22. problems in the shoulder & elbo

8/13/2019 22. Problems in the Shoulder & Elbo

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22 Problems in the shoulder and elbow JON C. CLASPER and ANDREW J. CARR

Congenital abnormalities

Sprengels deformity

This is the most common congenital abnormality around the shoulder, and results

from a failure of normal descent of the scapula. In the embryo, the scapula forms in

the midcervical region, and then descends to its midthoracic position. With the

Sprengel deformity, the scapula is high, small and rotated, and in approximately 50

per cent of cases the scapula is connected to the cervical spine by the omovertebral

body, a fibrous or bony bar. In addition there may be other congenital deformities,

hich include rib abnormalities, scoliosis of the thoracic spine, or cervical spineabnormalities including the !lippel"#eil syndrome $congenital fusion of the cervical

vertebrae% $#ig. &&.'%.

Treatment

The ma(or problem is usually cosmetic rather than functional, and this is particularly

true for unilateral deformities. In these cases excision of the omovertebral body or

superior angle is performed. Surgery is occasionally re)uired to improve function, and

in these circumstances more complex reconstructive procedures are carried out.

Acquired conditions

The painful shoulder

*fter bac+ pain, shoulder pain is the second most common musculos+eletal problemseen by primary care physicians. The commonest causes of the painful shoulder in

adults are disorders of the rotator cuff, particularly the supraspinatus tendon.

*lthough conditions such as the painful arc syndrome, impingement, rotator cuff tears

and cuff tear arthritis are often considered as separate conditions, in reality they

are part of a spectrum of disorders of the supraspinatus tendon. ther causes of

shoulder pain include calcific tendonitis, fro-en shoulder and degenerative disease.

Disorders o t!e rotator cu

In common ith some other tendons of the body, the supraspinatus tendon has a

relatively poor blood supply, and this can predispose to both degenerative changes

and tearing of the tendon. The anterolateral portion of the tendon is initially affected

and selling of this portion may lead to impingement beteen the greater tuberosityof the humerus and the anterior acromion ith its attached coracoacromial $/*%

ligament. This leads to pain, particularly on active abduction or flexion, and initially

leads to a painful arc beteen 0'&0degree.

*bnormalities of the bone occur, ith hoo+ing of the anterior acromion. These are

probably secondary changes, rather than the primary cause of the pain, but surgical

treatment is often directed against the acromion and the /* ligament.

"istor# and e$amination

The patient is usually middle aged, and the initial symptoms may be due to a specific

traumatic incident or a period of overuse of the arm, or there may be no precipitating

events. The pain is activity related, particularly on overhead activities, such as

reaching up to shelves or hair ashing. 1ardening and household activities often


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produce symptoms. Some patients complain of significant ea+ness, and this may

indicate the presence of a rotator cuff tear.

On e$amination, there is often no local tenderness. *ctive movements may be

limited, and usually reproduce the symptoms, hich occur beteen 0'&0degree of

abduction and flexion $#ig. &&.&%. There is usually much less pain on passive

movements, and this confirms the mechanical nature of the pain. Wea+ness of bothsupraspinatus and infraspinatus may be demonstrated, and suggest the possibility of a

tear in the cuff. Specific impingement tests have been described and help to confirm

the diagnosis $#igs &&.2 and &&.3%. Radiographsmay be normal, but usually there are

signs of subacromial sclerosis.

Subacromial injectionof local anaesthetic and cortisone often leads to improvements

in the symptoms and they are used for both diagnostic and therapeutic purposes. If the

diagnosis is correct, the symptoms are usually improved. The benefit may only be

short lived, but this is a valuable diagnostic aid. Improvement in symptoms occurs for

a fe ee+s after the in(ection, but subse)uent relapse commonly occurs.

#urther investigations

* subacromial in(ection is the most useful diagnostic test, and this is easily performedin the outpatient clinic. #urther investigations such as ultrasound and magnetic

resonance imaging $4I% are used to determine the presence of a tear of the rotator

cuff if surgery is contemplated6 they have little place in the diagnosis of impingement

$#ig. &&.5%.

Treatment

It is li+ely that most patients ill settle ith conservative treatment. The initial

treatment is by cortisone in(ection, and this is repeated up to three times if there is

prolonged relief of symptoms. Specific physiotherapy has a role, particularly in the

early stages, but most patients ho present to specialist clinics ill only have a

limited response. Surgery is eventually re)uired in 50 per cent of these patients, and is

indicated hen symptoms, sufficient to limit activities, have been present for over a

year. 7ecompression of the rotator cuff is carried out, either arthroscopically, or by an

open procedure, ith removal of the anterior overhang and division of the /*

ligament. In addition, repair of a rotator cuff tear may be re)uired. In the absence of a

rotator cuff tear, the prognosis is good.

otator cuff tears

8atients ith rotator cuff tears are usually slightly older than patients ith

impingement. Tearing of the supraspinatus muscles also starts at the front lateral edge

of the tendon, and can progress posteriorly along the tendon, detaching it from the

greater tuberosity. The tendon retracts medially leading to a 9shaped tear. The

patient is usually unaare of the rotator cuff tearing, and large tears of several yearsduration may be present before the patient see+s medical attention $#ig. &&.%.

Small tears of the supraspinatus

These are very common and may be found in up to &0 per cent of the normal

population, in the absence of any specific shoulder symptoms. The tear is usually less

than ' cm in length and, in the absence of significant pain, is not of a sufficient si-e to

cause ea+ness of the shoulder.

Treatment of small tears. Treatment is dependent on the presence and severity of

impingement symptoms. In the absence of symptoms, the tear can be left unrepaired,

and the patient +ept under revie. 8rogression of the tear is an indication for repair. If

impingement is a significant problem, decompression is carried out, and the tear can

be repaired if appropriate.Intermediate tears


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Tears of &"2 cm $as measured on ultrasound% are usually associated ith symptoms

of impingement or ea+ness of the shoulder, and these ill often re)uire

decompression and repair of the supraspinatus. This can be carried out through a

lateral sabretype incision. The tendon is mobilised, and then sutured into a bony

trough created on the edge of the greater tuberosity, using osseous sutures. esults of

repair are good for intermediate tears, but full recovery ill ta+e several months.:argetears of the supraspinatus

These are often 5 cm or greater, and may extend into infraspinatus. They are usually

associated ith ea+ness of the shoulder, and abduction may be limited to 00, often

ith a characteristic bunching of the shoulder $#ig. &&.;%. With massive tears of the

rotator cuff, superior migration of the humeral head can occur, and this further

impairs function. In addition, secondary osteoarthritis of the glenohumeral head may

occur due to the resulting incongruity of the (oint.

Treatment of large tears. If symptoms of impingement or ea+ness are sufficient,

decompression and repair should be considered. 9nfortunately repair is not alays

possible as the medial edge of the tendon retracts, and it may be impossible to

mobilise this to close the defect. Tendon grafts and synthetic meshes have been usedto close this defect but the results are less than satisfactory. This is due to

degeneration and disuse atrophy of the supraspinatus associated ith a chronic tear,

and although the gap may have been closed there is poor function from the repaired

tissue.

In many patients ith large tears, the predominant symptom is still pain rather than

ea+ness and in these patients if the tear is irreparable by direct suture, simple

decompression is carried out. 9p to istory and examination

The pain is often of sudden onset and may follo minor trauma. It is severe and often

disturbs sleep, and fractures or (oint infection may be considered in the differential

diagnosis. In the early stages, the shoulder is difficult to examine oing to the pain,

but as the disease progresses the range of motion is reduced, both actively andpassively. :ocal tenderness is often felt anteriorly over the rotator interval. The


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pathognomonic sign of fro-en shoulder is loss of external rotation and this

differentiates it from rotator cuff disease. 8lain ?rays exclude other intraarticular

pathology.

