The intended purpose of this book is to provide a practical and useful compendium of indications and techniques for the management of the full range of trauma from the upper extremity from the shoulder to the forearm. The subject of complex trauma of the upper limb is thoroughly addressed in the 18 chapters of this volume.
Preface
Acknowledgments
Contributors
Assistant Professor of Orthopedic Surgery Weill Cornell University College of Medicine Assistant Attending Orthopedic Surgeon Hospital for Special Surgery New York, New York. Assistant Professor of Orthopedic Surgery Weill College of Medicine Cornell University Hospital for Special Surgery.
Anatomy and Embryology of the Clavicle
Codman, 1934 The incidence of clavicle fractures is 50 per 100,000 population per year; only 4% of all fractures involve the clavicle. The management of this fracture, however, has recently evolved because new evidence has shown the importance of proper healing of the clavicle.
Function of the Clavicle
It seems to me that the clavicle is one of the greatest legacies of the human skeleton, because it depends to a greater extent than most animals, except monkeys and apes, on the use of its hands and arms. With the new importance of fitness as a vital principle and the resulting increase in sports activities, clavicle fractures are occurring more frequently in the general population, mainly in young people.
Classification
1 Operative Treatment of Fractures of the Clavicleof the Clavicle
In Neer's type II (Fig. 1–3), the break lies between the conoid and trapezoidal components of the CC ligaments. Occasionally, distinction is difficult when radiographic displacement of the proximal fragment does not indicate ligament damage.
Epidemiology
Patient Assessment
Fracture Mechanism
Treatment
Nonsurgical Treatment
Regarding the consequences after clavicle fractures, it is important not to focus only on non-union, which may not entail clinical symptoms, but to focus more on malunion, which may be responsible for pain, neurovascular symptoms, cosmetic complaints and functional deficits. .
Surgical Treatment
After a small skin incision, the T handle is changed to the other end of the pin. The end of the dorsal side is bent up to 90 degrees and the head is embedded in the surrounding soft tissues.
Postoperative Care
A comparison between tension strap wire and hook plate was carried out by Flinkkila et al. (47). They found a consistent score of 84 points in the K-thread group and 90 points in the hook plate. The mean follow-up was 6 years in the K-wire group, 2 years in the other group.
Conclusion
Can we predict long-term consequences after fractures of the clavicle based on initial findings. Fractures of the clavicle are often classified based on location according to Allman6 into middle third (type I), outer third (II), and medial third (III).
History
Fractures at both ends of the collarbone are much less common, but require surgical intervention relatively more often. The non-consolidating type of the clavicle is usually classified into atrophic, oligotrophic and hypertrophic according to Weber and Çech7.
Physical Examination
A recent systematic review of 2144 midclavicular fractures found that nonoperative treatment of 1145 fractures resulted in a nonunion rate of 5.9%. Distal or lateral fractures and nonunions of the clavicles were also classified by Neer based on their association with the coracoclavicular (CC) ligaments (types I and II) and whether the fracture extended into the acromioclavicular (AC) joint or not (type III) .8 Fractures of the medial clavicle and resulting nonunion are often a dislocation of the growth plate fracture (Salter–Harris I or II) when seen in patients younger than 25 years when the growth plate of the medial end of the clavicle finally closes.
2 Nonunions of the Clavicle
Medial clavicle fractures can (partially) obstruct the esophagus and upper airway when the displacement is posterior, and most of these will need reduction and stabilization.4 Although a large Scandinavian study reported good results after non-operative treatment of lateral clavicle fractures, there is an ongoing debate as to whether lateral clavicle fractures (intra- and extra-articular) should be fixed.5 Although nonunion of the medial and (mostly) lateral clavicle is not uncommon, literature on how to treat these is sparse. Lack of sensory and motor function of the shoulder and arm as well as vascular deficiencies should be documented.
Radiologic Evaluation
Brachial plexus palsies secondary to nonunion of the clavicle most often affect the medial cord and mainly cause ulnar nerve symptoms. The nonunions associated with brachial plexus palsies are usually hypertrophic and located in the midshaft where the medial cord crosses the clavicle (Fig. 2–1).
