Upper Extremity Trauma

Benjamin R. Pulley, MD

Claire B. Ryan, MD

David Ring, MD, PhD

Michael J. Gardner, MD

Dr. Ring or an immediate family member has received royalties from Skeletal Dynamics and Wright Medical Technology, Inc. and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association. Dr. Gardner or an immediate family member has received royalties from Synthes; is a member of a speakers’ bureau or has made paid presentations on behalf of KCI; serves as a paid consultant to or is an employee of Conventus, Globus Medical, KCI, OsteoCentric, SI-Bone, StabilizOrtho, StabilizOrtho, and Synthes; has stock or stock options held in Conventus, Genesis Innovations Group, Imagen Technologies, and Intelligent Implants; has received research or institutional support from Medtronic, OsteoCentric, SmartMedical Devices, and Zimmer; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association, the Orthopaedic Research Society, and the Orthopaedic Trauma Association. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Pulley and Dr. Ryan.

ABSTRACT

Many of the principles of upper extremity trauma have remained unchanged for some time, but the role of surgical treatment and methods of fixation are subjects of debate for acromioclavicular dislocation, displaced diaphyseal clavicle fractures, and diaphyseal humerus fractures. There are even advocates for fixation of a subset of displaced fractures of the scapula. The mainstays of discussion regarding proximal humerus fractures revolve around patient selection for nonsurgical management, methods of surgical fixation, and the growing role of reverse total shoulder arthroplasty. Recent research regarding periarticular fractures of the elbow addressed the biomechanics of plate fixation for supracondylar humerus fractures, the management of elbow joint instability, the role and design of radial head arthroplasty, the treatment of olecranon fractures, and the outcomes of total elbow arthroplasty after distal humerus fractures. There are still advocates for intramedullary nail fixation of diaphyseal fractures of the forearm. Distal radioulnar joint instability, compartment syndrome, and forearm fracture nonunion are also highlighted in recent reports. Diagnostic strategies, treatment modalities, and cost-effectiveness are areas of investigation for fractures of the distal radius and scaphoid.

Keywords: acromioclavicular joint injury; clavicle fracture; forearm fracture; hand fracture; humeral shaft fracture; periarticular elbow fracture; proximal humerus fracture; wrist fracture

Introduction

This chapter reviews evidence published in the last 5 years that might help guide decision making for patients regarding upper limb trauma. High-level data have raised questions about common treatment strategies and additional data are needed.

Acromioclavicular Joint Injury

The role of surgical treatment of acute acromioclavicular (AC) dislocation is debated. Only complete dislocations (100% loss of apposition of the joint) are considered for surgery. Some people believe that dislocations with muscle interposition merit surgery, but that can only be discerned at surgery, and it is not clear that the degree of displacement correlates with muscle interposition. Guesses based on radiographs may not be helpful.

A recent meta-analysis of 19 studies (954 patients)¹ favored nonsurgical treatment of complete AC joint dislocations. There were five randomized controlled trials comparing a variety of surgical interventions (ie, K-wire, screw, nonrigid reconstruction, hook plate, etc) with nonsurgical treatment. The surgical fixation
group had better aesthetic and radiographic outcomes. The nonsurgical treatment group had quicker return to activity and avoided implant removal and other adverse events related to surgery. The Constant-Murley score (CMS) was slightly better in the surgical group, a difference that may not be meaningful to people with this injury. The Disabilities of the Arm, Shoulder, and Hand (DASH) score, return to sport, and subsequent surgery were comparable.

A prospective randomized trial involving 83 patients found that hook plate fixation of acute complete AC joint dislocation and nonsurgical treatment had comparable patient-reported outcomes.² A smaller retrospective cohort study found comparable Short Form-36 (SF-36) scores after hook plate fixation or nonsurgical treatment.³

Two meta-analyses⁴^,⁵ found loop suspensory fixation was associated with better CMS and lower Visual Analog Scale (VAS) for pain at the cost of longer surgical time⁴ and higher complication rates when compared with a hook plate.⁵ Additionally, a retrospective cohort study found a better SF-36, VAS for pain, DASH, CMS, and global satisfaction after arthroscopic-assisted coracoclavicular fixation versus hook plate fixation.⁶

Clavicle Fracture

Clavicle shaft fractures have transitioned from no surgery to frequent surgery in the last three decades, because the benefit of surgical treatment of completely diaphyseal fractures of the clavicle (more than 100% loss of apposition of the fracture surfaces) is unclear. In three recent prospective randomized controlled trials comparing surgical versus nonsurgical management for displaced midshaft clavicle fractures,⁷^,⁸^,⁹ there were more nonunions, but comparable patient-reported outcomes with nonsurgical treatment.

