Shoulder Trauma: BoneShoulder Trauma: Bone

Department of Orthopaedics, CKUHDepartment of Orthopaedics, CKUH

Sen-Jen LeeSen-Jen Lee

Reference: Orthopaedic Knowledge Update 6Reference: Orthopaedic Knowledge Update 6

Proximal Humeral FracturesProximal Humeral Fractures

4% to 5% of all fractures4% to 5% of all fractures 85% of proximal humeral fractures are minim85% of proximal humeral fractures are minim

ally displacedally displaced Result from falls and involve osteoporotic bonResult from falls and involve osteoporotic bon

ee The humeral neck is the weakest region of thThe humeral neck is the weakest region of th

e proximal humeruse proximal humerus Blood supply Blood supply

Anterior humeral circumflex artery Anterior humeral circumflex artery

Proximal Humeral FractureProximal Humeral Fracture

Classification of Proximal Humeral Classification of Proximal Humeral Fractures: 4-part System of NeerFractures: 4-part System of Neer

Humeral head, greater tuberosity, lesser tubeHumeral head, greater tuberosity, lesser tuberosity, and humeral shaftrosity, and humeral shaft

Determination of displacement >1 cm or anguDetermination of displacement >1 cm or angulation > 45lation > 45

Radiographic imaging, the trauma series: scaRadiographic imaging, the trauma series: scapular anteroposterior (AP), lateral, and axillarpular anteroposterior (AP), lateral, and axillary radiographs y radiographs

The Treatment of Proximal The Treatment of Proximal Humeral FracturesHumeral Fractures

Based on: patient age, bone quality, medical Based on: patient age, bone quality, medical comorbidities, other concurrent injuries, and frcomorbidities, other concurrent injuries, and fracture typeacture type

Plate and screw fixationPlate and screw fixation and and ender nails with fender nails with figure-of-8 tension bandigure-of-8 tension band were the strongest co were the strongest constructs nstructs

Tension band with nonabsorbable suture or wTension band with nonabsorbable suture or wireire were the weakest fixation were the weakest fixation

The Treatment of Proximal The Treatment of Proximal Humeral FracturesHumeral Fractures

For minimally or nondisplaced fracturesFor minimally or nondisplaced fractures Nonsurgical treatmentNonsurgical treatment Early passive motion within 14 days is recommendEarly passive motion within 14 days is recommend

ed for stable fractures. ed for stable fractures. Active range of motion is started at 4 to 6 weeks wActive range of motion is started at 4 to 6 weeks w

hen healing is evidenthen healing is evident 77% resulted in good or excellent results77% resulted in good or excellent results

Two-part Fractures of the Two-part Fractures of the Surgical NeckSurgical Neck

Mode of treatment depends on the stability of Mode of treatment depends on the stability of the fracture.the fracture. CRCR CR + percutaneous pinsCR + percutaneous pins OR + IFOR + IF

• Ender nails with figure-of-8 tension banding or plate and Ender nails with figure-of-8 tension banding or plate and screwscrew

Surgical reconstruction of nonunions of the suSurgical reconstruction of nonunions of the surgical neck remains challengingrgical neck remains challenging

Two-part Fractures of the Two-part Fractures of the Greater tuberosityGreater tuberosity

Commonly occurCommonly occur In conjunction with a glenohumeral dislocation.In conjunction with a glenohumeral dislocation. Rule out an associated surgical neck fracture befoRule out an associated surgical neck fracture befo

re attempting reductionre attempting reduction

ORIFORIF Superior or posterior displacement > 5 to 10 mm Superior or posterior displacement > 5 to 10 mm Fixation of the tuberosity fragment with repair of thFixation of the tuberosity fragment with repair of th

e rotator cuff tear e rotator cuff tear • Intraosseous sutures incorporating the cuff insertionIntraosseous sutures incorporating the cuff insertion• Screw fixation Screw fixation • acromioplastyacromioplasty

Two-part Fractures of the Lesser tTwo-part Fractures of the Lesser tuberosityuberosity

Rare and can be associated with posterior Rare and can be associated with posterior shoulder dislocations.shoulder dislocations.