/linical course

The clinical course of fro-en shoulder can be divided into three stages as follos.

@ Stage I " a painful phase " can last for &"= months. The shoulder becomesincreasingly painful, especially at night, and the patient uses the arm less and less.

The pain is often very severe, and may be unrelieved by simple analgesics.

@ Stage & " a stiffening phase " can last for 3"'& months and is associated ith a

gradual reduction in the range of movement of the shoulder. The pain usually resolves

during this period, although there is commonly still an ache, especially at the

extremes of the reduced range of movement.

@ Stage 2 " the thaing phase " lasts for a further 3"'& months and is associated

ith a gradual improvement in the range of motion.

The clinical course runs over a period of '"2 years and usually resolves ithout any

longterm se)uelae.

Treatmentften no treatment is re)uired and the condition ill usually resolve as described

above. The range of motion may be slightly reduced compared ith the unaffected

side, but the vast ma(ority of patients has no functional problems.

Treatment in the acute stage is pain relief. /orticosteroids may be tried but have

variable effects. *ctive and passive mobilisation can be carried out if comfort allos

but aggressive physiotherapy should be discouraged.

Surgery is usually reserved for prolonged stiffness affecting function but can also

produce good pain relief in the acute stage. Surgical treatment has a limited place in

management. 4anipulation under anaesthetic may produce an increased range of

motion. *rthroscopic distension of the (oint ith saline allos inspection of the

shoulder before treatment. If these measures fail to produce any benefit, open release

of the rotator interval can be carried out through an anterior approach.

/alcific tendonitis

This is a common disorder of un+non aetiology hich results in an acutely painful

shoulder. /alcium is deposited ithin the supraspinatus, and it is thought that this

may be part of a degenerative process. The differential diagnosis includes fro-en

shoulder, ith both conditions occurring most commonly in middleaged omen.

>istory and examination

This pain is usually of rapid onset, often ith no precipitating cause. In common ith

impingement, the pain is felt on the anterolateral aspect of the shoulder and is orse

ith activities, particularly overhead activities. The pain can be very severe andusually disturbs sleep. n examination, the shoulder is tender anterolaterally, and

there is often some restriction of active and commonly passive motion. Axternal

rotation ill be possible and this differentiates the condition from fro-en shoulder.

The calcific deposits can be seen on plain radiographs, lying ithin the supraspinatus

tendon, inferior to the acromion and (ust medial to the tuberosity of the humerus.

They can also be seen on ultrasound $#ig. &&.


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Surgery

esistant cases of calcific tendonitis are an indication for surgical treatment. pen

excision of the calcific deposits can be carried out through a sabre incision but

arthroscopy of the shoulder ith subacromial decompression is an alternative. The

cuff can be debrided and, if the deposits are prominent, they can be removed through

a smaller incision.The prognosis for calcific tendonitis is generally good.

*rthritis of the shoulder

heumatoid arthritis

The glenohumeral (oint is commonly involved in inflammatory arthritis, particularly

rheumatoid arthritis $*%, ith up to onethird of these patients developing severe

problems. Initially the pain is related to synovitis and this responds to medical

management, including intraarticular steroid in(ection.

Impingement symptoms can also occur, either ith or ithout a rotator cuff tear.

These ill respond to subacromial in(ection but decompression may be indicated.

*rthroscopic synovectomy can be carried out at the same time but, in general, open

synovectomy is not indicated in the management of * of the shoulder. /hemicalsynovectomy may be indicated for symptoms that are resistant to medical treatment

but this is not commonly performed for *.

#or advanced disease, glenohumeral arthroplasty is indicated, ith very good relief of

pain, but there is often little improvement in the preoperative stiffness.

Osteoart!ritis

steoarthritis of the glenohumeral (oint is either primary or more commonly

secondary. Secondary arthritis is usually due to previous trauma or to endstage

rotator cuff disease, in association ith a massive tear of the cuff and superior

migration of the humeral head.

Treatment. *s ith osteoarthritis of other (oints, medical measures are initially tried.

#ailure of medical management is an indication for surgery. 7Bbridement of the (oint

and osteotomy have little if any place in the management of glenohumeral

osteoarthritis, and (oint replacement is the treatment of choice. Coth total shoulder

replacement and hemiarthroplasty, ithout glenoid replacement, can be carried out

$#ig. &&.=%. Total shoulder replacement should only be carried out if the rotator cuff is

intact. In most patients ith *, and all patients ith cuff tear arthritis, the cuff is

deficient and hemiarthroplasty is therefore the most common replacement performed6

this can be carried out through an anterior deltopectoral approach. Shoulder

replacement is a very good painrelieving procedure but, in general, ill not restore

movement to a stiff shoulder.*rthrodesis of the (oint is an alternative in the youngerpatient, especially if there is a history of sepsis or any neurological problem that

ould affect the stability of a (oint replacement. The perioperative morbidity is

higher, hoever, and 23 months of immobilisation are re)uired. The patient retains a

surprisingly good range of movement at the shoulder and can function ell oing to

scapulothoracic movement $#ig. &&.'0%.

Art!ritis o t!e acromiocla%icular &AC' (oint

7egenerative changes of the */ (oint on plain radiographs are relatively common and

are usually age related. Symptomatic disease, hoever, usually affects males in their

&030s and is commonly due to a previous in(ury. It is often seen in individuals ho

play sport or are involved in an occupation that stresses the upper limbs. If inferiorosteophytes are present, impingement on the underlying rotator cuff can occur.


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"istor# and e$amination.

The pain is activity related and, unli+e most causes of shoulder pain, it is ell

localised, ith the patient pointing to the */ (oint as the source of the pain. n

examination, there is usually a bony abnormality, ith prominence of the distal end of

the clavicle. This may be tender and movement of the (oint by depressing the clavicle

hilst pushing up the humerus ill reproduce the pain. #lexing and adducting the armto place the hand behind the opposite shoulder ill also produce pain. *n intra

articular in(ection of local anaesthetic ill confirm the (oint as the site of the pain. If

the symptoms are related to the inferior osteophytes, the pain is less ell localised,

and impingement signs and symptoms are present.

Treatment. Intraarticular in(ection of corticosteroids ill usually produce some

benefit and a course of three in(ections may be tried. If medical management fails,

then surgery may be appropriate. The distal 'D& to ' cm of the clavicle is excised by a

direct approach, ith good relief of pain and no functional difficulties. In patients

ith predominately impingement symptoms, arthroscopic dehridement of the

osteophytes can be carried out.

Ru)ture o t!e bice)s tendonupture of the long head of biceps is a relatively common condition, occurring in

middle age and in the elderly. The condition is closely related to rotator cuff disease

and the tendon usually ruptures oing to chronic attrition. *lthough many patients

present acutely, an asymptomatic biceps rupture is a relatively common finding

during arthroscopy for rotator cuff surgery.

"istor# and e$amination

The patient usually complains of something giving, often hen they are lifting. The

arm is often bruised and hen the patient flexes the elbo a lump is evident in the

middle of the biceps. The lump is initially tender and poer is diminished $#ig.&&.''%.

Treatment

This condition is treated conservatively, and the patient can be reassured that the pain

ill ease and the poer return, although this may ta+e several months.

upture of the distal insertion of biceps is an uncommon condition that usually occurs

in younger patients, particularly after a sporting in(ury. *gain pain and ea+ness are

present hut, unli+e rupture of the long head, the ea+ness ill not improve. Surgical

repair is indicated.

Instability of the glenohumeral (oint

Traumatic dislocation of the shoulder ill be considered in the next section but

recurrent instability is a common se)uele of dislocation. ecurrent traumaticinstability is age related, ith over half of shoulder dislocations becoming recurrent in

the under &5 year olds. In some patients, the shoulder may dislocate after relatively

little force, and a further group of patients ith shoulder instability may be able to

dislocate the shoulder at ill. The diagnosis is based on an accurate history and

further investigations, other than plain radiographs, are not usually re)uired.

