, II, and most type III injuries
Sling for 3 weeks, early range of motion, return to activities at 12 weeks
Operative
Indicated in type IV, V, and VI injuries
Consider in type III injuries in laborers and elite athletes
ORIF or ligament reconstruction
ORIF with CC screw or suture fixation: beware of proximity of neurovascular structures inferior to the coracoid.
ORIF with hook plate: requires second surgery for plate removal.
CC ligament reconstruction: transfer of coracoacromial ligament to distal clavicle (modified Weaver-Dunn), free tendon graft.
Primary AC joint fixation: rarely performed.
Rehabilitation: sling without abduction, shoulder range of motion beginning at 6 weeks, return to activities at 4–6 months
Complications
AC joint arthrosis: treat with open or arthroscopic distal clavicle excision.
Chronic instability: distal clavicle excision with stabilization of the stump.
Bibliography
1.
Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009. p. 1759–60.
2.
Clarke HD, McCann PD. Acromioclavicular joint injuries. Orthop Clin North Am. 2000;31(2):177–87.
3.
Mazzocca AD, Arciero RA, Bicos J. Evaluation and treatment of acromioclavicular join injuries. Am J Sports Med. 2007;35:316–29.
4.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 707.
4 Scapula Fractures
Take-Home Message
High-energy injuries with high rates of associated injuries and 2–5 % mortality rate.
Nonoperative management indicated for the majority of scapula fractures.
Operative treatment indicated for glenoid fractures with significant articular involvement and displacement or humeral head instability and glenoid neck fracture with significant displacement and/or angulation.
Consider fixation of floating shoulder injuries.
General
Uncommon injuries associated with high-energy mechanisms
80–90 % associated injuries: rib fractures, pulmonary injury, pneumothorax closed head injury, vascular injury, ipsilateral clavicle fracture, spine fracture, pelvis/acetabulum fracture, brachial plexus injury
2–5 % associated mortality rate
Imaging
True AP, scapular Y, and axillary lateral.
CT scan: assess for intra-articular involvement and displacement.
Classification
Coracoid fractures
Type I: proximal to CC ligament
Type II: distal to CC ligament
Acromial fractures
Type I: nondisplaced or minimally displaced
Type II: displaced without compromise of subacromial space
Type III: displaced with compromise of subacromial space
Glenoid fractures
Type Ia/Ib: anterior/posterior rim fracture, respectively
Type II/III/IV: glenoid fossa fracture exiting scapula laterally/superiorly/medially, respectively
Type Va/Vb/Vc: combinations of types II, III, and IV
Type VI: severe comminution
Glenoid neck fractures
Assess for floating shoulder: associated AC joint separation or clavicle fracture.
Superior shoulder suspensory complex (SSSC): 2 struts comprised of the clavicle and lateral scapular body linked by a bony and soft tissue ring made up of the coracoid, acromion, AC and CC ligaments, distal clavicle, and glenoid process.
Disruption of the complex at two sites is more problematic than disruption at one site.
Many floating shoulder injuries are stable and can be managed nonoperatively with good outcomes.
Unstable injuries with disruption of the SSSC or >1 cm displacement may benefit from ORIF.
Fixation of clavicle alone is typically sufficient and may restore adequate alignment of the scapula fracture.
Scapular body fractures
Treatment
Nonoperative
Indicated for the majority of scapula fractures.
Sling for 2 weeks, early range of motion; expect union at 6 weeks and not functional deficits.
Operative
Indications for surgical fixation
Glenoid fractures: involvement of >25 % glenoid with humeral head subluxation/instability, >5 mm glenoid articular step-off or major gap
Glenoid neck fractures: >40° of angulation, >1 cm translation, translation of the glenoid and humeral head anterior to the proximal fragment or excessive glenoid medialization
Coracoid fractures: >1 cm displacement in high-demand patients
Open fractures
Open reduction internal fixation may be combined with shoulder arthroscopy depending on the fracture pattern.
Complications
Scapulothoracic crepitation: may develop as sequelae of scapular body fracture and cause pain.
Open treatment typically utilizes the posterior Judet approach, with risk of injury to the suprascapular nerve and artery and circumflex scapular artery.
Bibliography
1.
Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009. p. 1760–5.
2.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 707–9.
3.
Van Noort A, van Kampen A. Fractures of the scapula surgical neck: outcome after conservative treatment in 13 cases. Arch Orthop Trauma Surg. 2005;123:696–700.
4.
Veysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV. Multiple trauma and scapula fractures: so what? J Trauma. 2003;55(6):1145–7.
5.
Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;20(3):230–3.
5 Scapulothoracic Dissociation
Take-Home Message
Maintain high index of suspicion for scapulothoracic dissociation with neurovascular injury and >1 cm lateral displacement of the scapula on AP CXR
High incidence of associated trauma to the heart, chest wall, lungs, and ipsilateral shoulder girdle
Functional outcome determined by the severity of the associated neurologic injury
Mortality rate: 10 %
General
High-energy injury with traumatic disruption of the scapulothoracic articulation
Typically caused by a lateral traction injury
High incidence of associated injuries
Trauma to the heart, chest wall, lungs
Neurologic injury (90 %): brachial plexus most common, poor outcomes, neurologic injury more common than vascular injury
Vascular injury: subclavian artery most common, axillary artery
Careful neurovascular exam is critical in patient assessment.
Mortality rate: 10 %.
Imaging
AP CXR: >1 cm lateral displacement of the scapula from the spinous process compared to the contralateral side
Possible additional findings: widely displaced clavicle fracture, AC separation, sternoclavicular dislocation
Angiogram: evaluate for injury to the subclavian and axillary artery.
EMG: consider 3 weeks after injury to further evaluate neurologic injury.
Treatment
Nonoperative
Immobilization and supportive care
Indicated in hemodynamically stable patients without significant vascular injury
Operative
Vascular repair indicated in hemodynamically unstable patients with significant vascular injury.
Consider ORIF of associated clavicle and AC joint injuries.
Forequarter amputation indicated for complete brachial plexus injury.
Complications
Poor outcomes overall
Functional outcome largely determined by severity of neurologic injury
~50 % of patients will have a flail extremity
Bibliography
1.
Althausen PL, Lee MA, Finkemeier CG. Scapulothoracic dissociation: diagnosis and treatment. Clin Orthop Relat Res. 2003;416:237–44.
2.
Clements RH, Reisser JR. Scapulothoracic dissociation: a devastating injury. J Trauma. 1996;40(1):146–9.
3.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 709.
4.
Zelle BA, Pape HC, Gerich TG, Garapati R, Ceylan B, Krettek C. Functional outcome following scapulothoracic dissociation. J Bone Joint Surg Am. 2004;86-A(1):2–8.
6 Glenohumeral Dislocations
Take-Home Message
Shoulder dislocation must be evaluated with an axillary radiograph.
Anterior glenohumeral dislocations are most common.
Age at time of first dislocation is an important risk factor for recurrent instability and informs risk of associated injuries.
Posterior shoulder dislocation is the commonly missed injury.
Luxatio erecta has the highest risk of associated neurovascular injury.
Assess for concurrent labral, cartilage, bony, and rotator cuff injuries which inform treatment options.
Treatment of first time dislocators is controversial.
General
The shoulder’s extensive range of motion presents risk for instability, making it the most commonly dislocated joint in the body.
Direction of dislocation and age of onset key in determining risk of associated injuries and recurrent instability and in guiding treatment.
Imaging
Standard x-ray series
True AP: unreliable, may see “lightbulb” sign with posterior dislocation.
Scapular Y.
Axillary: best view to demonstrate dislocation; consider Velpeau view if patient is unable to abduct.
Westpoint view: assess for glenoid fracture or bone loss (bony Bankart lesion).
Stryker notch view: assess posterior humeral head (Hill-Sachs lesion).
CT scan: may help assess location and extent of bony injuries/defects.
MRI: assess labral tears and rotator cuff tears.
Anterior Dislocations
Typically traumatic and unilateral
Determinants of anterior static shoulder stability
SGHL: arm at side
MGHL: 45° abduction and external rotation
Anterior band of IGHL: 90° abduction and external rotation
Examination: apprehension sign, relocation sign, sulcus sign
Associated injuries
Labral and cartilage injuries
Bankart lesion: avulsion of the anterior inferior capsulolabral complex.