In a prospective randomized trial involving 160 patients evaluated for 1 year⁷ in the Netherlands, there were no differences in Constant or Disabilities of the Arm, Shoulder, and Hand (DASH) scores at any time point, but the rate of nonunion was significantly greater in the nonsurgical group (23% vs 2.4%). Only about half the patients chose to have surgery to treat the nonunion (13% in the nonsurgical group and 1.2% in the surgical group).

In a trial of 117 patients evaluated for a year⁸ in Brazil, DASH scores were comparable at all time points. The rate of nonunion was 15% with nonsurgical treatment compared with no nonunions with surgical treatment.

A multicenter trial from the United Kingdom with a total of 301 patients⁹ found that CMS and DASH scores were better in the surgical group 6 weeks and 3 months after fracture, but comparable at 9 months. Nine months after injury there were fewer nonunions in the surgical group (0.8%) than the nonsurgical group (11%).

The weight of evidence to date (including these three trials) is that nonunions are more common with nonsurgical treatment, but—on average—symptoms and limitations are similar a year after injury.¹⁰^,¹¹ Recent meta-analyses compared fracture healing and functional outcomes after surgical and nonsurgical treatment of displaced diaphyseal clavicle fractures. Most recently, a systematic review of 1,352 patients treated in 14 randomized trials found a lower risk of nonunion with surgical treatment. Three of 14 studies included analyzed DASH scores at short-term follow-up and found significantly better scores in patients treated with surgery. Seven studies found a higher DASH score at 9-month follow-up in the surgical group. These results are limited, however, by the fact that no studies included in the meta-analysis blinded patients to the treatment they received. It should also be noted that seven other studies in the meta-analysis found no significant difference in long-term functional outcomes in patients treated with surgery as compared with those treated nonsurgically.¹⁰

A systematic review that included both randomized control trials and well-designed observational studies comparing surgical and nonsurgical treatment of displaced midshaft clavicle fractures found lower rates of nonunion with surgical treatment, but no clinically significant difference in symptoms and limitations measured using DASH and Constant-Murley scores.¹¹ In other words, nonunions are more common without surgery, but clinical outcomes are similar over the long term, suggesting that many nonunions can be accommodated.

A retrospective cohort study of 1,215 patients found a higher rate of total complications in patients who had surgery for midshaft clavicle fracture nonunion compared with surgical fixation of acute midshaft clavicle fracture. The most common complications were wound infections, but no individual type of complication was significantly more common in nonunions.¹² When interpreting studies that compare surgery for acute fracture with surgery for nonunion, readers should be mindful that many patients with nonunion do not request surgery. Furthermore, both patients with nonunion as well as patients who request surgery for nonunion may have important differences from the average patient with a completely displaced midshaft clavicle fracture that are not adequately accounted for in these types of studies. It would be helpful to determine the number needed to treat, number needed to harm, and similar numbers.

When surgical treatment of midshaft clavicle fractures is selected, there is debate about the best method of fixation. A prospective randomized trial of 123 patients compared elastic nailing (2.0 to 3.5 mm titanium) versus plate fixation and found that plate fixation had a lower rate of implant removal and yielded quicker functional recovery (based on CMS and DASH score at time points up to 6 months after surgery) especially in comminuted fractures. However, elastic nailing had shorter surgical time (53 vs 70 minutes) and lower rate of infection.¹³

One downside of surgical fixation of a midshaft clavicle fracture is the prominence of implants placed on a subcutaneous bone in a prominent aesthetic location and an area of straps that may bear weight. A retrospective cohort study involving 81 patients reported that their technique of dual mini-fragment plating for midshaft clavicle fractures yielded good union and functional recovery and a low rate of implant removal for soft-tissue irritation (3.7%).¹⁴ It is difficult to interpret the advantages and disadvantages of specific techniques in terms of implant prominence without randomization and controls.

Scapula Fracture

Scapula fractures are usually treated nonsurgically with good success and most surgeons see little role for surgery in the absence of a glenoid rim fracture contributing to glenohumeral instability. Nevertheless, several recent reports from advocates of surgical treatment suggest a subset of fractures might benefit from surgery.

An uncontrolled retrospective cohort study reported good functional outcomes in 61 patients with extra-articular fractures of the scapula that were treated surgically¹⁵ based on specific displacement criteria: medial or lateral displacement ≥20 mm, angulation ≥45°, medial or lateral displacement ≥15 mm plus angulation ≥30°, double disruptions of the superior shoulder suspensory complex with both displaced ≥10 mm, glenopolar angle ≤22°, and open fractures.

