12 Regional injuries

John Keating, Geoffrey Hooper, James Robb

Essential facts

1. Non-operative treatment is used for most clavicle, humeral, distal radial, metacarpal and phalangeal fractures.

2. Gleno-humeral dislocation is the most common major joint dislocation and is associated with an 80% recurrence in younger patients and rotator cuff tears in older patients.

3. Displaced supra-condylar humeral fractures in children are associated with a significant risk of vascular and neurological injury.

4. Distal radius fractures in adults are very common; 30% are unstable in a cast.

5. Scaphoid fractures may not be obvious on initial radiographs and are associated with a risk of avascular necrosis.

6. Intra-capsular hip fractures interfere with femoral head blood supply and are frequently complicated by non-union and avascular necrosis.

7. Extra-capsular hip fractures generally heal after internal fixation.

8. The one-year mortality rate after a hip fracture is 30%.

Upper limb injuries

Fractures of the clavicle and shoulder girdle

Clavicular fractures

These are common injuries in adults and children (Fig. 12.1). The majority of cases follow a fall on the shoulder. Most fractures involve the middle third of the bone. Clinical diagnosis is not difficult in most cases – there is tenderness with visible and palpable deformity at the site of the fracture. A small proportion of these patients have high-energy trauma and in these cases there is an association with brachial plexus injuries and vascular injury. Clinical assessment should include an assessment of the neurovascular status of the upper limb.

FIGURE 12.1 Angulated mid-shaft clavicular fracture in a child; this will heal uneventfully

Virtually all of these fractures can be diagnosed with plain radiographs. In the majority of cases, management is non-operative using a collar and cuff sling for 4–6 weeks, and analgesic medication. Patients should be advised to avoid overhead activity for the first 6 weeks and heavy manual work for 3 months. In adults, radiographs should be obtained at 2 weeks, 6 weeks and 3 months to ensure the fracture progresses to union.

In children, complications are unusual; very few require any additional treatment and the fracture heals rapidly. Full function can be expected, but the child and parents will be aware of a swelling over the fracture for several months after healing. This is due to external callus formation, which usually remodels well.

Surgical treatment of clavicular fractures is occasionally indicated. Patients with a vascular injury or brachial plexus palsy will usually require plating of the clavicle. Non-union occurs in 10% of adult clavicular fractures and is more common in mid-shaft fractures with more than 1 cm of displacement or with comminution. Non-union of mid-shaft fractures can be treated successfully in most cases with plating. In lateral third fractures, delayed union or non-union is the norm if the coraco-clavicular ligaments are ruptured, which results in superior migration of the medial fragment. They can be treated non-operatively if asymptomatic. In patients with troublesome pain, internal fixation is indicated.

Treatment of grade I and II injuries is non-operative with a sling for comfort until early mobilization is commenced 1–2 weeks after injury. Most grade III injuries can also be treated non-operatively. However, occasionally the clavicle is widely displaced and comes to lie in a subcutaneous position. These injuries are best treated surgically. The clavicle can be repositioned using a coraco-clavicular screw.

Gleno-humeral dislocation

The gleno-humeral joint is the most frequently dislocated major joint. The usual mechanism is a fall on the extended arm with the shoulder in extension. The humeral head dislocates in an anterior dislocation and comes to lie medial to the glenoid, just below the coracoid process. Posterior dislocation also occurs, but is uncommon, and accounts for less than 5% of shoulder dislocations. It is often associated with high-energy trauma, an epileptic fit or as a consequence of an electric shock. Gleno-humeral dislocation is a very unusual injury in a child.

The diagnosis of anterior dislocation is obvious on clinical examination. There is swelling and deformity of the shoulder, and the humeral head is palpable in the anterior sub-coracoid position. Posterior dislocations are less obvious on physical and radiographic examination, but one key clinical feature is that the gleno-humeral joint is fixed in internal rotation. If there is a history of unusual trauma, and the shoulder is in fixed internal rotation, it should be assumed there is a posterior dislocation. A plain antero-posterior (AP) radiograph shows anterior dislocations readily, but posterior dislocations are easily missed. Axillary or modified oblique views are better for diagnosis of posterior dislocation. Axillary nerve injury, brachial plexus palsy and rotator cuff tears are all well recognized complications of gleno-humeral dislocation and should be looked for clinically.

Closed reduction of the dislocation under sedation is usually possible. Occasionally general anaesthesia is required and should always be used in a child. Posterior dislocations are often associated with an impaction fracture of the humeral head, which becomes locked on the edge of the glenoid, rendering closed reduction difficult. Open reduction is more frequently required. After closed reduction of a shoulder dislocation a period of 3–4 weeks of immobilization is recommended in younger patients to minimize the risk of recurrent dislocation. In patients over the age of 40 years this is less of a risk and early mobilization is encouraged.