Laboratory Studies
A straight 3.5-mm plate (standard pelvic reconstruction, limited contact dynamic compression plate [LC-DCP], DCP, or reconstruction locking compression plate [LCP]) is contoured to fit the superior or anteroinferior aspect of the clavicle. Our experience with the anteroinferior position of the plate is that patients rarely request removal.
Summary
Using the same anteroinferior plate positioning techniques, one of the authors (PK) has treated 20 nonunion mid-clavicles with comparable results with a titanium 3.5-mm LCP reconstruction plate and autologous bone graft over the past 6 years. Poster presented at: 20th Annual Meeting of the Orthopedic Trauma Association; October Salt Lake City, UT.
Glenoid Fractures
Appropriate clinical suspicion, a complete radiographic examination and a thorough knowledge of the bony and ligamentous anatomy of the shoulder girdle will allow appropriate treatment to maximize the chance of a good outcome. Due to the complex bony anatomy and often overlapping cortical bone on radiographs, complete visualization of the fracture anatomy can be difficult.
3 Treatment of Glenoid Fractures and Injuries to the Superior Shoulder
However, the type of fracture and the location of the major fragments allow for a general approach to the injury. Figure 3–3 (A–D) The preferred approach for most glenoid fractures is posteriorly through the lesser infraspinatus-teres interval.
Injuries to the Superior Shoulder Suspensory Complex
Later authors reiterated these recommendations and added that reduction and stabilization of the glenoid neck is often achieved indirectly only after fixation of the clavicle. Fracture of the neck of the scapula - impact of persistent glenoid neck abnormality on clinical outcome.
Etiology and Mechanism of Injury
However, treatment of displaced greater tuberosity fractures is subject to controversy regarding indications for operative treatment, surgical approach, and choice of optimal fixation to maintain anatomic reduction. Although acute anterior glenohumeral dislocations13,14 and simultaneous rotator cuff tears15 are often associated with larger tuberosity fractures, in this chapter we will focus on the diagnosis and optimal treatment of isolated tuberosity fractures with an emphasis on determining surgical indications. operative techniques and postoperative management.
Anatomy
Isolated tuberosity fractures, however, have a significantly lower reported incidence.1–6 In a review of 930 operatively treated fractures of the proximal humerus at the AO Documentation Center (Davos Platz, Switzerland), less than 2% were isolated tuberosity fractures.7 Several authors have suggested that they may isolated fractures of the greater tuberosity are underreported due to misdiagnosis caused by commonly seen radiographic findings. 1,8–12 The general consensus in the literature is that nondisplaced tuberosity fractures can be treated nonoperatively. These injuries can be deceptively difficult to treat surgically, as they often consist of suboptimal fragments for traditional internal fixation techniques, and the muscle forces acting on the greater tuberosity can make achieving and maintaining reduction more challenging than preoperative imaging would suggest.
Isolated Tuberosity Fractures
This distance progressively increased to a mean distance of 13.9 mm at the inferior aspect of the teres minor insertion. The anterolateral branch of the anterior humerus circumflex artery travels superiorly in the lateral aspect of the intertubercular groove to enter bone as it approaches the greater tuberosity and this branch then becomes the arcuate artery.
Indications for Surgery
Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity. The effect of displaced fractures of the greater tuberosity on shoulder mechanics.
Percutaneous Pinning of Proximal Humeral Fractures
30 degrees of retroversion of the humeral head relative to the epicondylar axis of the distal humerus. It is important to restore the height, slope and retroversion of the humeral head.
6 Open Reduction and Internal Fixation of Proximal Humeral Fractures Using
Anatomy of the Proximal Humerus
Classifications of Proximal Humeral Fractures
In principle, both surgical and conservative treatment can be considered for fractures of the proximal humerus. The majority of fractures of the proximal humerus can be treated non-operatively with good expected results.