Treatment of 3- and 4-part FracturTreatment of 3- and 4-part Fractures of Proximal humeruses of Proximal humerus

ControversialControversial Anatomical reduction > residual displacement.Anatomical reduction > residual displacement. Techniques: Techniques:

Ender nails with figure-of-8 tension band Ender nails with figure-of-8 tension band percutaneous reduction and screw fixationpercutaneous reduction and screw fixation

Four-part fractures usually are treated with huFour-part fractures usually are treated with humeral head replacement.meral head replacement. ORIF: osteonecrosis --9% to 11%ORIF: osteonecrosis --9% to 11% Humeral head replacementHumeral head replacement 73% of patients had difficulty with some functional ta73% of patients had difficulty with some functional ta

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Fractures of the ClavicleFractures of the Clavicle

4% to 15% of all fractures and 35% of fractur4% to 15% of all fractures and 35% of fractures about the shoulderes about the shoulder

85%: middle third of the clavicle85%: middle third of the clavicle Associated injuries occur in less than 3% Associated injuries occur in less than 3% Direct trauma > indirect mechanism( fall onto Direct trauma > indirect mechanism( fall onto

the outstretched hand)the outstretched hand)

Fractures of the M/3 ClavicleFractures of the M/3 Clavicle

Sternocleidomastoid and trapezius muscles Sternocleidomastoid and trapezius muscles tthe weight of the arm and pectoralis majorhe weight of the arm and pectoralis major

Nonsurgical treatmentNonsurgical treatment Figure-of-8 bandage or sling for 6 weeks Figure-of-8 bandage or sling for 6 weeks Shortening and a residual painless deformityShortening and a residual painless deformity

Indications for surgical treatmentIndications for surgical treatment Open fracturesOpen fractures Neurovascular injury/compromiseNeurovascular injury/compromise Displaced fractures with impending skin compromiseDisplaced fractures with impending skin compromise

Fractures of the L/3 ClavicleFractures of the L/3 Clavicle

Coracoclavicular (C-C) ligamentsCoracoclavicular (C-C) ligaments Type I: minimally displaced Type I: minimally displaced

Interligamentous fractures between the conoid and Interligamentous fractures between the conoid and trapezoid trapezoid

Between the coracoclavicular and coracoacromial Between the coracoclavicular and coracoacromial ligaments.ligaments.

Type II: displaced Type II: displaced Lateral to the coracoclavicular ligaments with C-C lLateral to the coracoclavicular ligaments with C-C l

igments ruptureigments rupture Type III fractures involve the articular surface Type III fractures involve the articular surface

of the lateral clavicle with no ligamentous injuof the lateral clavicle with no ligamentous injuryry

Treatment of L/3 clavicular fracturTreatment of L/3 clavicular fracturee

Type I fractures are stable and treated in the saType I fractures are stable and treated in the same manner as middle third fracturesme manner as middle third fractures

Treatment for the unstable type II fractures remTreatment for the unstable type II fractures remains controversial.ains controversial. ORIF for displacementORIF for displacement

Type III fractures can be adequately managed nType III fractures can be adequately managed nonsurgicallyonsurgically Distal clavicle resection is the procedure of choice if sDistal clavicle resection is the procedure of choice if s

ymptomatic degenerative disease occurs.ymptomatic degenerative disease occurs.

Complications After clavicular FraComplications After clavicular Fracturesctures

The incidence of nonunionThe incidence of nonunion 0.9% to 4.0%. 0.9% to 4.0%.

Acute laceration of the subclavian vessels or Acute laceration of the subclavian vessels or brachial plexus injury.brachial plexus injury.

Malunion is common and rarely symptomatic Malunion is common and rarely symptomatic but can cause an unacceptable prominence. but can cause an unacceptable prominence. Surgical intervention to improve cosmesis maSurgical intervention to improve cosmesis may result in an ugly scar or a painful nonunion.y result in an ugly scar or a painful nonunion.