In younger patients the main risk is recurrent dislocation; in those under 20 years of age the risk is 80%. In patients over the age of 40 years, rotator cuff tears and nerve injury are more frequent. Greater tuberosity fractures or rotator cuff tears are present in 10–30% of gleno-humeral dislocations. They are more common in older patients. Nerve injuries (most commonly the axillary nerve) can be treated non-operatively as they recover spontaneously in 95% of cases. They are present in 30% of patients over the age of 50 years with dislocation. Rotator cuff tears are easily missed because they are difficult to diagnose at presentation after reduction of the dislocation owing to pain and limited motion. In patients who have not regained active abduction by 4–6 weeks after injury, an urgent ultrasound or MRI scan is indicated to diagnose a rotator cuff tear and carry out surgical repair in suitable patients.

Proximal humeral fractures

Fractures of the proximal humerus are most frequent in elderly women. Clinical examination reveals bruising and swelling of the shoulder. The bruising migrates down the arm in the first 10–14 days after injury and eventually may be more obvious at the elbow. Neurological injuries are present in 20–30% of older patients and tend to involve the axillary nerve or brachial plexus.

Most of these fractures are not markedly displaced and unite reliably with non-operative treatment in a sling in a few weeks. Wide displacement of the fragments or the presence of displaced tuberosity fragments warrants consideration of internal fixation or humeral head replacement (Fig. 12.2). Non-operative treatment is associated with a high rate of mal-union and shoulder stiffness, but operative treatment in osteoporotic bone seldom produces superior functional results, except in the most displaced fracture patterns.

FIGURE 12.2 Complex fracture dislocation of proximal humerus

In children the injury may involve the physeal plate (see section on physeal injuries) or the proximal metaphysis (Fig. 12.3). Most injuries can be treated non-operatively and, even if there is noticeable angulation at the fracture site, the proximal humerus has excellent potential for remodelling in the child.

FIGURE 12.3 Lateral view of a fracture of the proximal humerus in a child; the angulation is acceptable and will remodel

Humeral shaft fractures

Humeral shaft fractures occur as a result of direct or indirect trauma applied to the upper arm. Although they are often the result of high-energy trauma they are quite a frequent injury in elderly patients or patients who drink alcohol to excess as a consequence of simple falls. The diagnosis is based on the history, physical examination and plain radiographs. The radial nerve has a close relationship to the humeral diaphysis and radial nerve palsy occurs in 12% of humeral fractures.

The humerus has a good blood supply and the majority of these fractures will heal with non-operative treatment. Moderate degrees of mal-union (angulation and/or rotation of up to 20° with shortening of up to 3 cm) can be accepted due to the range of motion of the shoulder, which allows compensation for the mal-union. The usual treatment is immobilization in a plaster U-slab, which can be replaced after the first 2–4 weeks by a functional brace. Fractures usually unite between 8 and 12 weeks. The presence of a radial nerve palsy is not an indication for surgery as 95% of these can be expected to recover spontaneously. Humeral shaft fractures in children are managed in the same way as for the adult.

Not all humeral shaft fractures can be treated non-operatively. Indications for surgery include:

• Open fractures

• Fractures with a brachial plexus palsy

• Fractures associated with a vascular injury

• Bilateral humeral fractures

• Humeral fractures associated with an ipsilateral forearm fracture

• Patients with multiple trauma

• Pathological humeral fractures

• Displaced transverse fractures – high risk of non-union with closed treatment.

If surgery is required, plating is the preferred fixation option for most fractures. Intra-medullary nailing is possible, but has been associated with a high rate of non-union and other surgical complications. In children, rigid nails and any fixation device that crosses a physis are not used. Flexible intra-medullary nails or plate fixation are appropriate.

Fractures around the elbow

Distal humeral fractures

Fractures involving the distal humerus are not common, but are difficult to treat in adults. They usually occur as a fall directly on to the elbow. They may be extra-articular, but more commonly the elbow joint surface is involved.

Non-operative treatment of these injuries is difficult, but an above-elbow cast is the usual method. Most injuries are treated by internal fixation. This treatment has the advantage of restoring anatomical reduction of the joint surface and is associated with the best long-term outcome. In older patients anatomical reconstruction may be difficult and use of total elbow arthroplasty is an alternative to internal fixation in this situation.

Complications of this injury include ulnar nerve injury, heterotopic ossification, post-traumatic arthritis and infection. However, the most common complication is stiffness. Stiffness may be associated with heterotopic ossification. It is usually treated by a soft-tissue release and excision of ectopic bone.

Fractures of the distal humerus and metaphysis in children are usually managed non-operatively.

