Upper Extremity Trauma
Mara Schenker, MD, FAAOS
Michael McDonald, DO
Thomas Moore Jr, MD
Dr. Schenker or an immediate family member serves as a paid consultant to or is an employee of Johnson & Johnson and serves as a board member, owner, officer, or committee member of the AO North America and 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. McDonald and Dr. Moore.
ABSTRACT
The upper extremity is unique in that it is not weight bearing and with a few exceptions most areas have good vascular supply with reliable healing potential. Certain areas of the upper extremity such as the clavicle, scapula, humerus, distal radius, and fingers are able to tolerate deformity because of the large range of motion of adjacent joints. This creates controversy in the management of these injuries, especially in lower demand populations. Although most proximal humeral fractures can be managed nonsurgically, reverse total shoulder arthroplasty is gaining popularity for severely displaced fractures in the geriatric population. A large number of humeral shaft fractures initially managed nonsurgically eventually require surgical intervention for various reasons. Despite limited evidence on the benefits of surgery, many distal radius fractures are managed surgically in patients older than 60 years. There is certainly room to grow in terms of better defining who will benefit from surgical intervention for some of these controversial upper extremity fractures rather than strictly age-based cutoffs. Conversely, many injuries clearly benefit from surgery such as forearm fractures and intra-articular injuries about the elbow. In these fractures, debate often exists regarding the best methods of fixation rather than surgery versus nonsurgical management. A shared decision-making process with each patient based on injury characteristics, activity level, overall health, and preference is critical.
Keywords: clavicle fracture; distal radius fractures; humeral shaft fracture; proximal humerus fracture; terrible triad fracture
Introduction
It is important to provide an overview of evidence-based practice for the management of upper extremity fractures to guide practitioners in their clinical decision-making. With recent well-conducted studies having brought into question some traditional treatment options for certain fractures of the upper extremity, every practitioner should critically evaluate the literature to apply evidence-based medicine into their practice.
Acromioclavicular Joint Injuries
Management of acromioclavicular joint injuries remains controversial; however, nonsurgical management is appropriate for most of these injuries. Rockwood type I and type II injuries reliably do well with nonsurgical management. Type III and type V acromioclavicular joint injury management is controversial, with much of the literature supporting initial nonsurgical management. Type III injuries can be divided into stable (IIIA) and unstable (IIIB), with unstable injuries being those that cause persistent pain, weakness, decreased flexion and abduction, and scapular dyskinesis; early surgical intervention for the unstable group may be beneficial. Although considerably rare, types IV and VI acromioclavicular joint injuries are generally considered for surgical management.
A 2019 Cochrane database review of five randomized controlled trials (RCTs) with 357 patients was performed comparing surgical versus nonsurgical management of acromioclavicular joint dislocations in adults.1 It was concluded that surgical management is not beneficial in terms of return to activity, quality of life, overall function, pain at 1-year follow-up, secondary surgery, and cosmetic patient satisfaction. A meta-analysis of 10 trials was performed comparing nonsurgical and surgical management of type III
injuries, and it was concluded that there was no difference in pain, weakness, tenderness, posttraumatic arthritis, restriction of strength, unsatisfactory function, or functional outcome scores.2
injuries, and it was concluded that there was no difference in pain, weakness, tenderness, posttraumatic arthritis, restriction of strength, unsatisfactory function, or functional outcome scores.2
The type of surgical fixation is also controversial, with more than 60 described techniques in the literature. In 2020, a meta-analysis of TightRope (Arthrex) versus hook-plate fixation for types III-V injuries was performed and demonstrated an advantage for TightRope fixation in terms of postoperative pain.3 A 2019 meta-analysis of 1,704 patients compared the outcomes of different surgical techniques and found that there was no significant difference in reduction loss, complications, or revisions between open and arthroscopic techniques.4
Clavicular Fractures
Optimal treatment for displaced midshaft clavicular fractures has been debated for multiple decades, with the pendulum swinging between nonsurgical and surgical management. Most studies have shown a higher nonunion rate with nonsurgical management; however, the clinical significance has been questioned.
A 2020 meta-analysis5 evaluated 22 RCTs and found that union rates were lower in the nonsurgical groups (88.9%) compared with the surgical groups (96.7%), with a number needed to treat of 10. This study also found that the surgical group did show improvement in Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores although these differences did not meet the defined minimal clinically important difference (MCID). Another 2019 meta-analysis evaluated nine well-designed RCTs and showed that surgical management had better union rates (98.7% versus 86.6%), appearance dissatisfaction rates, and shoulder appearance defect rates.6 A different meta-analysis in 2019 looked at 1,469 patients to compare surgical and nonsurgical management and concluded that surgery does not improve functional outcomes or affect pain and that nonsurgical management may decrease the risk of unplanned secondary surgery.7 Symptomatic malunion was more common in the nonsurgical group (11.3% versus 1.2%); however, there was no significant difference in adverse outcomes between the two groups.