Types of Proximal Humeral Fractures
The surgical treatment of such problems is particularly challenging due to disruption of the normal tuberosity. In rare cases, a proximal humerus fracture or the extent of the injury is not fully appreciated.
Two-Part Surgical Neck Malunions
As the average age of the population increases, the prevalence of proximal humerus fractures and the late consequences of such fractures increases. Successful treatment of proximal humerus malunions requires a thorough preoperative evaluation, a meticulous preoperative plan, a comprehensive understanding of the necessary surgical techniques, and a well-developed postoperative rehabilitation protocol.
Two-Part Tuberosity Malunions
In many cases, the treating physician willingly accepts a non-anatomical extension due to the patient's age or underlying medical problems. It is often difficult to obtain good screw purchase in the cancellous bone of the humeral head or tuberosity, and displacement may occur.
Proximal Humeral Malunions
Isolated malunions of the lesser tuberosity result from medial pulling of the fragment due to the pulling force of the subscapularis. This displacement causes a spreading in the anterior fibers of the rotator cuff at the rotator interval, causing a bony prominence.
Three- and Four-Part Malunions
Fracture-Dislocation Malunions
A careful assessment of the motor strength of the axillary, musculocutaneous and suprascapular nerves should be made. It is important to remember that sensory deficit at the lateral border of the deltoid is not a reliable indicator of axillary nerve injury.
Radiologic Assessment
If avascular necrosis is absent and the articular surface of the humeral head is preserved, In some cases, the humeral head may have articular surface damage involving 40% of the surface.
Operative Treatment of Proximal Humeral Nonunions
In all these techniques, the purchase of the screws in the head of the humerus is at risk. A two-band tension technique for the treatment of surgical neck of humerus nonunions.
9 Arthroplasty for Proximal Humeral Fractures
Epidemiology and Mechanism of Injury
Once control of the tuberosities is achieved, the humeral head is released from the glenohumeral joint. The effect of tuberosity placement on the results of hemiarthroplasty for fractures of the proximal humerus.
Etiology
Varus valgus and anteroposterior angulation remained within 5 degrees.2 Perfect alignment is not essential; An angulation of 20 to 30 degrees and a shortening of up to 3 cm can be tolerated in the upper extremity without significant functional limitations.1 The angulation can be compensated functionally by movement of the shoulder and elbow and aesthetically by the muscles and subcutaneous tissue. tissues of the arm. Nonunion of the humeral shaft occurs when the healing process, which should be complete within four months, does not progress.1 If union is not observed within 24 to 32 weeks of the injury, the fracture is unlikely to occur. healed and is being considered. Nonunion.1,3 Nonunion of the humeral shaft occurs in up to 10% of fractures treated nonoperatively and in up to 15% of fractures treated surgically.1–4As If a non-union occurs, the fracture lines will become wider and the edges will become wider. sclerotic.
Nonunions of the Humeral Shaft
Plate ORIF of the humeral shaft delayed unions and nonunions of the humeral shaft: is healing dependent on the type of bone graft. The radial nerve crosses the posterior aspect of the humerus ∼20 cm proximal to the medial epicondyle.
Complex Fractures of the Distal Humerus
Several technical points will facilitate the internal fixation of the more complex articular fractures. The fracture can be shortened to improve bone contact and stability of the plate fixation.
Timing of Surgery
Total Elbow Arthroplasty
Open reduction and internal fixation of the distal humerus: Functional outcome in the elderly. Complex fractures of the distal humerus in the elderly: the role of total elbow replacement as primary treatment.
Open Reduction and Internal Fixation for Fractures about the Elbow in the Elderly
Anatomy of the Elbow
Epidemiology and Mechanisms of Injury
Recently, O'Driscoll added an additional fracture pattern (type IV) to describe a sagittal plane fracture of the coronoid that involves attachment of the anterior bundle of the medial collateral ligament.16 The Colton classification of olecranon fractures reflects the displacement and anatomy of the fracture and thus provides guidance regarding the biomechanical the most appropriate type of fixation. Additional levels are added based on the position and orientation of the fault line and the degree of comminution.