Supra-condylar fractures of the humerus are the commonest elbow injury in children aged 5–7 years and result from a fall on to the outstretched hand. The force is transmitted up the forearm and the humerus fails in the metaphysis, the area of least structural strength. Some 95% of supra-condylar fractures are extension types and the remainder have a flexion pattern. The degree of displacement of the distal fragment may range from being undisplaced to some displacement, but with posterior cortical continuity or complete displacement (Fig. 12.4). Completely displaced fractures may be associated with loss of circulation to the forearm and hand as the brachial artery is trapped in the fracture site. Neurological damage may also occur as peripheral nerves at the elbow are contused or stretched by the injury; the anterior interosseous nerve is affected most commonly (see Chapter 2). Loss of circulation to the hand is a surgical emergency and urgent reduction of the fracture under general anaesthesia is required. Displaced fractures are generally pinned after reduction. Neurological injury is usually managed conservatively and generally carries a good outlook. Healing of the fracture is rapid and the child can begin mobilizing the elbow after 3 weeks. Mal-union of the fracture may occur and cubitus varus (a medial deviation of the forearm) may be seen (Fig. 12.5). This is a cosmetic deformity that does not affect function, but most children and parents eventually find the appearance unacceptable and it can be corrected by supra-condylar osteotomy.

FIGURE 12.4 (A) Antero-posterior and (B) lateral view of supra-condylar humeral fracture in a child. This is completely displaced and requires reduction and pinning

FIGURE 12.5 Antero-posterior view of both arms in a 6-year-old who had sustained a supra-condylar humeral fracture 2 years earlier. There is a mal-union and resulting cubitus varus

Fracture of the lateral condyle in children (Fig. 12.6) is the second commonest injury at the elbow in children aged 5–7 years. The injury passes through the elbow joint and across the growth plate, and if there is any displacement the fracture is fixed to ensure anatomical reduction of the joint surface and growth plate. If a displaced lateral condyle is not fixed and a non-union ensues, there is a likelihood of the child developing a progressive lateral drift of the forearm and tardy ulnar nerve palsy as an adult. The palsy is due to the ulnar nerve being stretched at the elbow and results in muscle weakness in the hand and difficulty in performing fine hand movements (See Chapter 1 for anatomy review).

FIGURE 12.6 (A) Lateral condyle fracture of distal humerus in a child. (B) Position after fixation

Olecranon fractures

The olecranon process is commonly fractured in falls on the elbow. The triceps inserts on to the olecranon and this commonly results in distraction of the fracture. Non-operative treatment is, therefore, seldom feasible. Internal fixation using a tension-band wire system is the most common method of operative treatment (Fig. 12.7). Postoperatively a short period of immobilization is usual for 10–14 days, after which cautious mobilization of the elbow out of a cast may begin. The main complication is failure of fixation with delayed or non-union of the fracture. In children the injury can be treated conservatively if the articular surface has not been disrupted, or surgically if there is loss of continuity of the joint surface.

FIGURE 12.7 Postoperative view of tension-band wiring of olecranon fracture

Radial head and neck injuries

Fractures of the radial head and neck are quite frequent and result as a consequence of a fall on the outstretched hand. Force transmitted up the radial shaft results in a compressive axial force on the radius with a fracture of the head itself, or the neck. Radial neck fractures are often minimally displaced and if the angle subtended by the radial articular surface is less than 30° no specific treatment is needed. Fractures with tilt of the head in excess of 30° usually need to be manipulated or have open reduction and fixation. Complete dislocation of the radial head may require radial head replacement. In children, an angulation of up to 20° can be accepted, but a greater tilt is an indication for closed reduction, which can be achieved by manipulation or by using a percutaneous wire to reduce the fracture (Fig. 12.8).

FIGURE 12.8 (A) Displaced radial neck fracture. (B) Satisfactory reduction after manipulation

Radial head fractures are treated according to the degree of comminution and displacement. Undisplaced fractures can be treated in a sling with early mobilization. Two-part or three-part fractures require internal fixation with screws if displaced. Very comminuted head fractures that cannot be reconstructed are treated by radial head replacement. Radial head fractures are rare in children and the head should not be excised.

Elbow dislocations and fracture dislocations

The elbow may dislocate as a result of a fall on the outstretched hand with the elbow extended. The olecranon and radial head dislocate in a postero-lateral direction. Neuropraxia of the nerves round the elbow is an occasional complication. Closed reduction can be achieved in the majority of cases by application of manual traction with the elbow slightly flexed. Sedation is necessary, but general anaesthesia is not generally required. The elbow is usually stable after reduction. After 10–14 days of immobilization in a back-slab plaster, the elbow is mobilized. Some high-energy dislocations are associated with more extensive degrees of soft-tissue disruption and the joint may be unstable. In the majority of these adult cases, exploration of the elbow with ligament repair is necessary. The same principles apply to children (Fig. 12.9), except that operative repair of disrupted ligaments is not usually indicated. The injury may also be associated with an avulsion of the medial epicondyle, which can then be incarcerated in the joint as a result of either the injury or the subsequent reduction. If this occurs, the elbow should be opened, the fragment retrieved and pinned back in place (Fig. 12.10).