/lassification

There are many ays of classifying shoulder instability, based on direction, the

degree of violence re)uired as ell as considering subluxations and true dislocations.

There is a spectrum of instability but, in general, three groups of patients can be

considered as follos $#ig. &&.'&%.

ecurrent traumatic instability. This is predominately in one direction, mostcommonly anteroinferiorly. There is a definite traumatic event initially, although less


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violence is re)uired subse)uently. The patient is aare of apprehension on certain

activities and sport may be made difficult. The shoulder may sublux or dislocate and

often the dislocation has to be reduced in a medical facility. n examination, there is

a full painless range of motion but apprehension on forced abduction and external

rotation $#ig. &&.'2%. ther (oints are usually normal. *s discussed in the section on

trauma, there is usually a Can+art defect ith detachment of the anteroinferior glenoidlabrum and damage to the humeral head $#ig. &&.'3%.

Treatment./onservative treatment has little place and, if the instability causes

functional difficulties, surgery is indicated. #or anterior instability, repair of the

Can+art defect, in addition to some tightening of the capsule, ill produce good

results in =0"=5 per cent of patients. This is carried out through an anterior

deltopectoral approach $#ig &&.'5%. #or recurrent posterior instability $uncommon%

tightening of the posterior capsule through a posterior approach is carried out.

*traumatic instability. *lthough there may be an initiating event, this is often less

traumatic, for example a fall climbing stairs rather than a sporting in(ury. In many

cases there is no initial in(ury and the instability may occur in more than one

direction. The shoulder usually subluxes rather than dislocates and the patient canoften reduce the shoulder themself. The subluxation is painful and the patient ill not

dislocate the shoulder at ill. n examination, generalised ligament laxity is

commonly present and the shoulder can often be subluxed inferiorly to produce a

sulcus sign, ith a lateral sulcus appearing beneath the acromion as the arm is pulled

don. *pprehension tests are again positive but often in more than one direction.

Treatment.8hysiotherapy, by an experienced therapist, should be tried first in these

patients. *s ell as muscle strengthening reeducation of the patient and shoulder is

necessary, and specific muscle groups may need to be targeted.

*pproximately half of the patients ill re)uire surgery and a capsular tightening

procedure is carried out through an anterior approach. This is a successful procedure

but there is a higher failure rate than ith patients found to have a Can+art defect.

*rthroscopic shrin+age of the capsule may have a place in these patients, and this is

currently being evaluated.

"abitual dislocation.

This is a much smaller group of patients, but one hich does not respond ell to

surgical treatment. The patient is able to sublux the shoulder at ill and this is usually

not painful $#ig. &&.'5%. There is underlying (oint laxity, hich is usually generalised,

and there is rarely a significant traumatic event. The patient may sublux the shoulder

as a Eparty tric+, or for emotional or psychological reasons.

Treatment.

It is vital that these patients are assessed and managed by an experienced therapist.The patient must be educated to avoid subluxing the shoulder and shon exercises as

appropriate. Surgery is associated ith a high failure rate and should be avoided.

Disorders o t!e elbo*

Tennis elbo

Axcluding traumatic conditions, this is the most common cause of pain around the

elbo, and usually occurs in patients in their 20"50s. The exact cause is un+non

but the condition commonly follos a period of overactivity, particularly anunaccustomed activity that involves active extension and suppination of the rist. The


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tendon of extensor carpi radialis brevis is most commonly involved and, at

exploration, a partial tear and chronic inflammatory tissue have been described.

>istory and examination

The patient complains of pain around the lateral epicondyle and in the bac+ of the

forearm. This is activity related and often a particular activity is implicated. There is

not usually a history of trauma, but the patient may relate the onset to a period ofunusual activity. n examination, the patient is locally tender, hich is commonly

(ust distal and anterior to the lateral epicondyle rather than the epicondyle itself.

#orced palmar flexion and pronation against resistance reproduces the pain. The

diagnosis is essentially a clinical one, although ultrasound and 4I may be indicated

if there is any doubt.

Treatment

The prognosis is generally good. 4any cases probably resolve ithout the need for

any medical input, particularly if the precipitating activity can be avoided. Simple

analgesia may be sufficient, but often a local in(ection of hydrocortisone is re)uired.

This can be repeated if there is some response, but repeated in(ections should be

avoided. 8hysiotherapy, particularly local measures including ultrasound, can help, ascan a tennis elbo splint, hich is designed to alter the pull of the muscle. Surgery

may be occasionally indicated and local excision of the abnormal tissue ill produce

good results in ;0"


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Treatment. ften no treatment is re)uired other than reassurance about the nature of

the condition. steoarthritic elbos seldom deteriorate rapidly and often the

symptoms ill improve after retirement. #or the patient ho is unable to carry out his

normal activity, early retirement or a change of or+ is the best solution, as there is

no satisfactory surgical procedure that ill guarantee a return to a heavy manual (ob.

7Bbridement is practised in the 9S* and ill increase the range of motion6 hoever,lac+ of movement is seldom a ma(or complaint by the patient. esurfacing

arthroplasty using tendon or fascia has been tried but, in general, gives a less than

satisfactory outcome. Goint replacement should not he carried out in a patient ho

ishes to return to heavy or+ but is indicated for severe pain and functional

problems in a more sedentary patient. *rthrodesis of the elbo is rarely carried out.

In general, the results of elbo replacement for osteoarthritis are not as good as for

*. This may be related to the different lifestyles of the patients.

:oose bodies

*fter the +nee, the elbo is the second most common site of symptomatic loose

bodies. The most common cause is osteoarthritis but in the younger patient

osteochondritis dissecans is the usual cause. 4ost patients complain of sudden unexpected pain and loc+ing of the elbo, and often they have to sha+e or manipulate

the elbo to relieve it. 8lain radiographs ill confirm the diagnosis in =0 per cent of

cases and further investigation is not necessary. *rthroscopic removal is indicated

and, in the presence of mechanical symptoms, good results can be expected in most

patients. In the absence of an appropriate history simple removal of loose bodies from

a degenerate elbo ill not result in any lasting benefit.

steochondritis dissecans

steochondritis dissecans is much less common in the elbo than the +nee, and

usually affects the capitellem. Teenage boys are usually affected and the condition is

often related to sporting activities. The main symptoms are pain and selling, and on

examination there is a loss of full extension. Treatment is normally conservative ith

a rest from sport, hut arthroscopy may he re)uired if the fragment detaches and the

patient develops mechanical symptoms suggestive of a loose body.

lecranon bursitis

Inflammation of the olecranon bursa is relatively common. The elbo is often very

red, arm, sollen and painful, and a septic arthritis may initially be suspected. The

signs andsymptoms are, hoever, confined to the bac+ of the elbo $#ig. &&.';% and

movement ithin an arc of 20H'200 is usually possible. The bursitis is usually

chemical rather than infective, and management consists of rest, ice, anti

inflammatories and a compression dressing. If there is any suspicion of a penetrating

ound, antibiotics should be administered but formal drainage of the bursa should beavoided, unless purulent material is present.

/hronic bursitis can occur and may be associated ith small calcific nodules. In

general these should not be removed and surgical excision of the bursa should be

avoided if possible.

9lnar nerve compression

This is the second commonest nerve entrapment after carpal tunnel syndrome. The

most common sites of compression are around the elbo and there is a number of

possible sites

@ the arcade of Struthers and the medial intermuscular septum " as the nerve passes

into the posterior compartment of the distal humerus6

@ medial epicondyle " particularly if osteophytes are present6


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@ cubital tunnel " as the nerve passes beteen the to heads of flexor carpi ulnaris

$#ig. &&.'


