Clavicle Fractures
Overview
- 1.
Most clavicle fractures require no reduction.
- 2.
Closed reductions cannot be maintained and should not be attempted.
Indications for Use
- 1.
Minimally displaced clavicle shaft fractures ( Fig. 9.1 )
Fig. 9.1
- 2.
Medial physeal clavicle fractures
Precautions
Do not attempt heroic measures to reduce clavicle fractures.
Pearls
- 1.
Clavicle fractures with more than 1.5 cm of overlap result in long-term disability and should be treated with open reduction and internal fixation.
- 2.
Fractures that tent the skin can erode through the skin and are unlikely to heal without open reduction and internal fixation.
- 3.
There is no difference in outcome between a figure-of-8 splint and a sling for closed management of clavicle fractures.
- 4.
The sling or figure-of-8 strap should be relatively tight to support the weight of the arm.
Improvisation
If no sling is available, then a simple scarf or a towel can be used.
Equipment
- 1.
A sling
- 2.
A figure-of-8 strap (alternative)
Basic/Detailed Technique
- 1.
A sling (see Chapter 13 )
- 2.
A figure-of-8 strap (see Chapter 13 )
Acromioclavicular Separations
Overview
- 1.
Most acromioclavicular (AC) separations require no reduction.
- 2.
Closed reductions cannot be maintained and should not be attempted.
Indications for Use
- 1.
Minimally displaced AC separations (grades 1–3) ( Fig. 9.2 )
Fig. 9.2
- 2.
Severely displaced AC separations (grades 4–6) ( Fig. 9.3 )
Fig. 9.3
Precautions
Do not attempt heroic measures to reduce AC separations.
Pearls
- 1.
AC separations with severe displacement or soft tissue interposition (grades 4–6) should be surgically reduced on an elective basis.
- 2.
AC separations that tent the skin are unlikely to heal without fixation.
- 3.
The sling should be relatively tight to support the weight of the arm.
Improvisation
If no sling is available, then a simple scarf or a towel can be used.
Equipment
A sling
Basic/Detailed Technique
A sling (see Chapter 13 )
Glenohumeral Dislocations
Overview
- 1.
Most glenohumeral dislocations can be reduced in a closed manner.
- 2.
The reduction technique varies according to the direction of dislocation.
- 3.
An axillary or modified axillary view is an essential part of the radiographic series ( Fig. 9.4 ).
Fig. 9.4
Indications for Use
- 1.
Anterior glenohumeral dislocation
- 2.
Posterior glenohumeral dislocation
- 3.
Inferior glenohumeral dislocation (luxatio erecta)
Precautions
- 1.
Confirm that no fracture is present on diagnostic films before attempting a reduction. Standard reduction maneuvers can result in a displaced four-part fracture that requires surgical fixation/prosthetic replacement.
- 2.
Confirm that the humeral head is not impacted onto the glenoid (known as a Hill-Sachs lesion) before attempting a reduction (see Fig. 9.4 ). Standard reduction maneuvers can result in a head-splitting fracture.
- 3.
When applying traction, make sure that the force is applied over a broad area; otherwise, this can result in a forearm fracture.
- 4.
Be aware that some persons may voluntarily initiate a glenohumeral dislocation in an effort to gain access to drugs.
- 5.
Reducing dislocations in persons who present more than a few days after the injury may not be possible, and attempting to do so could result in a fracture; it is preferable to not attempt a reduction and instead take the patient to the operating room if simple traction does not succeed in reducing the dislocation.
- 6.
When reducing posterior dislocations, do not externally rotate the humerus until the head is disimpacted from the glenoid or else this may result in a fracture.
Pearls
- 1.
Be patient; the stability of the shoulder is largely provided by a set of small but powerful muscles that must be overcome with gentle sustained traction before a reduction is possible.
- 2.
Gentle internal and external rotation of the shoulder can coax the humerus back in place.
- 3.
For posterior dislocations, stretching the rotator cuff muscles by maximal internal rotation of the shoulder may be necessary.
- 4.
General anesthesia may be required if muscle spasms are not overcome with sedation.
- 5.
External rotation is a better position for immobilization of both anterior and posterior dislocations after reduction, although a gunslinger brace may not be immediately available.
- 6.
The sling or gunslinger brace can be loosely applied for comfort.
Improvisation
When all else fails, try traction at different angles of abduction and extension.
Anterior Glenohumeral Dislocations
Equipment
- 1.
Two bedsheets
- 2.
A stretcher
- 3.
Medications for conscious sedation
- 4.
A sling or a gunslinger brace (if available)
Basic Technique
- 1.
Patient positioning:
- a.
The patient is supine on the stretcher.
- b.
The patient’s elbow is bent 90 degrees, and the forearm is vertical.
- c.
The patient’s shoulder is abducted 30–60 degrees.
- d.
A bedsheet is tied around the patient’s trunk and to the opposite side of the stretcher.
- e.
A bedsheet is tied around your waist and to the patient’s forearm.