FIGURE 12.9 (A) Elbow dislocation showing visible deformity. (B) Plain radiograph showing posterior dislocation

FIGURE 12.10 (A) Antero-posterior and (B) lateral view of elbow after reduction of dislocation showing medial epicondyle in joint (arrows), and (C) position after fixation of medial epicondyle (arrowed)

Fracture dislocations of the elbow are rare, but are more serious injuries often associated with poor outcomes in adults. The ‘terrible triad’ of the elbow refers to a dislocation in association with a coronoid process fracture and a radial head fracture in adults. There are several varieties of fracture dislocation, but the principles of treatment are similar. Restoration of bony anatomy is essential to relocate the joint and restore stability. This usually requires internal fixation of the fractures involving the olecranon, coronoid process and ulnar shaft. The radial head may also need to be reconstructed, but in comminuted cases, radial head replacement is needed. Careful early follow-up of these patients is needed to detect any loss of joint stability. The functional outcome is often compromised by stiffness and a soft-tissue release is frequently required to restore a functional range of motion.

Fractures of the forearm

Fractures of the forearm are very common injuries in children, but much less common in adults. The peak age of fractures in children is between the age of 5 and 12 years, and fractures in this age group account for 50% of children’s fractures. These injuries vary from plastic deformation (Fig. 12.11), to greenstick fractures, to complete fractures, and many can be treated by closed manipulation and an above-elbow cast. Cast treatment is generally continued for 3–5 weeks depending on the age of the child. At that stage, healing is sufficiently advanced to allow cast removal and mobilization. Complications are uncommon, but mal-union occasionally occurs. Rotational mal-union is poorly tolerated in the forearm particularly and results in loss of forearm rotation. To avoid this complication children should be reviewed and radiographs taken 1 and 2 weeks following reduction. Open reduction and fixation with flexible nails or plates is indicated if a satisfactory alignment cannot be achieved or if the child is approaching skeletal maturity.

FIGURE 12.11 Antero-posterior (left) and lateral (right) radiographs of forearm in a child showing plastic deformity

Forearm fractures in adults are more often a consequence of high-energy trauma. Compartment syndrome is a well recognized complication. Most mid-shaft forearm fractures are completely displaced and are not readily amenable to non-operative treatment. Internal fixation with plates is the treatment of choice (Fig. 12.12). Failure to achieve anatomical reduction is associated with loss of the range of pronation and supination. Non-union and infection can complicate surgical treatment, but rates are usually less than 5%. Cross-union between the forearm bones after fracture complicates 2% of injuries and is more common in proximal third fractures, particularly in patients who have delayed fixation, head injury or those who develop infection.

FIGURE 12.12 Postoperative view of forearm fracture in adult treated by plating

Isolated ulnar shaft fractures are often the result of an assault when the victim sustains a blow on the forearm. If these fractures are undisplaced, non-operative treatment in a cast is an acceptable form of treatment. Radiographs are required within the first 2 weeks of treatment to ensure no displacement occurs. Displaced ulnar fractures are best treated by internal fixation as this allows early mobilization.

Two patterns of forearm fracture dislocation occur and are eponymously known as the Monteggia fracture dislocation and the Galeazzi fracture dislocation. The Monteggia is the more common pattern and is characterized by an ulnar shaft fracture and a radial head dislocation. The Galeazzi pattern is a radial shaft fracture and a dislocation of the distal radio-ulnar joint. Good-quality radiographs including elbow and wrist joints are necessary in all forearm injuries to avoid missing associated dislocations at these joints. These patterns are also seen in children (Fig. 12.13) and, although internal fixation is indicated in all forearm fracture dislocations in adults, it is possible to manage these fracture patterns in children conservatively, provided that a reduction of the radial head in the Monteggia fracture and the radio-ulnar joint in the Galeazzi fracture can be obtained and maintained. If this is not possible, surgical management is required. Closed reduction of radial head dislocations may be possible, but open reduction and soft-tissue repair is indicated if a stable closed reduction cannot be achieved. For distal radio-ulnar dislocations, additional fixation of the joint may be required. Typically the ulna has dislocated dorsally with respect to the radius. Kirschner wire fixation of the ulna to the radius should be used in patients who have an unstable joint following reduction. These wires require removal at 6 weeks to allow the patient to restore forearm rotation.