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fibrosarcomas, after the distal femur and proximal tibia. Treatment is on conventional

lines. The shoulder is the second most common peripheral site after the proximal

femur for chondrosarcomas, and the scapula body is also a common site. The

principal method of treatment for chondrosarcomas is surgical excision and this may

be technically difficult around the shoulder. Subtotal excision of the scapula can be

carried out ith good preservation of function if the glenoid can be left. The humerusis also a relatively common site for lymphomas and Aings tumour. Treatment is,

again, along conventional lines.

Cenign and intermediate tumours such as osteochondromas, giant cell tumours and

aneurysmal bone cysts are also relatively common. The proximal humerus is the most

common site for unicameral bone cysts, hich are thought to represent an

abnormality of cells of the groth plate. They commonly present as pathological

fractures in children around the age of '0 and affect boys more commonly than girls.

The lesion may resolve after fracturing but local medical treatment is often re)uired

$#ig. &&.&0%.

The humeral shaft is a common site for secondary deposits and intramedullary nailing

may be re)uired for pathological fracture or impending fracture. The ma(ority ofprimary tumours is found in the breast or prostate, but secondary spread from the

thyroid, lung, +idney and boel can also occur.

#ractures of the upper limb In adults Introduction

#ractures of the upper limb are very common in(uries in all age groups. In adults,

beteen the ages of '5"3=, these in(uries are more common in males and are usually

due to highenergy mechanisms such as road traffic accidents. Ceteen the ages of

5and


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up to 5 per cent of fractures and is more common after highenergy mechanisms such

as road traffic accidents $#ig. &&.&'%.

Surgery.pen reduction and plate fixation are occasionally re)uired and may be

indicated for open fractures associated neurovascular in(uries or fractures of the

lateral end of the clavicle ith significant displacement of the fragments. Internal

fixation and bone grafting are indicated for symptomatic nonunions.*cromioclavicular (oint in(uries

7isruption of the */ (oint is a relatively common in(ury and is typically seen in

young males. It is usually caused by trauma, commonly sporting in(uries, and is

associated ith superior subluxation or dislocation of the lateral end of the clavicle

$#ig. &&.&&%.

/lassification.

@ Type ' " the capsule and coracoclavicular ligaments are damaged but not ruptured,

and no subluxation of the (oints occurs.

@ Type & " the (oint is subluxed, ith some superior displacement of the clavicle6 this

is associated ith increased damage to%, but not rupture of, the ligaments

@ Type 2 " the ligaments are ruptured and the clavicle dislocates superiorly.@ Type 3 " the lateral end of the clavicle dislocates and lies subcutaneously due to

severe soft tissue in(ury.

@ Type 5 " the clavicle dislocates and lies posterior to the acromion $rare%.

@ Type " the clavicle dislocates and lies inferior to the acromion $rare%.

Treatment. 4ost in(uries can be treated conservatively, ith good results expected. *

broad arm sling can be used, ith mobilisation as comfort allos. In certain circum

stances, early surgery may be indicated, especially for the less common type 3"

in(uries. :ate reconstruction of the */ (oint is occasionally re)uired for persistent

displacement of the clavicle associated ith pain and functional impairment.

Scapular fractures

These are uncommon in(uries and are usually caused by direct trauma, often due to

road traffic accidents. 4ost can he treated conservatively. Internal fixation is

indicated for some articular fractures of the glenoid.

* glenoid fracture usually represents a fracture dislocation of the shoulder. The si-e

and displacement of the fragment must be assessed and this can be done by

computerised tomography. /onservative treatment ith immobilisation ill be

re)uired for minimally displaced fractures, although rarely for more than 2 ee+s.

Indications for internal fixation, usually by a lag scre techni)ue, include large

displaced fragments and an unstable shoulder. perative approach, method of fixation

and postoperative mobilisation ill be determined by the fracture pattern and fixation

achieved at surgery.7islocation of the glenohumeral (oint

*pproximately 35 per cent of all (oint dislocations in adults occur at the glenohumeral

(oint. 4ost dislocations occur anteriorly and result from a forced abductionDexternal

rotation mechanism, often due to sporting in(uries. The in(ury is therefore more

common in males in the age group &'"20, although glenohumeral dislocation does

occur in elderly females. In this age group rotator cuff damage may occur in

association ith the dislocation.

7islocation is fre)uently associated ith damage to the glenoid labrum and

detachment of the anteroinferior segment, the Can+art lesion. In addition, damage to

the bac+ of the humeral head can occur as a >ill"Sachs lesion $#ig. &&.'3%. Coth of

these abnormalities predispose to recurrent dislocation. :ess than 5 per cent ofprimary dislocations are posterior.


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Treatment. The dislocation should be reduced as early as possible and this can usually

be accomplished under sedation. There are three common methods of reduction

dislocations. #olloing reduction, the arm is rested in a sling for approximately '

ee+ and mobilisation commenced. 8rolonged immobilisation, as previously

recommended, does not seem to influence the recurrent dislocation rate.

>ippocratic method. The patient lies supine on a bed, although classically the patientlies on the ground. Traction is applied to the arm ith the elbo extended and the arm

is flexed and abducted at the shoulder. *s traction is continuously applied, the

humeral head is eased bac+ into the (oint by the surgeons stoc+inged foot.

!ochers method. Traction is applied to the arm, ith the elbo flexed to =00. The

arm is sloly externally rotated, and then internally rotated and flexed across the body

to reduce the shoulder. This may be modified by abducting as ell as externally

rotating the arm, and a collar and cuff bandage can be used to provide countertraction

over the humeral head. *ll these manoeuvres should be carried out gradually as spiral

fractures of the humerus and brachial plexus in(uries have been reported.

>angingarm method. This method may be tried ithout sedation. The patient is

placed face don on a bed or bent over a chair. The arm is alloed to hang free, iththe elbo extended6 an intravenous fluid bag can be tied to the arm to provide

traction.

/omplications.Jerve palsy. Jeurological dysfunction is common after shoulder

dislocation and electrophysiological tests have revealed abnormalities in over half of

the patients. Significant problems occur in approximately 5 per cent of patients, ith

the axillary nerve, or occasionally the suprascapular nerve, involved. The ma(ority of

palsies recovers ith conservative treatment.

ecurrent dislocation. This is age related and is usually due to the presence of a

Can+art lesion. In the under &5s approximately 0 per cent ill have further

instability and approximately half of these ill re)uire surgery. nly &5 per cent of

the over 23 age group ill have further problems. Instability of the glenohumeral (oint

is considered in more detail in the previous section.

8osterior dislocation of the glenohumeral (oint is much less common and has been

associated ith epilepsy and electrocution. The humeral head appears lightbulb

shaped on anteroposterior radiographs, an appearance that is normally seen on a

lateral or an axillary vie. eduction is achieved by applying traction to the abducted

arm and then gently externally rotating the arm.

8roximal humeral fractures

#ractures of the proximal metaphysis of the humerus are one of the most common

fractures in the elderly ith a dramatic increase in incidence after the age of 0. They

account for approximately 5"; per cent of adult fractures and are most common inelderly females.

/lassification of fractures. 8roximal humeral fractures ere classified by Jeer in

'=;0 and this is still an accepted classification. 4inimally displaced fractures are

ignored, and the fractures are classified by anatomical location and the number of

main fragments. The more severe in(uries consist of four main parts the shaft, the

articular surface, together ith separate, displaced greater and lesser tuberosities $#ig.

&&.&2%.

Treatment. Treatment of these in(uries is dependent on the severity and displacement

of the fractures. The ma(ority of fractures is minimally displaced and treated

conservatively ith good results expected. To to three ee+s of immobilisation in asling is recommended. 7isplaced fractures, particularly in the younger patient, are


14/25

treated by internal fixation ith a plate and scres, multiple pins or an intramedullary

device6 again good results can be anticipated.