Humeral avulsion of the glenohumeral ligament (HAGL): increased risk of recurrent dislocation.
Glenoid labral articular defect (GLAD): sheared of articular cartilage with labrum.
Anterior labral periosteal sleeve avulsion (ALPSA): torn labrum may heal medially along the glenoid neck.
Bone injuries
Hill-Sachs lesion: anterior dislocations, clinically significant if it engages the glenoid
Bony Bankart lesion: fracture of the anterior inferior glenoid, present in 50 % of patients with recurrent anterior dislocations
Greater tuberosity fracture: anterior dislocations in patients >50
Nerve injuries
Axillary nerve injury: most common (5 %), transient neurapraxia
Musculocutaneous nerve injury second most common
Rotator cuff tears
Increasing incidence with increasing age
Bimodal distribution for risk of recurrent dislocation and associated injury
If <20 years old at time of first dislocation
High rate of recurrent dislocations
High rate of associated labral tears
If >40 years old at time of first dislocation
Lower rate of recurrent dislocations
High rate of associated rotator cuff tears
Posterior Dislocations
Comprise 2–5 % of shoulder dislocations
Missed diagnosis in up to 50 % upon presentation to ED
May result from acute traumatic insult or microtrauma with labral injury and posterior capsule stretching (lineman, weight lifters, overhead athletes)
Associated with high-energy trauma, seizure and electrocution (internal rotators overpower external rotators), ligamentous laxity, glenoid retroversion, or hypoplasia
Examination: inability to externally rotate
Posterior shoulder stabilizers
Posterior band of IGHL: primary static restraint in internal rotation
Subscapularis: primary dynamic restraint in external rotation
Coracohumeral ligament: primary restraint to interior translation in adduction and external rotation, primary restraint to posterior translation in flexion, abduction, and internal rotation
Associated injuries
Labral and cartilage injuries
Reverse Bankart lesion: avulsion of posterior inferior capsulolabral complex
Posterior labral cyst
Bone injuries
Reverse Hill-Sachs lesion: present in 50 % of posterior dislocations
Reverse bony Bankart lesion: fracture of the posterior glenoid rim
Lesser tuberosity fracture: posterior dislocations
Inferior Dislocations: Luxatio Erecta
Rare injuries, 0.5 % of all shoulder dislocations
Associated with MVAs and sports injuries
Examination: arm overhead in 100–160° abduction
Associated injuries
Highest incidence of neurovascular injury of all types of shoulder dislocation
Axillary nerve and artery most common
Axillary nerve palsy typically resolves with reduction.
May have diminished or absent pulses on presentation with return after reduction.
Axillary artery thrombosis may develop late.
Glenohumeral ligament tears
Capsulolabral tears possible
Rotator cuff tears common
Treatment
Nonoperative
Closed reduction, sling for 2–4 weeks and physical therapy with rotator cuff and periscapular muscle strengthening, activity modification
Immobilize posterior shoulder dislocation in neutral to external rotation.
Reduction maneuvers: many described, simple traction-countertraction most commonly used
Operative
Anterior dislocations
TUBS (traumatic unilateral Bankart surgery)
Open/arthroscopic Bankart repair +/− capsular shift: high success rate
Latarjet procedure: transfer of coracoid to address >20 % glenoid deficiency
Remplissage: posterior capsule and infraspinatus tendon advancement into >25 % Hill-Sachs lesion
Hill-Sachs bony reconstruction: allograft reconstruction, arthroplasty, or rotational osteotomy to address large engaging Hill-Sachs lesion
Posterior dislocations
Open/arthroscopic reverse Bankart repair +/− capsular shift: high success rate
McLaughlin: lesser tuberosity and subscapularis transfer to reverse Hill-Sachs defect <50 %
Hemiarthroplasty: reverse Hill-Sachs defect >50 %, chronic dislocations, severe humeral head arthrosis or collapse
Total shoulder arthroplasty: hemiarthroplasty indication with glenoid arthrosis
Inferior dislocations
Open/arthroscopic repair: indicated in young, active patients to address specific capsulolabral and rotator cuff pathology
Complications
Recurrent instability: <10 % after operative treatment
Adhesive capsulitis
Capsular overtightening: may lead to subluxation or impingement
Posttraumatic arthrosis
Bibliography
1.
Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. Philadelphia: Saunders; 2009. p. 1717–35.
2.
Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009;18(2):317–28.
3.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 324–6, 711.
4.
Millett PJ, Clavert P, Hatch 3rd GF, Warner JJ. Recurrent posterior shoulder instability. J Am Acad Orthop Surg. 2006;14:464–7.
5.
Sewecke JJ, Varitimidis SE. Bilateral luxatio erecta: a case report and review of the literature. Am J Orthop. 2006;35(12):578–80.
7 Proximal Humerus Fractures
Take-Home Message
Most proximal humerus fractures result from low-energy trauma in elderly patients.
85 % of proximal humerus fractures are minimally displaced and can be treated nonoperatively.
Many patients will have significant residual functional deficits, irrespective of treatment.
General
Comprise 5 % of all fractures
More common in women
Low-energy falls: osteoporosis, third most common fracture in elderly
High-energy trauma: young patients, increased incidence of neurovascular injures
Blood supply to the humeral head
Ascending branch of the anterior humeral circumflex artery, which runs in the lateral aspect of the bicipital groove, is classically described at the primary blood supply to the humeral head.
Posterior humeral circumflex artery shown to be the main supply to the humeral head in more recent studies.
Vascularity of the articular segment more likely to be preserved if >8 mm of calcar remains attached.
45 % associated nerve injury
Axillary nerve injury most common
Distinguish from deltoid atony with pseudosubluxation of the humeral head.
Increased risk with fracture-dislocations
Imaging
Trauma series x-rays: true AP, scapular Y, axillary.
CT scan: further assess fracture displacement, intra-articular involvement, and preoperative planning.
Classification
Neer classification: part = displacement >1 cm or angulation >45° of the articular surface, greater tuberosity, lesser tuberosity, and shaft
One part
Nondisplaced or minimally displaced fracture, most commonly involving the surgical neck
Two part
Surgical neck: anteromedial displacement of the shaft from pull of pectoralis major
Greater tuberosity: posterosuperior displacement from pull of supraspinatus, infraspinatus, and teres minor
Displacement >5 mm may impinge and block external rotation and abduction.
Lesser tuberosity: posteromedial displacement from pull of subscapularis, associated with posterior shoulder dislocations
Anatomic neck: rare injury pattern
Three part
Displacement of greater or lesser tuberosity and articular surface
Four part
Displacement of shaft, articular surface, and both tuberosities
Head-splitting variant: split through articular surface
Valgus impaction
Posteromedial calcar typically intact: preserved blood supply to the articular segment, decreased risk of AVN
Treatment
Nonoperative
Sling immobilization, early shoulder range of motion, and rehabilitation
Indicated for minimally displaced fractures, grater tuberosity fracture with <5 mm displacement and poor surgical candidates
Consider age, fracture characteristics, bone quality, medical comorbidities, and concurrent injuries.
Operative
Closed reduction percutaneous pinning
Two-part surgical neck fractures, some three-part and valgus impacted fractures
Consider bone quality, metaphyseal comminution, and involvement of medial calcar
Open reduction internal fixation
Greater tuberosity fracture with >5 mm displacement.
Techniques include screw fixation, nonabsorbable suture, and tension band wiring
Consider in two-, three-, and four-part fractures and head-splitting fractures in younger patients.
Lesser tuberosity component: large fragment amenable to ORIF; small fragments may be excised with cuff repair.
Intramedullary nailing
Consider in surgical neck fractures, some three-part fractures, and combined humeral shaft fractures.
Improved outcomes in younger patients.
Hemiarthroplasty
Anatomic neck fractures in the elderly or with significant comminution in younger patients, three- and four-part fractures not amenable to ORIF, fracture-dislocations, head-splitting fracture fractures, humeral head defect >40 %, loss of humeral head blood supply.
Consider in nonunions and malunions.
Requires an intact glenoid.
Humeral height, humeral version, and tuberosity reconstruction are important contributors to outcome.
Superior border of the pectoralis major insertion is a reliable landmark to determine height of the prosthesis.