A retrospective cohort study from the same group described¹⁶ patients aged 65 and older with scapula fractures treated surgically based on the same extra-articular criteria as well as more than 4 mm of articular step or gap. They reported low complication rates (three patients had temporary postoperative delirium, one patient had a urinary tract infection, one patient had removal of an intra-articular screw, and one patient had a second surgery to remove postoperative heterotopic ossification) and good functional outcomes (mean range of motion and strength of the affected shoulder was >70% of that of the contralateral shoulder and DASH and SF-36 were comparable to normal populations).¹⁶

Another retrospective case series of 24 patients with fractures of the glenoid fossa treated nonsurgically found that those with intra-articular displacement 3 mm or less had better CMS than those with displacement 5 mm or greater.¹⁷ A study in cadavers found that measurement of glenopolar angles is more reliable on 3D CT reconstructions of the scapula than radiographs.¹⁸ In another cadaveric study the modified Judet approach allowed access to the same key anatomic landmarks despite exposing only 20% of the surface area as the classic Judet approach.¹⁹

Proximal Humerus Fractures

Fractures of the proximal humerus are common, particularly in older patients with osteoporosis. Deformity is relatively well adapted, particularly for low-demand or infirm individuals. There was optimism that locking plates had improved the results of surgical treatment, but there is no fixation method that is not prone to technical adverse events such as implant migration or prominence and loss of reduction. Hemiarthroplasty is less used and inverse total shoulder arthroplasty more used for complex fractures in infirm, less active patients. Given the success of nonsurgical treatment, there is increasing interest in starting nonsurgical and moving to inverse arthroplasty when merited.

The 5-year results of the PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) trial, a prospective randomized trial involving 164 patients, were consistent with the original report. There was no difference in function based on the Oxford Shoulder Score (OSS), quality of life based on EuroQol 5D-3L (EQ-5D-3L), or subsequent surgery between nonsurgical and surgical treatment groups.²⁰

A prospective randomized trial involving 72 patients compared intramedullary nail versus locking plate fixation in patients with two-or three-part surgical neck fractures of the proximal humerus and found no differences in functional scores, range of motion, or humeral neck-shaft angle 12 months after surgery but reported more complications and reoperations in patients receiving intramedullary nails.²¹

A prospective cohort study looked at 60 patients with osteoporotic four-part proximal humerus fractures treated either with open reduction and internal fixation (ORIF) incorporating a fibular strut allograft and a plate or with hemiarthroplasty and found better motion and functional recovery (CMS and DASH) in the surgical fixation group.²²

Reverse total shoulder arthroplasty (rTSA) has become a preferred method of treatment for proximal humerus fractures in older, more infirm, and less active adults, particularly those with more complex fracture, bad bone quality, and large rotator cuff defects. When comparing rTSA versus hemiarthroplasty, a meta-analysis of seven studies involving 255 patients found superior forward elevation, abduction, tuberosity healing, and outcome scores after rTSA; only external rotation was better after hemiarthroplasty.²³

Given the difficulty demonstrating a benefit—on average—to surgical treatment of acute fractures, one idea is to treat fractures in older, infirm, and inactive patients nonsurgically to start and then address major problems with later rTSA. Three separate retrospective cohort studies recently compared patients treated with acute rTSA for fracture with those who underwent delayed rTSA, either after loosened or broken ORIF or after nonunion or malunion after nonsurgical treatment. It is important to note these studies have the important drawbacks of comparing people with surgery for an acute fracture with people who choose surgery because they are not happy with the results of the treatment of the acute fracture.

One study involving 44 patients found that rTSA after loss of fixation of a proximal humerus fracture was associated with slightly higher complication rates compared with acute rTSA for an acute fracture, but there was no difference in revision surgery rate or American Shoulder and Elbow Surgeons (ASES) score.²⁴

A second study involving 60 patients found that patients with loose proximal humerus locking plate fixation who had a second surgery for rTSA had marginally worse CMS and DASH scores and experienced more complications than patients treated with immediate rTSA.²⁵

A third study of 49 patients found comparable outcome scores (Shoulder Pain and Disability Index [SPADI], Simple Shoulder Test-12 [SST-12], ASES score, University of California-Los Angeles [UCLA] shoulder rating scale, CMS, and Short Form-12 [SF-12]) and motion in patients who underwent rTSA as the initial treatment for fracture and those who had rTSA for later nonunion or malunion. They also reported that acute rTSA for fracture is marginally better than salvage rTSA for problems after hemiarthroplasty or plate fixation.²⁶