The treatment of fourpart fractures in the elderly osteoporotic patient is still

unresolved oing to the unsatisfactory results ith all methods of treatment.

/onservative treatment can result in a stiff painful shoulder but operative treatment

often results in the same outcome. * number of methods of fixation have beendescribed including plates and scres, multiple ires, tension band iring and

intramedullary devices. Insecure fixation in the osteoporotic bone, together ith

difficulties in reattaching the tuberosities and subse)uent rotator cuff problems, ill

produce poor results. 8rimary replacement of the humeral head, ith a metal

prosthesis, is fre)uently performed and as originally recommended by Jeer for

severe in(uries. 9nfortunately hemiarthoplasty is also fre)uently complicated by

stiffness or rotator cuff problems.

*vulsion of the greater tuberosity

This fracture is included in the classification described by Jeer but should also be

considered separately. The in(ury is often associated ith dislocation of the

glenohumeral (oint and represents a rotator cuff in(ury. The fracture may appear to beminimally displaced after reduction of the dislocation.

Treatment. 7isplaced fractures should be anatomically fixed ith scres through a

lateral approach. 9ndisplaced fractures may be treated conservatively but regular

revie, initially ith ee+ly radiographs, is re)uired. 4alunited fractures ill lead to

impingement symptoms hich do not respond as ell to later decompression.

>umeral shaft fractures

These in(uries account for approximately 2 per cent of adult fractures and are most

common in patients in their ;0s, usually as a result of a simple fall6 approximately


15/25

after the in(ury. Aarly exploration is indicated if the nerve is initially intact but

dysfunction occurs after closed or open management.

7istal humeral fractures

These are the least common of the metaphyseal fractures of the upper limb, and

commonly re)uire internal fixation and early mobilisation to produce good results. *s

ith clavicle fractures, the in(ury is more common in young males and is usually dueto moderate to severe trauma. In the elderly distal humeral fractures are more

common in females and again are usually due to mild or moderate trauma.

*natomy and classification of fractures. The elbo consists of a medial and lateral

column, ith an articular surface at the distal end. The trochlea at the end of the

medial column articulates ith the ulna and contributes to flexion and extension at the

elbo. The capitellum, the articular surface of the lateral column, articulates ith the

radial head and contributes to pronation and supination at the elbo.

*natomically the fractures may involve the medial or the lateral column in isolation,

ith separation of the condyle from the rest of the humerus. These are relatively

uncommon, accounting for only 5 per cent of elbo fractures in adults. The more

complex in(uries involve both columns, ith complete separation of the articularsurface from the diaphysis, together ith a fracture through the articular surface. It is

these T or Kshaped fractures that can be particularly difficult to treat.

Treatment. 4inimally displaced fractures can be treated conservatively ith splintage

folloed by gentle mobilisation as comfort allos. In adults immobilisation of the

elbo for longer than &"2 ee+s should be avoided as stiffness and functional

restriction can occur. This is particularly true for complex in(uries, or folloing

operative management of the fractures.

#or displaced fractures internal fixation is recommended for all age groups6 stable

fixation ith plates andDor scres should be used to allo early mobilisation. Single

column fractures can usually be stabilised through a limited approach but the complex

T or Kfractures re)uire a ide exposure of the (oint to ensure accurate reduction,

and usually to plates are necessary for stable fixation to the humeral shaft. In order

to gain the necessary access, osteotomy of the ulna is usually re)uired and these

in(uries re)uire surgical s+ill and experience to achieve good results.

In the elderly osteoporotic patient, especially ith very distal fractures, stable internal

fixation is not possible. In these patients primary elbo replacement has been carried

out ith good results. This avoids the need for an osteotomy, ith its ris+ of nonunion

and implant problems, and allos immediate mobilisation of the elbo.

adial head fractures

These are relatively common fractures6 the ma(ority occurs in females, in the age

group &0"50, after a fall on the outstretched hand.*pproximately 30 per cent of fractures are undisplaced, involving only part of the

articular surface. In a further 30 per cent a fragment of the radial head is displaced,

ith depression of the articular surface. The remainder of the fractures involves all of

the articular surface, either as a single fragment ith a fracture of the radial nec+ or as

a comminuted fracture of the radial head.

Some fractures are not visible on plain radiographs, although evidence of an effusion

can often be seen. This in(ury should be suspected in patients ith a typical history,

pain over the radial head and restricted movement of the elbo

/lassification. * number of classifications has been described but one of the most

commonly used is that described by 4ason $#ig. &&.&5%

@ type ' " undisplaced partial articular $marginal% fractures6@ type & " displaced marginal fractures6


16/25

@ type 2 " comminuted fractures of the radial head.

Treatment. 9ndisplaced fractures are treated by a temporary collar and cuff support,

folloed by early mobilisation. If the elbo is particularly painful, aspiration of the

haemarthrosis can be carried out folloed by intraarticular in(ection of local

anaesthetic. *spiration can be safely carried out through the centre of the triangleformed by the lateral epicondyle, radial head and the olecranon.

The treatment of displaced, partial articular fractures is dependent on the si-e and

displacement of the fragment. Small fragments $L&5 per cent of the articular surface%

are treated conservatively, unless the range of motion is significantly restricted. In

these circumstances aspiration of the (oint and in(ection of local anaesthetic is carried

out. If there is still a bloc+ to extension, and particularly full supination, exploration

of the elbo via a lateral incision is indicated. :arge fragments are treated by open

reduction and internal fixation ith small scres if possible6 smaller fragments can be

excised.

4ore complex in(uries are treated by internal fixation, although this may not be

possible if significant comminution is present. In these circumstances excision of theradial head can be carried out. If, hoever, there is any damage to the collateral

ligaments of the elbo or the interosseous membrane of the forearm, prosthetic

replacement may be indicated. This is seen in patients sustaining highenergy in(uries,

such as road traffic accidents or falls from a height. In these patients radiographs of

the entire forearm including rist should be obtained, and the distal examined

carefully, both clinically and radiologically.

lecranon fractures

These are common in(uries and are usually due to indirect trauma such as a fall on the

outstretched hand. The in(ury is

$c% * grossly displaced fracture of the radial head and nec+.

essentially an avulsion fracture due to the pull of the triceps muscle. 4ost fractures

are intraarticular, although extraarticular fractures do occur ith a small bony

fragment avulsed $#ig. &&.&%.

/lassification. * number of classifications has been described but the main factors

that determine the treatment are the location and displacement of the fracture, and the

number of fragments.

Treatment. 9ndisplaced fractures can be treated conservatively, but late displacement

can occur and regular revie is necessary. 4ost fractures are displaced and internal

fixation is indicated. Axtraarticular and topart intraarticular fractures can be

treated ith a tension band iring system, using a figureofeight ire and

intramedullary ires or scres. Stable internal fixation should be achieved to alloearly mobilisation of the elbo. * tension band ire is not suitable for comminuted

articular fractures or more distal fractures, and plate fixation is recommended.

The prognosis for this in(ury is good, ith a full functional recovery expected. The

metal is often prominent and can be troublesome. It can be removed, if necessary,

after the fracture has healed.

Albo dislocation

*pproximately &0 per cent of all dislocations occur at the elbo and most occur in

children and young adults. The elbo usually dislocates posteriorly and is due to axial

loading on a slightly flexed elbo. #ractures of the distal humerus, radial head and

coronoid may be associated ith the in(ury $#ig. &&.&;%.

Treatment. The elbo should be reduced as soon as possible and this is usuallyaccomplished by closed means. Traction is applied ith the arm slightly flexed and


17/25

the olecranon can usually be pushed over the distal humerus, reducing ith a definite

clun+. 8ostoperatively the arm is immobilised in a collar and cuff, and mobilisation

commenced after ' ee+. 8rolonged immobilisation should be avoided as the elbo

often becomes stiff.