In elderly patients, hemiarthroplasty may improve pain long term even if there is little functional benefit compared to nonoperative management.
Total shoulder arthroplasty
Indications for hemiarthroplasty plus intact rotator cuff and glenoid compromise
Reverse shoulder arthroplasty
Consider in elderly patients with nonreconstructable tuberosities
May result in improved outcomes when compared to hemiarthroplasty in elderly patients
Complications
Avascular necrosis
20–75 % in four-part fractures.
Risk of AVN increased with disruption of the medial periosteal hinge, medial metaphyseal extension less than 8 mm, increasing fracture complexity, displacement greater than 10 mm, angulation greater than 45°.
Incidence does not correlate with method of surgical fixation.
If symptomatic, treat with arthroplasty.
Nerve injury
Axillary nerve most commonly injured.
Suprascapular nerve and musculocutaneous nerve are also commonly injured.
Some specific risks for nerve injury pending type of surgical intervention and approach.
Hardware failure
Screw cutout, the most common complication following ORIF of the proximal humerus fractures with locking plates.
Inferomedial calcar screw in plate and screw constructs can help prevent varus collapse.
Intramedullary rods may migrate in the osteoporotic bone.
Nonunion
Most common after two-part fractures of the surgical neck.
If symptomatic, consider treatment with arthroplasty.
Malunion
Surgical neck fractures with varus and apex anterior deformity are poorly tolerated.
May consider osteotomy in symptomatic, young active patients.
Rotator cuff deficiencies
Adhesive capsulitis
Infection
Bibliography
1.
Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. Philadelphia: Saunders; 2009. p. 1643–712.
2.
Cuff D, Pupello D. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013;95:2050–5.
3.
Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am. 2010;92(4):943–8.
4.
Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am. 1992;74:508–15.
5.
Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Südkamp N. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J Bone Joint Surg Am. 2010;92(Suppl 1 Pt 1):85–95.
6.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 709–11.
7.
Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humerus fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011;20:1025–33.
8.
Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am. 2002;84-A(11):1919–25.
8 Humeral Shaft Fractures
Take-Home Message
Nonoperative management with coaptation splint converted to functional bracing is indicated for the majority of humeral shaft fractures.
Acceptable alignment: <30° varus/valgus angulation, <20° flexion/extension, <3 cm shortening.
Absolute indications for surgical treatment: open fractures, associated vascular injury requiring repair, brachial plexus injury.
Relative indications for surgical treatment: polytrauma, pathologic fractures, soft tissue injury that precludes bracing, some fracture patterns.
Holstein-Lewis fracture: spiral distal 1/3 diaphyseal humerus fracture associated with increased risk of radial nerve injury.
Intramedullary nail fixation has higher complication rates compared to plate osteosynthesis.
The vast majority of radial nerve palsies resolve over time; observation is typically indicated as the initial treatment course.
General
Comprise 3–5 % of all fractures
Associated radial nerve injury most common
Radial nerve courses through the spiral groove.
20 cm proximal to the medial epicondyle.
14 cm proximal to the lateral epicondyle.
Increased risk of radial nerve injury with Holstein-Lewis fracture patterns.
Careful neurovascular exam prereduction/splinting and preoperatively is critical
Imaging
AP and lateral x-rays of the humerus, must include good visualization of the shoulder and elbow joints.
Traction views may be considered in some fracture patterns but are not required routinely.
Classification
Descriptive
Fracture location: proximal, middle, distal 1/3
Fracture pattern: transverse, spiral, comminuted
Holstein-Lewis fracture
Spiral distal 1/3 diaphyseal humerus fracture
22 % radial nerve injury
Treatment
Nonoperative
Nonoperative management is the treatment of choice when possible.
Acceptable alignment: less than 30° of varus/valgus angulation, less than 20° flexion/extension, less than 3 cm of shortening.
Coaptation splint for 7–10 days followed by conversion to functional bracing.
Low nonunion rate
Proximal 1/3 diaphyseal humerus fracture have an increased risk of nonunion.