- a.
- 2.
Landmarks:
- a.
Acromion
- b.
Humeral head
- c.
Coracoid
- a.
- 3.
Steps:
- a.
Position the patient.
- b.
Induce sedation.
- c.
Tie the bedsheet to the stretcher.
- d.
Tie the bedsheet to yourself.
- e.
Lean back to apply traction.
- f.
Gently externally rotate the shoulder.
- g.
Await a clunk as the shoulder reduces.
- h.
Place the shoulder in a sling or a gunslinger brace.
- i.
Obtain postreduction films.
- a.
Detailed Technique
- 1.
Position the patient supine on the stretcher.
- 2.
Induce conscious sedation.
- 3.
Prepare the traction setup:
- a.
Make sure that the guard rails are down on the ipsilateral side and up on the contralateral side.
- b.
Slide a rolled bedsheet around the patient’s trunk under the ipsilateral shoulder and tie it over the contralateral upper corner of the stretcher for countertraction ( Figs. 9.5 and 9.6 ).
Fig. 9.5
Fig. 9.6
- c.
Tie another rolled bedsheet around your waist, leaving about a foot of slack.
- d.
Place the patient’s forearm inside the sheet around your waist so that the entire proximal half of the forearm is covered by the sheet ( Fig. 9.7 ).
Fig. 9.7
- a.
- 4.
Apply traction:
- a.
Position yourself along the ipsilateral side of the stretcher so that the shoulder is slightly abducted.
- b.
Lean back slowly and gently to apply traction while providing countertraction on the distal half of the forearm with both palms.
- (1)
Apply traction over the broadest surface area possible to prevent a forearm fracture.
- (2)
Be patient; slow, steady traction is necessary to achieve reduction (5–30 min of traction may be required depending on the level of sedation).
- (1)
- a.
- 5.
Gently externally rotate the shoulder ( Fig. 9.8 ).
- a.
If reduction is not achieved, then alternate between internal rotation ( Fig. 9.9 ) and external rotation.
Fig. 9.9
- b.
Vary the degree of abduction if necessary ( Fig. 9.10 ).
Fig. 9.10
Fig. 9.8
- a.
- 6.
Await a clunk or sudden palpable shift.
- 7.
Gently release the traction.
- 8.
Place the arm in a sling (see Chapter 13 ) in internal rotation or in a gunslinger brace in external rotation.
- 9.
Obtain postreduction radiographs, including an axillary view, before terminating sedation.
Posterior Glenohumeral Dislocations
Equipment
- 1.
Two bedsheets
- 2.
A stretcher
- 3.
Medications for conscious sedation
- 4.
A sling or a gunslinger brace (if available)
Basic Technique
- 1.
Patient positioning:
- a.
The patient is supine on the stretcher.
- b.
The patient’s elbow is bent 90 degrees, and the shoulder is internally rotated.
- c.
The patient’s shoulder is abducted 30–60 degrees.
- d.
A bedsheet is tied around the patient’s trunk and to the opposite side of the stretcher.
- e.
A bedsheet is tied around your waist and to the patient’s forearm.
- a.
- 2.
Landmarks:
- a.
Acromion
- b.
Humeral head
- c.
Coracoid
- a.
- 3.
Steps:
- a.
Position the patient.
- b.
Induce sedation.
- c.
Tie the bedsheet to the stretcher.
- d.
Tie the bedsheet to yourself.
- e.
Lean back to apply traction.
- f.
Gently rock the shoulder in slight internal and external rotation.
- g.
Once the humeral head is disimpacted, translate the humerus anteriorly.
- h.
Gently externally rotate the shoulder.
- i.
Await a clunk as the shoulder reduces.
- j.
Place the shoulder in a sling or a gunslinger brace.
- k.
Obtain postreduction films.
- a.
Detailed Technique
- 1.
Position the patient supine on the stretcher.
- 2.
Induce conscious sedation.
- 3.
Prepare the traction setup:
- a.
Make sure that the guard rails are down on the ipsilateral side and up on the contralateral side.
- b.
Slide a rolled bedsheet around the patient’s trunk under the ipsilateral shoulder and tie it over the contralateral upper corner of the stretcher for countertraction.
- c.
Tie another rolled bedsheet around your waist, leaving about a foot of slack.
- d.
Place the patient’s forearm inside the sheet around your waist so that the entire proximal half of the forearm is covered by the sheet.
- a.
- 4.
Apply traction:
- a.
Position yourself along the ipsilateral side of the stretcher so that the shoulder is slightly abducted.
- b.
Lean back slowly and gently to apply traction while providing countertraction on the distal half of the forearm with both palms.
- (1)
Apply traction over the broadest surface area possible to prevent a forearm fracture.
- (2)
Be patient; slow, steady traction is necessary to achieve reduction (5–30 min of traction may be required depending on the level of sedation).
- (1)
- a.
- 5.
Once the humeral head is disimpacted, translate the humerus anteriorly ( Fig. 9.11 ).