/omplications.

Instability.In most cases the elbo is stable after reduction but occasionally there is atendency for the elbo to redislocate in extension. In these circumstances, after

reduction, the elbo is managed in a cast brace preventing full extension initially. The

extension bloc+ can be gradually reduced over &"2 ee+s. :ate instability is rarely a

problem after simple dislocation and is more usually associated ith complex fracture

dislocations.

Stiffness. Some loss of extension is not uncommon after elbo dislocation but is

rarely a functional problem unless the arm has been immobilised for long periods.

#orearm fractures

These account for approximately 5 per cent of adult fractures and the ma(ority occur

in young adults as a result of moderate to severe trauma. In contrast to many other

fractures, these are unusual in the more elderly osteoporotic patient.4ost of these fractures involve both bones and result from indirect trauma. Single

bone in(uries can occur and are usually caused by direct violence, such as a blo ith

a stic+. Single bone fractures can also occur in association ith a (oint in(ury of the

other forearm bone, and this in(ury must be considered. adiographs of the elbo and

rist (oints should be obtained in all forearm fractures.

Treatment. The vast ma(ority of these fractures is displaced, and open reduction and

internal fixation ith plates is indicated. Coth bones are usually plated, through

separate incisions, ith early postoperative mobilisation. /onservative treatment is

not usually recommended as rotation at the fracture site is difficult to correct or

control in plaster. #ull functional recovery can be expected in these patients. The

forearm plates, particularly the radial, should not be removed unless there are specific

indications, as a high complication rate has been reported.

Specific in(uries. 4ontalgia fractures. 8roximal ulna fractures may be associated ith

dislocation of the radial head but these account for only ' per cent of forearm

fractures. If the ulna fracture is reduced accurately, the radial head usually reduces

and no specific treatment is necessary $#ig. &&.&


18/25

is therefore necessary to be aare of the ossification centres of the upper limb hen

dealing ith these in(uries.

ssification

* large part of the body of the scapula is ossified at birth. * secondary ossification

centre appears in the coracoid during the first year and fuses by about the '5th year.

The acromion usually develops to ossification centres, ith all ossification centresfused by about the age of &0. These may be confused ith fractures on radiographs or

predispose to epiphyseal separation. #ailure of fusion of the acromion resulting in an

os acromiale occurs in about 5 per cent of the population, although there is a number

of different reports of the incidence in the literature.

The clavicle develops to ossification centres around the fifth to sixth ee+ of foetal

life. These fuse ithin a fe ee+s of their appearance6 failure of this may produce a

congenital pseudoarthrosis of the clavicle. * secondary ossification centre appears in

the medial end of the clavicle in the late teens. *n epiphyseal in(ury may occur before

the appearance of this ossification centre giving the appearance of a sternoclavicular

dislocation. This epiphysis fuses by about the age of &5. The lateral end occasionally

develops a secondary ossification centre at the age of '


19/25

accounted for & per cent, and other fractures around the shoulder accounted for less

than ' per cent of all childhood fractures.

S)eciic in(uries

Sternocla%icular (oint

7islocations of this (oint are rare in children and most apparent dislocations, even inadults up to the age of about &5, represent epiphyseal separations. True dislocations

and epiphyseal in(uries can be manipulated and are often stable, even if unstable

fixation of these in(uries should be avoided. Internal fixation may damage nearby

structures ith disastrous results, and ires should be avoided as migration into the

chest has been reported. apid healing and remodelling ill occur. 8osterior

displacement may be a surgical emergency if vital structures are compromised.

#ractures of the clavicle

#ractures of the medial end of the clavicle are considered above.

#ractures of the shaft of the clavicle account for the ma(ority of clavicle fractures.

4any are caused by a fall on the outstretched hand6 a bicycle, climbing frame, or

bun+ bed is commonly involved. 1reenstic+ fractures commonly occur and may bemissed on initial radiographs. Temporary rest in a sling for a short period is all that is

re)uired for most of these fractures. 7isplaced fractures of the clavicle are very

common but rarely re)uire reduction. In many countries, including many *merican

centres, attempts are made to reduce the displacement ith a figureofeight bandage

to retract the scapula. To be effective this has to be tight, often uncomfortably tight,

and needs constant ad(ustment. * broad arm sling for &"2 ee+s until comfortable is

all that is re)uired. 4alunion is very common but rarely a functional problem6

nonunion is very uncommon in children. elatives can be reassured that the

prominent callus ill usually resolve over the subse)uent months.

pen reduction and fixation ith ires or a plate may be occasionally re)uired. The

indications are similar to those in the adult6 open fracture, s+in compromise, vascular

in(ury, etc.

#ractures of the lateral end of the clavicle may also be confused ith (oint

dislocations, as discussed belo.

*cromioclavicular (oint

True dislocations of this (oint are unusual in children, especially in the younger child.

The ligaments around the (oint are very strong and often the lateral end of the clavicle

ill fracture, although this may not be apparent on radiographs if unossified. Aven

ith true dislocations the inferior periosteum may be left behind ith the conoid and

trape-iod ligaments intact. These ill heal and remodel ith conservative treatment,

ith a sling for comfort folloed by early mobilisation.Scapular fractures

In children as in adults fractures of the body of the scapula are uncommon in(uries

and usually represent direct violence. The significance of this in(ury is the li+ely

in(ury to the chest all and possible pulmonary contusion rather than the scapula

fracture itself. These in(uries ill almost alays be treated conservatively ith

analgesia and a sling for comfort. The arm should be mobilised as comfort allos.

#ractures of the glenoid are also very uncommon in(uries in children.

7islocation of the glenohumeral (oint

Shoulder dislocation in children is unusual except in the adolescent as the ligaments

are stronger than the epiphysis6 usually a Salter and >arris fracture of the proximal

humerus ill occur. In adolescents as in adults, glenohumeral dislocation iscommonly due to a sporting in(ury and is nearly alays an anterior dislocation.


20/25

Treatment is along adult lines ith early closed reduction using standard techni)ues.

The redislocation rate is age related and is higher in the child or adolescent, ith a

recurrent dislocation rate of ;0"< 0 per cent reported in the age group '&"'.

*pproximately 50 per cent of these patients re)uire a stabilisation procedure.

*traumatic dislocations can occur in children ith (oint laxity or connective tissue

disorders.8roximal humerus

#ractures of the proximal humerus usually occur in the older child or adolescent. Jot

only are accidents more common at this age but the perichondral ring may be ea+er

(ust before s+eletal maturity. The ma(ority of in(uries occurs through the groth plate6

Salter and >arris type II in the older child and type I in the younger child. In the

younger child, child abuse should be considered, although humeral shaft fractures are

more common in child abuse. Salter and >arris type III and IM are very uncommon

in(uries of the proximal humerus.

#racture displacement is common and is due to the pull of the pectoralis ma(or

attaching to the distal fragment hich tends to pull it anteriorly and medially.

*lthough residual shortening is common, the ma(ority of patients ill havesatisfactory functional results. It has also been reported that manipulation of a

displaced fresh fracture did not improve the final outcome hen humeral groth or

function as assessed.

Treatment. Treatment therefore is generally conservative6 not only because of the

remodelling potential but also because of the malalignment that can be accepted

around the shoulder generally. #ortyfive degrees of angulation and 50 per cent of

displacement can be accepted. In the younger child ;0 per cent angulation and any

bony contact should heal ith good functional results. The fracture is usually treated

in a collar and cuff sling, although rarely a hanging cast may be used in the older child

ith significant shortening or angulation.

If the position is unacceptable closed reduction is attempted and the fracture held ith

to or three ires. These ires can be removed after 2 ee+s.

pen reduction may occasionally be re)uired for soft tissue interposition often the

biceps tendon and this can be achieved through a standard deltopectoral approach.