Clinical Examination
Fractures are described as nondisplaced and stable if they are displaced less than 2 mm and show no change in position with gentle flexion to 90 degrees or with extension against gravity. Displaced fractures can be further divided into avulsion fractures, transverse or oblique fractures, isolated comminuted fractures or fractures with associated dislocations.17.
Goals of Fracture Management in the Elderly
Those with displaced fractures usually have a marked deformity, and attempted movement may produce painful bony crepitus. Thorough assessment for concomitant diseases that trigger the injury (such as arrhythmia) and a detailed account of comorbid conditions are important.
Classification of Elbow Fracture
An assessment of range of motion (ROM) or elbow strength should not be pursued vigorously. A careful neurovascular examination, particularly of the ulnar nerve, is essential before any planned elbow manipulation.
Radiographic Assessment
An important sign to look for in isolated olecranon fractures is the inability to actively extend the elbow against gravity. Although pain may make it difficult to obtain patient cooperation, this inability indicates a disruption of the triceps mechanism.
Distal Humerus Fractures
Preformed anatomical plates are available and may be useful when delivering a lower profile implant on the medial side. In addition, angular fixed locking plates have been introduced with the potential benefit of improved stability and pull-out strength within the osteoporotic bone of the distal fragment.4,28 Regardless of implant choice, the distal placement of plates around the distal fragment may be imperative, thus relying on a combination of plate strength , placement of as many screws as possible in the distal fragment and interdigitation of screws in the distal fragment to optimize stability.24 A portable radiograph should be taken after fixation.
Proximal Ulnar Fractures
The wire is then passed deep to the triceps fibers adjacent to the bone below the K-wires. A posterior midline incision with the center of the olecranon is extended proximally 5 cm from the tip of the olecranon.
Radial Head Fractures
In the osteoporotic olecranon, direct trauma to the posterior aspect of the elbow can result in an isolated, severely comminuted fracture. Wound healing problems are sometimes seen, most commonly in the elderly due to pressure over the posterior aspect of the elbow.
Total Elbow Arthroplasty for Distal Humeral Fractures
Outcomes of Open Reduction and Internal Fixation
They suggested that TEA could be used successfully for severely comminuted fractures of the distal humerus in elderly patients. These patients are at increased risk of pathologic fracture of the distal humerus even with minor elbow injury.
Acute Fracture-Dislocations about the Elbow
Taken together, these studies highlight (1) the difficulties in treating these complex injuries, (2) reduction of the coronoid fragment is critical to restoring elbow stability, and (3) radial head resection is contraindicated. when the elbow is unstable. Implantation of a rigid radial head without coronoid bone reconstruction restored elbow stability.
Associated Radial Head Fractures
Posterior dislocation of the elbow is usually caused by a fall on the outstretched hand or wrist with either a hyperextension or posterolateral rotating mechanism. O'Driscoll et al described a combination of valgus stress and forearm supination with axial compression through the lateral column of the elbow as a mechanism for elbow dislocation.
Associated Proximal Ulna Fractures
The redesigned screw holes allow for a greater angle of screw placement and the possibility of compression from both sides of the screw hole. Proximal fixation of the plate is often the most challenging and cancellous screws should be used instead of cortical screws.
The Terrible Triad
The advent of newer preformed plates allows for a greater number of fixation points in the proximal fragment and 'cradles' the olecranon along the dorsal surface.
Monteggia Lesion
Excision of the radial head without replacement is contraindicated in elbow dislocation. Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow.
Reconstruction of Posttraumatic Stiffness and Instability
After a skin incision, the ulnar nerve is identified at the medial border of the triceps. The triceps and anconeus are raised from the posterior surface of the distal humerus and posterior ulnar capsule.