Humeral Shaft Fracture

The role of surgical treatment and the optimal method of fixation of diaphyseal humerus fractures are still being debated. A large meta-analysis involving 832 patients (16 of 17 studies were prospective randomized controlled trials) compared open reduction and plate and screw fixation, intramedullary nail fixation, and MIPO and found no differences in rates of nonunion or infection, but more shoulder pain with intramedullary fixation and more radial nerve palsy in the open reduction plate fixation group.²⁷

Another meta-analysis comparing the same treatment groups included eight prospective randomized controlled trials involving a total of 376 patients and concluded that MIPO resulted in a superior functional outcome compared with ORIF or intramedullary nailing and also reported that ORIF had the highest complication rate of the three groups.²⁸ Most reports of MIPO to date are introductory and promotional, so the data may not be representative.

A retrospective study compared MIPO versus intramedullary nailing in 30 patients with humeral shaft fractures and found a higher rate of major complications (radial nerve palsy, nonunion, infection, and revision surgery) in the intramedullary nailing group (53%) compared with the MIPO group (7%).²⁹

A recent prospective randomized controlled trial involving 110 patients compared MIPO and nonsurgical treatment with a functional brace. There were 15% nonunions with nonsurgical treatment and none with surgical treatment. At 6 months postoperatively, before treatment of the nonunions in the nonsurgical group, the functional brace group had worse DASH scores on average.³⁰

Intramedullary nailing of humeral shaft fractures raises concern about injury to the rotator cuff and subacromial impingement of implants. A prospective, randomized controlled trial involving 40 patients compared the use of an arthroscope to ensure proper nail placement with standard technique. Patients in the scope-assisted group were found to have better outcome scores and shorter fluoroscopy time as compared with the standard technique, although total surgical time was not reported.³¹

Distal Humerus Fractures

Researchers continue to measure the mechanics of surgical fixation of fractures of the distal humerus, perhaps because they can be problematic, particularly with low quality bone. A sawbones study comparing parallel versus orthogonal plating for ORIF of intra-articular distal humerus fractures found similar mechanics, but parallel plating was stiffer during axial loading of the radial column.³² A similar study in simulated extra-articular distal humerus fractures in cadavers found parallel plating to be stiffer in torsion and bending, and to have a higher extension load to failure.³³ Given that parallel plating uses longer screws in the articular segment (more metal), these conclusions seem to reflect common sense.

Total elbow arthroplasty does better than ORIF of distal humerus fractures in people older than 65 years in the short-term, but there are concerns about long-term outcomes and management of infection, loosening within a few years of surgery, and periprosthetic fracture. A retrospective cohort study described 44 patients treated with total elbow arthroplasty for distal humerus fractures 10 years after surgery and noted 92% survivorship in patients without rheumatoid arthritis (76% survivorship in patients with rheumatoid arthritis), but a relatively high rate of major complications, including 11% deep infection, 18% revision or resection, and 11% periprosthetic fracture.³⁴

Radial Head Fracture

Radial head arthroplasty is an alternative to ORIF for restoring radiocapitellar contact in the setting of a comminuted, displaced fractures of the radial head associated with other ligament injuries or fractures. A meta-analysis involving 319 patients with unstable displaced fractures of the radial head found that arthroplasty yielded higher satisfaction, better elbow scores, shorter surgical time, and lower incidence of recurrent instability compared with ORIF.³⁵

Radial head arthroplasty varies by modularity, movement (some have an articulation between head and neck), and stem (smooth loose vs porous fixed). A retrospective cohort study involving 57 patients found that DASH scores and Mayo Elbow Performance Index scores were the same between patients treated with radial head arthroplasties with either a smooth or porous stem design, but the porous stem group had higher rates of unintended loosening (64% vs 24%), greater loss of elbow flexion, and higher rates of overstuffing of the radiocapitellar joint.³⁶

Olecranon Fracture

Olecranon fractures tend to occur from a direct blow to the elbow. Displaced fractures are generally treated surgically, with the exception of infirm and low-demand patients.

A prospective randomized controlled trial involving 19 patients greater than 75 years old compared nonsurgical treatment with tension band fixation for management of geriatric olecranon fractures and found that there was no difference in functional outcome scores 1 year after injury. The trial was stopped after 19 enrollments because of an unacceptably high rate of complications in the surgical treatment group (82%).³⁷

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