#racture stabilisation is carried out as described as above.

4etaphyseal fractures

This may occur ith direct trauma or may occur as a pathological fracture, classically

through a unicameral bone cyst. 7isplacement is not usually significant6 angulation

may occur hut rarely produces a functional problem. The fractures usually heal

rapidly ith conservative treatment in a sling. The proximal humerus is the only

common site for pathological fractures around the shoulder.>umeral shaft fractures

These in(uries are less common in children than in adults. The fracture is usually

transverse or short obli)ue in pattern, and is due to direct violence6 an appropriate

history should be available. Jonaccidental in(ury should alays be considered ith

this in(ury, particularly in the younger child or ith spiral fractures hich are due to a

tisting force.

Treatment.The vast ma(ority of fracture can be treated conservatively ith either a

simple collar and cuff or a plaster 9slab. 9nion is usually rapid, particularly in the

younger child, considerable remodelling can occur and so malunion rarely results in a

functional problem. Jonunion is uncommon in children.

Internal fixation is occasionally re)uired for open fractures, associated vascularin(uries and the polytrauma patient.


21/25

Supracondylar fractures of the humerus

This is the most common fracture around the elbo in children and usually occurs in

children under the age of '0. The in(ury is usually due to a fall on the outstretched

hand ith an extended elbo and this results in a hyperextension in(ury ith posterior

angulation, ith or ithout posterior displacement of the distal fracture. Ceteen '

and 5 per cent of supracondylar fractures are caused by a flexion in(ury and associatedith an anterior deformity.

adiological diagnosis. 7isplaced fractures are readily diagnosed by plain

radiographs but angulated fractures may be difficult to assess. /omparison vies of

the other elbo can be ta+en but a number of radiographic lines can be assessed on

the in(ured elbo, as follos.

/apitellum angle. The capitellum is normally angulated and displaced anteriorly

to the humeral shaft. In the normal elbo, a line dran through the centre of the

capitellum (oins a line dran don the humeral shaft at an angle of 200.

@ *nterior humeral line. * line dran along the anterior cortex should pass through

the central portion of the capitellum.

@ *nterior coronoid line. * line dran along the coronoid process of the ulna should(ust pass through the anterior portion of the capitellum.

*ll of the above lines are dran on true lateral radiographs. In addition, on a true

anteroposterior vie, Caumans angle can be assessed. This is the angle formed

beteen the groth plate of the capitellum and a line perpendicular to the humeral

shaft. The normal angle is approximately 200 and can be used to assess the ade)uacy

of reduction of a fracture $#ig &&.&=%.

Classiication. *s noted above supracondylar fractures can be divided into extension

types and the much less common flexion types. Axtension types are further

subdivided into three types dependent on the angulation and displacement $#ig.

&&.20%.

@ Type '. The fractures are undisplaced but the radiographic lines should be carefully

assessed to confirm this.

@ Type &. The fractures are angulated posteriorly, but the posterior periosteum remains

intact, and prevent displacement and overlap of the fracture fragments.

@ Type 2. The fractures are completely displaced ith shortening and overlap of the

fragments.

Treatment. Type ' fractures can be treated conservatively in a collar and cuff, ith

=00 of flexion at the elbo This is maintained for &"2 ee+s, ith a chec+

radiograph ta+en after ' ee+. *s ith the initial film, the undisplaced nature of the

fracture should be confirmed by plotting the appropriate lines.Type & fractures should be treated by closed reduction if the position is unacceptable.

Thirty degrees of extension can be accepted due to the remodelling that ill occur in

the younger child. Caumans angle should be corrected if there is any varus or valgus

deformity as this ill not remodel. Significant rotational deformity is uncommon ith

this type of fracture. eduction is usually straightforard and the position can be

maintained ith the elbo at =00. arely ires may be re)uired to hold an unstable

reduction $#ig. &&.2'%.

Type 2 fractures usually re)uire reduction but this is often difficult and the fracture

site is commonly unstable after reduction, ith a significant rotational element. 9nder

genera% anaesthetic traction is applied to the suppinated forearm. The mediolateral

displacement of the distal fragment is reduced by direct finger pressure and thecarrying angle restored by comparison ith the unin(ured side. The extension element


22/25

of the fracture is the last thing to be corrected by flexing the elbo maximally hile

applying posterior pressure to the distal fragment. The reduction should be confirmed

radiographically, hoever the ?ray source rather than the arm should be moved to

obtain the vies. This avoids the ris+ of fracture displacement if the arm is rotated.

If the reduction is satisfactory, the position can be maintained by maximum flexion

but this may cause vascular compromise, and loss of reduction may occur if the elboextends, It has been recommended by a number of authors that the reduction should

be held by to ires. /ross ires through both condyles may be used but care must

be ta+en to avoid an ulnar nerve palsy, as the nerve may he difficult to locate in the

sollen elbo. *n open techni)ue may be used on the medial side, or the ire may

be inserted through an anterior starting point. *lternatively, to ires may he inserted

from the lateral side but biomechanically this is not as strong a fixation.

#ailure to obtain a reduction is an indication for open reduction but in the very

sollen elbo, traction is a better option. This may be temporary, until the selling

reduces, but can be used as a definitive method of treatment. Traction may be applied

using a bone cre inserted into the ulna, or by longitudinal s+in traction. Surprisingly,

the patient becomes relatively pain free very )uic+ly $#ig. &&.2&%./omplications. Mascular in(ury. cclusion of the brachial artery is an uncommon but

serious complication. 7espite the absence of a radial pulse, the arm has a good

collateral supply and ill not necessarily become ischaemic. Coth s+in temperature

and colour should be assessed, together ith 7oppler investigation of the pulse.

The treatment of vascular compromise is early reduction of the fracture under general

anaesthetic. If the pulse returns the arm should be monitored carefully. #ailure of

circulatory return is an indication for exploration of the artery and fracture site, ith

open reduction and internal fixation ith ires. *n arteriogram may be obtained but

should nor be alloed to delay exploration.

Jeurological in(ury. Transient neurological problems are relatively common after

supracondylar fractures. The radial nerve is reported to be the most commonly

affected, folloed by the median nerve. Treatment is conservative for 2 months

initially ith good recovery expected.

Mol+manns Ischaemic contracture. #lexion contractures of the fingers and rist are

caused by fibrosis of the anterior compartment of the forearm due to a missed

compartment syndrome. It can usually be prevented by avoiding immobilisation in

excessive flexion of the elbo. If greater than =00 of flexion is re)uired to maintain a

reduction, the reduction should be held by ires and the elbo extended.

7isproportionate pain in the forearm, particularly on passive extension of the fingers,

should be treated by immediate release of all dressings, even if this compromises the

reduction. If pain persists fasciotomy is indicated.4alunion.Some degree of malunion is relatively common after supracondylar

fracture. * flexion or extension deformity ill remodel and observation is indicated.

Marus malunion, ith a gunstoc+ deformity, is unsightly but is usually not a

functional problem. /orrective osteotomies, if necessary, should probably be delayed

until s+eletal maturity. Malgus deformity may be associated ith a tardy ulnar nerve

palsy and may re)uire treatment.

/ondylar and epicondylar fractures

:ateral condyle. This is a relatively common in(ury and, after supracondylar fractures,

is the second most common elbo fracture in children. It is usually due to a fall on the

outstretched hand. *lthough this in(ury can occur in younger children the diagnosis is

usually apparent on plain radiographs due to the early appearance of the ossificationcentre of the capitellum $see above% $#ig. &&.22%.