Operative
Absolute indications: open fracture, vascular injury requiring repair, brachial plexus injury
Relative indications: floating elbow, polytrauma (allow early weight bearing through humerus), pathologic fractures, soft tissues that preclude functional bracing, segmental fractures, neuromuscular conditions, some fracture patterns
Plate fixation
Considered the gold standard for most humeral shaft fractures indicated for surgical fixation
High union rates
Decreased secondary operations
Safe to allow weight bearing to tolerance
Intramedullary nailing
May be advantageous with pathologic fractures, segmental fractures, humeral shaft fractures combined with proximal humerus fractures, and poor soft tissues.
Antegrade or retrograde technique may be employed.
Higher total complication rates including nonunion, shoulder pain, and nerve injury
Early weight bearing does not affect union rate.
Radial nerve at risk with lateral to medial distal locking screw.
Musculocutaneous nerve at risk with anterior to posterior distal locking screw.
Complications
Radial nerve palsy
Occurs in 5–10 % of humeral shaft fractures.
Increased incidence with distal 1/3 fractures and transverse fractures.
85–90 % resolve over 3–4 months with observation
Wrist extension and radial deviation are expected to be regained first.
If not improving by 6–12 weeks, obtain EMG.
Radial nerve palsy in closed fracture after reduction: typically observe, and consider exploration for new pain.
Consider surgical exploration for open fractures with radial nerve palsy, closed fractures that fail to improve at 3–4 months, and fibrillations on EMG.
Nonunion
2–10 % overall
Slightly higher rates of nonunion with surgical treatment
Risk factors: fracture distraction, open fractures, segmental fractures, infection, shoulder/elbow stiffness, patient factors (smoking, obesity, malnutrition, etc.).
Treat with compression plating with autogenous bone grafting.
Malunion
Varus angulation most common but typically asymptomatic
Increased risk of malunion in proximal 1/3 diaphyseal fractures and transverse fractures.
Pull of the deltoid on the proximal fragment contributes to varus malalignment.
Bibliography
1.
Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14(3):162–6.
2.
DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006;31(4):655–63. Review.
3.
Heineman DJ, Poolman RW, Nork SE, Ponsen KJ, Bhandari M. Plate fixation or intramedullary fixation of humeral shaft fractures. Acta Orthop. 2010;81(2):216–23. Review.
4.
McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br. 2000;82(3):336–9.
5.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 711–3.
6.
Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82(4):478–86.
9 Distal Humerus Fractures
Take-Home Message
The majority of distal humerus fractures are indicated for surgical fixation.
Distal intercondylar fractures are the most common variant.
Maintain a high index of suspicion for nerve injury, brachial artery injury, and forearm compartment syndrome.
Goal to restore functional elbow range of motion: 30–130°.
For ORIF, both parallel plating and 90–90 plating configurations are supported.
Triceps splitting, triceps sparring/paratricipital, and transolecranon osteotomies may be employed with different potential advantages and disadvantages pending fracture configuration.
Ulnar nerve transposition not shown to decrease the incidence of ulnar nerve symptoms.
Surgical fixation of comminuted, osteoporotic fractures is very challenging – consider total elbow arthroplasty.
General
Most common in young males (high-energy falls) and elderly females (low-energy falls).
Distal intercondylar fractures are the most common variant.
Elbow position at injury impacts fracture pattern
Axial load with elbow flexed <90°: transcolumnar fracture
Axial load with elbow flexed >90°: intercondylar fracture more likely
Associated injuries include elbow dislocations, terrible triad injury, floating elbow, and forearm compartment syndrome.
Careful neurovascular exam to assess radial, ulnar, and median nerve as well as distal pulses
Maintain high index of suspicion for brachial artery injury and pursue further vascular work-up if there is any abnormality.
Injuries often complicated by low fracture lines, metaphyseal and articular comminution, and poor bone quality.
Goal to restore functional elbow range of motion: 30–130°
Poor outcomes in up to 25 % of patients
Imaging
AP and lateral x-rays of the elbow, humerus, and forearm.
Obtain dedicated wrist views if additional elbow injury is identified or if there is wrist tenderness.
Consider oblique views and traction films for surgical planning.
CT scan often obtained for surgical planning, particularly helpful with coronal shear fractures of the capitellum and trochlea.
Classification
Extra-articular supracondylar humerus fractures
Many variants: high extension, high flexion, low extension, low flexion, abduction, adduction.Related posts:
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