Anteroinferior versus superior plate position is a topic of debate. A meta-analysis of 1,484 patients was performed to compare the two plate positions (390 anteroinferior and 1,104 superior).8 No difference was found in terms of outcomes except that the superior plating group had a significantly higher rate of symptomatic hardware and subsequent removal. Another study looked at four RCTs and eight observational studies comparing the two plate positions and found that anteroinferior plating had decreased surgical time, blood loss, and time to union.9 Dual plating has become a popular technique for treating clavicular fractures. Although several biomechanical studies demonstrate similar or improved stability with dual plating, there is as of yet no high-level evidence to support this treatment. In 2020, a meta-analysis comparing plate fixation with intramedullary nailing (IMN) for displaced clavicle fractures found that the IMN group had improved Constant and DASH scores (that did not meet MCID), lower infection rates, and shorter duration of surgery and hospital stay, but higher implant removal rate.10
Scapular Fractures
Scapular fractures are relatively uncommon injuries that typically occur as a result of high-energy mechanisms and are often accompanied by other injuries. High-quality evidence is limited, with most of the literature composed of small case series and retrospective reviews. Most of these fractures are minimally displaced and can be managed nonsurgically with good success. Fractures involving the glenoid are often categorized as isolated glenoid rim fractures as a result of instability events and glenoid fossa fractures extending into the neck or body as a result of high-energy mechanisms.
Surgical indications for displaced scapular fractures are controversial. Several have been proposed: more than 2 cm of scapular body lateralization, at least 45° of angulation on a scapular Y view, combined ≥30° of angulation with at least 15 mm of scapular body lateralization, glenopolar angle less than 22°, at least 1 cm displaced double disruption of the superior shoulder suspensory complex, and >4 mm intra-articular step-off. However, intra-articular displacement of scapular fractures involving the glenoid is controversial with acceptable displacement ranging from 2 to 10 mm. A 2020 systematic review evaluated extra-articular scapula fractures from 42 studies with 669 patients in total; 464 patients were treated surgically and 205 nonsurgically.11 A total of 316 patients in the surgical group were treated using the aforementioned indications, whereas 148 patients were treated with additional study-specific indications. A union rate of 99.4%, mean Constant score of 84.4, and forward flexion of 158° were found in the surgical group compared with a union rate of 85.1%, mean Constant score of 79.0, and forward flexion of 153° in the nonsurgical group. Of note, only one of the studies in the review was an RCT and one was a prospective cohort, the rest were retrospective reviews, case series, or case reports.
Humeral Fractures
Proximal Humeral Fractures
Proximal humeral fractures are very common injuries, and despite numerous high-quality studies, there is a lack of consensus on the ideal treatment. It is well accepted that minimally displaced fractures do well if managed without surgery. Displaced fractures are typically classified into parts based on the Neer classification. In general, nonsurgical management for three-part and four-part fractures has led to poor functional scores and range of motion (ROM) limitations. Surgical treatment options include open reduction and internal fixation (ORIF) with locking plates, reverse total shoulder arthroplasty (rTSA), hemiarthroplasty, and IMN, among others.
An RCT published in 2019 compared nonsurgical management with ORIF of displaced (>1 cm or >45°) two-part proximal humeral fractures.12 There were no statistical differences in multiple outcome scores between the two groups at 2 years postoperatively, and there were more complications in the surgical group. In a 2019 retrospective review of 368 patients with severely displaced proximal humeral fractures and fracture-dislocations that were managed with ORIF,13 the authors found that the revision surgery rate at 10 years postoperatively was 26%; however, when revision surgeries for stiffness were excluded, the rate dropped to 10%. The patients were surveyed at an average of 10 years postoperatively and reported good to excellent function, pain, and satisfaction rates. IMN for proximal humeral fractures has been gaining popularity. An RCT in 2019 comparing locking blade IMN with ORIF in 68 patients found improved DASH scores at 1 year postoperatively and decreased reduction loss and screw cutout in the IMN group.14
rTSA has been gaining popularity and has largely replaced hemiarthroplasty as a treatment option for proximal humeral fractures in the elderly. A meta-analysis of eight RCTs compared nonsurgical treatment, ORIF, rTSA, and hemiarthroplasty for three-part and four-part proximal humeral fractures.15 It was concluded that rTSA resulted in fewer adverse events and better clinical outcome scores than hemiarthroplasty. However, it was also reported that nonsurgical treatment was associated with lower rates of unplanned surgery and adverse events compared with ORIF and similar clinical scores, adverse events, and unplanned surgeries compared with hemiarthroplasty and rTSA. The DELPHI trial is a well-designed RCT that compared rTSA with ORIF in displaced proximal humeral fractures in the elderly population (older than 65 years).16 A total of 124 patients were evaluated and significantly better Constant scores were found in the rTSA group. Another recent study using Nordic registry data evaluated the 5-year survival rate of rTSA for 1,523 proximal humeral fractures and found that survivorship was 97%.17 However, another study using the same registry evaluated 3,245 patients who underwent delayed rTSA for proximal humeral fractures and found 1-, 5-, and 10-year survival rates of 94%, 89%, and 85%, respectively.18 This indicates that delayed rTSA may have more complications than acute rTSA for proximal humeral fractures.