23/25

/lassification.4ilch has classified this in(ury based on the location of the articular

fracture. * type I fracture either passes through the ossification centre of the

capitellum or (ust passes through the aspect of the trochlea. In either case the ma(ority

of the trochlea is intact and the elbo does not dislocate. In type II fractures the

fracture line passes at or medial to the trochlear groove and the elbo (oint may

dislocate if the fracture displaces.Treatment.9ndisplaced fractures can be treated by immobilisation for approximately

2 ee+s, but chec+ radiographs are re)uired. 4ost fractures are, hoever, displaced,

and open reduction and internal fixation is re)uired as closed reduction is seldom

possible. *natomical reduction is re)uired and ires or scres can he used.

/omplications.Jonunion occasionally occurs, often as a result of missed fractures or

inade)uate fixation. This may lead to a valgus deformity and tardy ulnar nerve palsy.

Internal fixation and bone grafting can be utilised, either at presentation or at s+eletal

maturity.

4edial epicondyle. This is the third most common fracture around the elbo and is

usually seen in older children. It is due to an avulsion in(ury and, despite the

proximity of the ulnar nerve, it is rarely affected. 7iagnosis can usually be made onplain radiographs, although, as ith all childrens fractures, comparison vies of the

other side can be ta+en if there is any doubt $#ig. &&.23%.

Treatment.9ndisplaced fractures can be treated conservatively, ith early

mobilisation as comfort allos. 7isplaced fractures are usually internally fixed,

especially if instability of the elbo is present.

ther elbo fractures

#ractures of the medial condyle, lateral epicondyle and intercondylar fractures are rare

in children6 treatment depends on displacement.

Albo dislocation

This is an uncommon in(ury in children. *s ith adults the elbo usually dislocates

posteriorly and radiographs should be studied carefully for associated fractures.

Treatment is early reduction6 instability is rarely a subse)uent problem.

8roximal radius fractures

These are the fourth most common of the fractures around the elbo in children. They

differ from the intraarticular radial head fractures seen in adults as, ith children, the

in(ury usually occurs through the epiphysis of the radial nec+, and the articular surface

displaces as a single piece. The in(ury usually results from a fall on the outstretched

hand, although it can occur in association ith a posterior dislocation of the elbo.

This fracture usually occurs after the ossification centre of the proximal radius

appears and so the diagnosis is readily made on plain radiographs.

Treatment.In common ith many childrens fractures there is considerable potentialfor remodelling. 9p to 200 of angulation can be accepted, provided there is groth

remaining. These in(uries can be treated ith a simple sling folloed by early

mobilisatson.

If angulation exceeds 200, manipulation under anaesthetic is carried out, hich can be

aided by the use of a percutaneous lever to push the radial head. #or irreducible or

completely displaced fractures $commonly seen after elbo dislocation% open

reduction is carried out. This is usually supplemented by ire fixation, but ires

should not be placed across the radiocapitate (oint. These are removed after &"2

ee+s folloed by mobilisation.

lecranon fractures


24/25

These are uncommon in(uries and are often minimally displaced. #or the occasional

in(ury ith significant displacement, open reaction and tension band iring along

adult lines is recommended.

#ractures of the forearm bones

#ractures of the radius and ulna are the most common fractures in children. The distal

third of the bones is most commonly involved and the in(ury can occur in all agegroups after the age of al+ing. 4any in(uries are greenstic+ fractures, often ith

angulation at the fracture site. /ompletely displaced fractures do occur and can be

difficult to manage by closed means. The combination of a completely displaced

distal radius fractures ith a greenstic+ fracture of the distal ulna is also common and

can be difficult to control in plaster.

*etiology.In common ith many in(uries of the upper limb, forearm fractures are

usually due to a fall on the outstretched hand. It is believed there is also a rotational

element ith forced suppination. 7iagnosis is readily made on plain radiographs,

although a fracture line may not alays be evident6 in this situation the cortical bulge

of the torus or buc+le fracture can be seen.

Treatment.4any of these fractures are minimally displaced and can be treatedconservatively ith &"3 ee+s in plaster, depending on the age of the child.

#ractures of the distal sixth of the forearm can be managed in a beloelbo plaster6

more proximal fractures re)uire the elbo to be immobilised.

4anipulation under anaesthetic should be considered if angulation of the fracture site

exceeds &00. The age of the child and the potential for remodelling should be

considered, as correction of up to '00 per year is possible. *lthough remodelling of

an angulation of 2030 degree is possible in the younger child, parental pressure to

correct the obvious deformity may be an indication for manipulation.

7isplaced fractures can also be managed by manipulation, as a periosteal hinge often

remains intact and can be used to hold the reduction. #ailure to reduce the fracture is

an indication for open reduction and internal fixation, usually ith a plate6 small to

to fourhole plates can be used in younger children. Instability of the fracture site after

a satisfactory reduction, either at the original operation or at subse)uent outpatient

revie, is an indication of a temporary thin ire to maintain reduction. Thin ires can

be safely passed across the distal radial epiphysis, provided care is ta+en and repeated

attempts are avoided. The ire is removed after &"3 ee+s.

ne fracture pattern hich is notorious for loss of reduction is a completely displaced

fracture of the distal radius ith an intact or greenstic+ fracture of the ulna6 iring of

the radius at the initial operation should be considered.

/omplications. 4alunion. This is relatively common after closed reduction of a

displaced fracture. ften, by the time the malreduction is diagnosed, the fracture istoo stic+y to allo remanipulation and the position has to be accepted. #or fractures

of the distal forearm ith volar or dorsal angulation, considerable remodelling, as

described above, can occur and the patient can be reassured. #or malunions involving

a rotation element, particularly ith shortening of one bone, ta+e don of the fracture

site or osteotomy has to he considered.

efracture.This is not an uncommon complication and usually occurs in the first fe

ee+s after the plaster is removed. *lthough it may be due to inade)uate immobili

sation, the usual cause is a return to the original cause of the in(ury. *lthough a

pathological process should considered it is not usually present and treatment should

follo similar lines to a firsttime in(ury.

Com)artment s#ndrome


25/25

. This is uncommon after a simple forearm fracture and severe pain is usually due to a

tight dressing. *ll patients re)uiring a general anaesthetic for manipulation should be

admitted overnight and the limb elevated. Severe pain should be treated by immediate

splitting of the plaster and all dressings don to the s+in. In the vast ma(ority of cases

this ill provide immediate relief but a compartment syndrome should be considered

if pain persists, particularly in patients ith complicated in(uries. /ompartmentsyndrome is treated by fasciotomy, irrespective of the age of the child.

4onteggia fracture

This in(ury, characterised by a dislocation of the radial head at the elbo together

ith a $usually proximal% ulna fracture, is uncommon in children, accounting for less

than ' per cent of all forearm fractures. *s in adults it is imperative that the (oint

above and the (oint belo a fracture should be visualised radiographically. With the

forearm, if a fracture of only one bone is evident, the rist and elbo (oints must be

examined and radiographs obtained $#ig.&&.25%.

In children this in(ury can often be managed by manipulation and immobilisation in

an aboveelbo plaster. #olloup radiographs must be obtained as redisplacement

can occur. If a reduction cannot be achieved open reduction and internal fixation isindicated.

1alea--i fracture

In children this in(ury is also uncommon and often consists of a distal radius fracture

ith separation of the distal ulna epiphysis, rather than a true (oint disruption. It often

occurs in the older child and, as ith proximal humeral fractures, may be due to a

ea+ness of the perichondral ring. /losed reduction is usually possible ith this

in(ury.

#urther reading

4orrey, C.#. $'==2% The Albo and Its 7isorders, WC. Saunders, :ondon.

oc+ood, /.*. Gr, 1reen, 7.8., >ec+man, G.7. et at. $'==;% #ractures, :ippincott

Williams N Wil+ins, :ondon.

oc+ood, /.*. Gr, and 4atsen, #.*. III $'==

22. problems in the shoulder & elbo

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