Fractures of the ScapulaFractures of the Scapula

0.5% to 1% of all fractures and 3% to 5% of s0.5% to 1% of all fractures and 3% to 5% of shoulder fracturehoulder fracture

High-energy traumaHigh-energy trauma Associated injuries: severe and life-threateningAssociated injuries: severe and life-threatening Ipsilateral rib fracture with Ipsilateral rib fracture with

• Hemopneumothorax (27% to 54%) Hemopneumothorax (27% to 54%) • Clavicular fracture (17% to 38%)Clavicular fracture (17% to 38%)• Closed head injury (11% to 57%)Closed head injury (11% to 57%)• Injury to the face and skull (10% to 24%)Injury to the face and skull (10% to 24%)• Brachial plexus disruption (3% to 8%)Brachial plexus disruption (3% to 8%)

Fractures of the ScapulaFractures of the Scapula

True scapular AP and lateral views and an axiTrue scapular AP and lateral views and an axillary view (trauma series)llary view (trauma series)

West point axillary viewWest point axillary view Stryker notch viewStryker notch view CT scanCT scan

Classification of Scapular Classification of Scapular FracturesFractures

Fractures of the body and spine (50%)Fractures of the body and spine (50%) Short-term immobilization in a sling and swathe bandaShort-term immobilization in a sling and swathe banda

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Scapular neck (25%)Scapular neck (25%) ORIF: if the glenoid fragment is displaced > 1 cm or aORIF: if the glenoid fragment is displaced > 1 cm or a

ngulated > / = 40°ngulated > / = 40°

Acromion (7%)Acromion (7%) ORIF: encroach on the subacromial space and interferORIF: encroach on the subacromial space and interfer

e with rotator cuff functione with rotator cuff function

coracoid process (3%) fractures.coracoid process (3%) fractures.

Glenoid Fracture (Ideberge Classifi.)Glenoid Fracture (Ideberge Classifi.)

Intra-articular glenoid Fractures Intra-articular glenoid Fractures

Type I fractures involve the glenoid rim.Type I fractures involve the glenoid rim. ORIF: 25% of the anterior glenoid or 33% of the pORIF: 25% of the anterior glenoid or 33% of the p

osterior glenoid with fracture displacement > 10 mosterior glenoid with fracture displacement > 10 mmm

Types II through VITypes II through VI ORIF:ORIF:

• Subluxation of the humeral head with a major fragment Subluxation of the humeral head with a major fragment • > / = 5 mm intra-articular step-off> / = 5 mm intra-articular step-off• Severe separation between the glenoid fragmentsSevere separation between the glenoid fragments

Shoulder Girdle Unstable: Shoulder Girdle Unstable: Complexity of Scapular FracturesComplexity of Scapular Fractures

Superior shoulder suspensory complex (Superior shoulder suspensory complex (SSSSSSCC): ): Glenoid process, coracoid process, coracoclaviculGlenoid process, coracoid process, coracoclavicul

ar ligaments, distal clavicle, acromioclavicular jointar ligaments, distal clavicle, acromioclavicular joint, and acromial process, and acromial process

ORIF is indicated for double disruption ORIF is indicated for double disruption Often surgical stabilization at 1 siteOften surgical stabilization at 1 site

““Floating shoulder”: M/3 clavicle and glenoid Floating shoulder”: M/3 clavicle and glenoid neck neck Treated by surgical stabilization of the clavicle or aTreated by surgical stabilization of the clavicle or a

cromioclavicular jointcromioclavicular joint

Shoulder Girdle Unstable: Shoulder Girdle Unstable: Complexity of Scapular FracturesComplexity of Scapular Fractures

Scapulothoracic DissociationScapulothoracic Dissociation

A rare, often fatal, closed injury manifested by lA rare, often fatal, closed injury manifested by lateral displacement of the scapula with associatateral displacement of the scapula with associated neurovascular injury and either acromioclavied neurovascular injury and either acromioclavicular or sternoclavicular separation or clavicular cular or sternoclavicular separation or clavicular fracturefracture

A severe direct force over the shoulder accompA severe direct force over the shoulder accompanied by traction applied to the upper extremity anied by traction applied to the upper extremity is the mechanism of injuryis the mechanism of injury

As a "closed, traumatic forequarter amputation.As a "closed, traumatic forequarter amputation." "

Humeral Shaft FracturesHumeral Shaft Fractures

3% of all fractures3% of all fractures Direct load : Direct load :

Short / long oblique fracture Short / long oblique fracture ± butterfly fragment± butterfly fragment

Indirect torque Indirect torque A spiral fractureA spiral fracture

The neurovascular status of the limb must be The neurovascular status of the limb must be assessedassessed

Nonsurgical Treatment of Humeral Nonsurgical Treatment of Humeral Shaft FracturesShaft Fractures