Humeral Shaft Fractures
Most humeral shaft fractures, even if displaced, do well with nonsurgical management and this remains the mainstay of treatment. There are few high-level studies comparing nonsurgical and surgical management. Absolute surgical indications include fractures with an associated brachial plexus injury, vascular injury requiring repair, floating elbow, and severe soft-tissue injury or bone loss. Radial nerve palsy with a humeral shaft fracture occurs approximately 20% of the time, but most cases (90%) recover spontaneously.
A 2020 RCT performed in Finland compared outcomes of nonsurgical management with those of ORIF in 78 closed displaced humeral shaft fractures.19 The study authors found no statistically significant difference in DASH scores at 12 months but a nonunion rate of 25% in the nonsurgical group with a 30% crossover rate into the surgical group.20 It was concluded that patients should be informed that nonsurgical management typically yields successful outcomes, and up to one-third of patients will convert to surgical management and may have decreased functional results if surgery is delayed. An RCT in 201921 compared nonsurgical management with ORIF in 60 patients and found a shorter time to union in the ORIF group with no difference in DASH scores at 12 months.
Distal Humeral Fractures
Distal humeral fractures range from high-energy injuries in the young patient to low-energy injuries in the geriatric population. In patients with adequate bone quality and a fracture that is reconstructable, ORIF provides the best opportunity to achieve a functional elbow. Total elbow arthroplasty (TEA) for elderly patients with poor bone quality and/or fractures that are not reconstructable has become increasingly more common.
A meta-analysis of 362 patients from 5 well-designed studies compared those who underwent ulnar nerve transposition with those who had in situ release of the ulnar nerve at the time of fixation.22 This study found
that there was a higher rate of ulnar neuropathy in the transposition group (23.5% versus 15.3%) and recommended against regularly transposing the nerve at the time of fixation. A 2019 follow-up study from a prior RCT reported the results of 15 patients treated with ORIF and 25 treated with TEA with a mean follow-up of 12.5 years for patients still alive and 7.7 years for deceased patients.23 Four of 15 in the ORIF group and 3 of 25 in the TEA group underwent revision surgery, with 1 revision TEA, 1 heterotopic ossification excision, and 1 elbow contracture release. A total of 7 patients treated with TEA were living with their original implant and 15 had died with functioning implants in place.
that there was a higher rate of ulnar neuropathy in the transposition group (23.5% versus 15.3%) and recommended against regularly transposing the nerve at the time of fixation. A 2019 follow-up study from a prior RCT reported the results of 15 patients treated with ORIF and 25 treated with TEA with a mean follow-up of 12.5 years for patients still alive and 7.7 years for deceased patients.23 Four of 15 in the ORIF group and 3 of 25 in the TEA group underwent revision surgery, with 1 revision TEA, 1 heterotopic ossification excision, and 1 elbow contracture release. A total of 7 patients treated with TEA were living with their original implant and 15 had died with functioning implants in place.
Fracture-Dislocations of the Elbow
The most frequently discussed fracture-dislocations about the elbow are terrible triad and Monteggia fractures. Terrible triad injuries are characterized by elbow dislocation, radial head/neck fracture, and a coronoid fracture. Monteggia fractures are fractures of the proximal ulna associated with a radial head dislocation and are distinguished from transolecranon fracture-dislocation in that the proximal radioulnar joint is disrupted (Figure 1). There is limited high-quality literature regarding these complex injuries that are difficult to manage and are often accompanied by complications.
Terrible Triad Injuries
A 2019 meta-analysis evaluated 115 patients with terrible triad injuries from four studies and found that patients who underwent radial head arthroplasty (n = 64) rather than ORIF (n = 51) had better DASH scores, Mayo Elbow Performance scores (MEPS), better ROM, and fewer postsurgical complications.24 The largest cohort study to date that was recently published retrospectively reviewed 62 terrible triad injuries with more than 1-year follow-up. The study authors found a 45% revision surgery rate due to stiffness (21%), symptomatic hardware (18%), ulnar neuropathy (16%), instability (6%), incisional neuroma (2%), and wound problems (2%).25 In contrast to the aforementioned meta-analysis the only factor correlated with revision surgery was radial head treatment in favor of ORIF. However, these findings are limited in that only 4 of the patients underwent ORIF, whereas 55 had radial head replacements, and 3 had radial head excisions.
Monteggia Fractures
A retrospective multicenter study was performed in 2018 to evaluate midterm results of 46 patients after ORIF of Monteggia fractures with or without radial head replacement or fixation.26 Using the Mayo Modified Wrist Score and the MEPS, results were excellent (63% and 68%, respectively). A 2019 study evaluated 78 patients with Monteggia fractures and found that those with associated coronoid fractures and Mason III radial head fractures requiring arthroplasty were associated with significantly worse outcomes.27 A similar retrospective study conducted in 2020 evaluated Monteggia-like injuries that had associated radial head fractures requiring replacement among 27 patients.28 A complication rate of 41% was reported, leading to 15 revision surgeries in 9 patients (33%).
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