Patient Asssessment
Good and excellent results can be expected after anatomic reduction and rigid internal fixation of intra-articular fractures of the distal humerus.1-3 However, in a small subset of patients, complications such as elbow stiffness and periarticular fibrosis, heterotopic ossification , ulnar neuritis, malunion and delayed union or nonunion occur.2 Fortunately, the prevalence of delayed fusions and nonunions of the distal humerus is low, ranging from 2 to 10%. free and treatable with braces in a small minority of patients, most patients complain of a fragile, painful, and essentially nonfunctional upper extremity. Proximity of the ulnar nerve with periarticular elbow instability often leads to worsening of an existing ulnar neuritis that interferes with the patient's disability.
Nonunions of the Distal Humerus
The delayed union and non-union can be classified into supracondylar, transcondylar, T-condylar (or intercondylar) and low transcondylar according to Mitsunaga and colleagues. In our experience, the vast majority of patients with nonunion of the distal humerus will benefit from surgical intervention and will be able to undergo the proposed treatment.
Surgical Reconstructive Procedures
Proximally, the distal aspect of the intermuscular septum should be released to increase the mobility of the ulnar nerve. Open reduction and internal fixation of delayed and nonunion fractures of the distal humerus.
17 Nonunions and Malunions of Monteggia Fracture Dislocations
Reconstruction of the coronoid with a fragment of the radial head of the olecranon can be considered. Instability with subluxation (9 patients) or dislocation (2 patients) of the ulnohumeral joint occurred.
Diaphyseal Forearm Nonunion
There are also two articular components: the proximal joints (PRUJs) and the distal radioulnar joints (DRUJs), which allow rotation of the radius about a relatively fixed ulnar axis. In both scenarios, symmetrical shortening of both bones may not alter the congruity of the PRUJ or DRUJ, provided there is no significant associated angular deformity.
Nonunions, Malunions, and Synostosis of Forearm Fractures
Depending on the shortening and angulation, there may be a simultaneous dislocation of the radial head. The skin portion of the graft is sutured into the overlying soft tissue defect.
Postoperative Rehabilitation
In long-standing cases, open reduction of the radial head and annular ligament reconstruction may be necessary. It must be kept in mind that revascularization of freely morcellized cancellous graft is directly dependent on the vascularity of the soft tissue.
Results and Complications
Restoration of length in minor defects is achieved by fixing the plate with screws to the distal fragment and using a joint tension device in distraction mode at the proximal end of the plate. Figure 18–3 (A, B) Radiographs of an infected nonunion of the distal third of the radius after an open complex comminuted fracture.
Malunion of the Forearm Bones
However, successful long-term results have recently been reported using this technique for atrophic nonunions of the femur29,30 and humerus.31 The advantage of using "pressure-resistant corticocancellous bone blocks", as proposed by Weber and Çech,6 is the immediate reconstruction of the load-bearing capacity of the cortical part of the graft opposite the plate. Union and incorporation of the grafts are directly dependent on the length of the defect, the vascularity of the recipient points, the local perfusion of the soft tissues, the mechanical stability and the absence of infection.
Potential for Spontaneous Correction during Growth
If corticocancellar blocks are used, screw attachment to the plate is mandatory to minimize micromotion and promote undisturbed revascularization.
Pathomechanics and Clinical Correlation of Posttraumatic Forearm Deformity
Angular metaphyseal malunions of the proximal radius lead to significant radial head misalignment in the sigmoid notch and cause severe limitation of pronation. There is usually a valgus malalignment of the proximal radius, resulting in lateral subluxation of the radial head, resulting in significant misalignment of the PRUJ and radiocapitellar joint.
Interosseous Membrane
Chronic dislocation of the radial head can be the result of old unreduced Monteggia fractures with persistent ulna angulation or malunions with a length discrepancy between the radius and ulna. Finally, more complex patterns of proximal forearm fractures with associated articular disruption of the radial head, as in high-energy multifragmentary fractures, may develop massive rotator cuff contracture due to posttraumatic degenerative changes in the PRUJ and severe soft tissue contracture, including the IOM (Figure 2). 18–4).
Corrective Osteotomy of the Forearm Bones