CR and immobilization with splint or hanging arm casCR and immobilization with splint or hanging arm cast followed by a functional brace at 1 to 2 weekst followed by a functional brace at 1 to 2 weeks 2020 of anterior or posterior angulation, of anterior or posterior angulation, 3030 of varus or valgus angulation, and of varus or valgus angulation, and 3 cm of shortening3 cm of shortening

Contraindications to use of the functional brace Contraindications to use of the functional brace Massive soft-tissue or bone lossMassive soft-tissue or bone loss An unreliable or uncooperative patientAn unreliable or uncooperative patient An inability to obtain or maintain acceptable fracture alignmeAn inability to obtain or maintain acceptable fracture alignme

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Range of motion (ROM) exercisesRange of motion (ROM) exercises

Surgical Treatment of Humeral Surgical Treatment of Humeral Shaft FracturesShaft Fractures

Indications Indications Open fracture, except low-energy handgun wound Open fracture, except low-energy handgun wound Associated vascular injury Associated vascular injury Floating elbow Floating elbow Segmental fracture Segmental fracture Pathologic fracture Pathologic fracture Bilateral humeral fractures Bilateral humeral fractures Humeral fracture in polytrauma patientHumeral fracture in polytrauma patient Neurologic loss after lacerating injury Neurologic loss after lacerating injury Neurologic loss during closed fracture alignment inability Neurologic loss during closed fracture alignment inability

to maintain acceptable alignment to maintain acceptable alignment Displaced intra-articular fracture extensionDisplaced intra-articular fracture extension

Surgical Treatment of Humeral Surgical Treatment of Humeral Shaft FracturesShaft Fractures

Surgical fixation using plates and screws Surgical fixation using plates and screws Dynamic compression plate Dynamic compression plate Reconstruction plates, T platesReconstruction plates, T plates The surgeon should obtain 5 to 6 cortices of fixation both proThe surgeon should obtain 5 to 6 cortices of fixation both pro

ximal and distal to the fractureximal and distal to the fracture Intramedullary fixation Intramedullary fixation

Flexible IM devices: ender pins, and rush rodsFlexible IM devices: ender pins, and rush rods Locked IM nailsLocked IM nails

Results and outcomesResults and outcomes 96% united with an average time to union of 9.5 weeks for cl96% united with an average time to union of 9.5 weeks for cl

osed fractures and 13.6 weeks for open fracturesosed fractures and 13.6 weeks for open fractures

Results and OutcomesResults and Outcomes

CR & immobilization with functional brace: CR & immobilization with functional brace: 96% united96% united Varus deformity: average, 9Varus deformity: average, 9 External rotation: lost between 5External rotation: lost between 5 and 45 and 45

ORIF with plates and screws: ORIF with plates and screws: 87%87% (102 p’ts) (102 p’ts) 5 early failures of internal fixation, 2 nonunions, and 4 postoper5 early failures of internal fixation, 2 nonunions, and 4 postoper

ative infectionsative infections

ORIF with IM flexible rods or nails: ORIF with IM flexible rods or nails: 94%94% (58 p’ts) (58 p’ts) Antegrade nailing: excellent resultsAntegrade nailing: excellent results Retrograde nailing: poor results Retrograde nailing: poor results

ORIF with an interlocked IM nail: ORIF with an interlocked IM nail: 100%100% (51 p’ts) (51 p’ts) 3 transient brachial plexus neurapraxias, 2 infections, 3 cases 3 transient brachial plexus neurapraxias, 2 infections, 3 cases

of nail impingement, and 2 intraoperative fracturesof nail impingement, and 2 intraoperative fractures

Complications of Humeral Shaft Complications of Humeral Shaft FracturesFractures

Radial nerve injury: up to 18% Radial nerve injury: up to 18% Most commonly associated with M/3 fractureMost commonly associated with M/3 fracture Neurapraxia or axonotmesis; 90% will resolve in 3 to 4 Neurapraxia or axonotmesis; 90% will resolve in 3 to 4

monthsmonths

Vascular injuryVascular injury Nonunion: 7%Nonunion: 7% Pathologic fracturesPathologic fractures

Interlocked nail is the implant of choice for these fInterlocked nail is the implant of choice for these fractures ractures