fractures of shoulder and elbow edited

8/8/2019 Fractures of Shoulder and Elbow Edited

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Fractures of Clavicle and

Humerus

Adapted from source


2/25

Clavicle

protector of brachial plexus

only bony connection betweenupper limb and the thorax

1st bone to ossify Medial end secondary

ossification centre ossifies atage 25

Classification

Middle third 80%

Distal third 15%

Medial third 5%


3/25

Clavicle Fractures

Middle 1/3 (80%);

- up

displacement of medial

frag bysternocleidomastoid

muscle.

- lat frag is

pulled down by wt oflimb

Xrays

in any clavicular frx,

carefully scutinize x-rays

for presence ofscapular

frx which represents a

floating shoulder


4/25

Clavicle

NonOperative Treatment:- difficult to reduce and

maintain the reduction of claviclefractures;

- despite deformity, healing

usually proceeds rapidly;- union usually occurs rapidly& produces prominent callus;

- there will also be somedegree of malunion;

- in these patients beattentive to medial cord nerve

symptoms (more often ulnarnerve)

Kids always unite

Treat with sling supporting thearm


5/25

Clavicle

Operative Treatment:- indications for surgery:

- open fracture- gross displacement

w/ tenting of skin- fractures w/ overlap

(causing medialization ofthe shoulder girdle);

- surgical considerations:- subclavian artery

- brachial plexus (esplower trunk damage (C8,T1);

- floating shoulder


6/25

Clavicle

Lateral third

High incidence of non

union especially with

disruption of Coroco-

Clav lig


7/25

Proximal Humerus Fractures

5% of all fractures

Incidence increasing due to

age and osteoporosis

Factors to consider indeciding traetment

Type of # (Neer)

Age/bone quality

General health

Surgery can be technically

difficult

May rquire long anaesthetic

Time from injury


8/25


Neer Classification

2 part

3 part

4 part

More than 1cm

displacement or

>45degree angulation


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2 part

Minimal displacement usually treat non-op

Stable Frx (impacted vs non impacted)

soft tissue hinges are most likely to be intact, so that AVN isunlikley

arm may be immobilized in a sling and early motion startedimmediately;

need for surgery is rare, except for stable frx w/ unacceptabledisplacement

excessive angulation in a young patient;- greater than 45 deg angulation will affect arm motion


10/25


Surgical neck

2 part fractures

Undisplaced fragmentsdont count

humeral shaft is usuallydisplaced medially &anteriorly by pectoralis

Can lead to delayed union =stiffness (due to prolongedimmobilisation)

-


11/25


2part

Anatomical neck #

anatomic neckrepresents the old

eiphyseal plate Blood supply to head is

compromised if minimaldisplaced # some thru

long head bicepstendon

AVN can result

If displaced

ORIF vs. prostheticarthroplasty;

- in young active pts,consider screws fromthe shaft into head maybe

inserted thru ananterior approach


12/25


2part

Greater tuberosity #

Usually following

reduction of shoulder

dislocation

If > 5mm requires ORIF

due to secondary

impingement

Lesser tuberosity

Rare injury in

osteoporotic bone


13/25


3 part

Difficult to tell between

3 and 4 part on Xrays

Do CT scan

ORIF in younger

patients

Hemiarthroplasty inolder with poor bone

quality


14/25


4 part


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Proximal Humeral Physeal Injuries

either Salter I or II fractures;

between ages of 11 and 15 years;

80% of longitudinal growth ofhumerus occurs in proximal

physis;

large percentage of growth allowssignificant remodelling followinginjuryies of proximal humeralphysis

Look for associated brachial

plexus injuries (traction) But all recover by 9 months

Osteochondritis (little leagueshoulder)

Treatment is almost always nonoperative periosteal hingeallows fracture healing

Manipulation can lead to growtharrest and AVN


16/25

Humerus shaft #

Classified as transverse, obliqueand spiral

bending force producestransverse frx of the shaft;

torsion force will result in a spiralfracture;

combination of bending andtorsion produce oblique frx w/ or

w/o a butterfly fragment;

compression forces will frx eitherproximal or distal ends ofhumerus

Exclude Radial n palsy in all


17/25

Humerus shaft #

Acceptable alignment

upper arm will

accommodate 10-20 deg

of anterior angulation &10-30 deg of varus

2.5cm overlap ok

2-5% non union rate

with non op treatment Hanging cast or Uslab

Cast brace at 2 weeks


18/25

Humerus shaft # Indications for Operative

Treatment:

unacceptable frx positionfollowing closed reduction;

new onset radial nerve palsyfollowing closed reduction;

multi-trauma patients;

open humeral fractures;

segmental humeral fractures;

loating elbow or ipsilateralarm injuries;

pathologic fractures


19/25

Distal Humerus #

Paediatric vs Adult

Adult Classification

Distal shaft

Lateral condyle Medial condyle

Intra-articular bi-condylar

Paediatric

Dist. Physeal separation

Lateral condyle

Medial epicondyle

Supracondylar


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Growth Plates in Kids

C.R.I.T.O.E

Capitellum (lat condyle)1yr

Radial head 3yr Internal (med)

epicondyle 5yr

Trochlea 7 yr

Olecranon 9yr

External (lateral)Epicondyle 11 yr


21/25

Supracondylar Fractures in Children

Classification

2 types: extension type (95%) &flexion type

Gartland for extension fractures:recognizes that anterior cortex

fails first w/ resultant posteriordisplacement of distal fragment;

- type I: non-displaced- type II: displaced with

intact posterior cortex- type III: displaced with

no cortical contact

Check pulse

Median/ant interosseus n palsy


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Non-op Treatment for

undisplaced

Collar & Cuff

Backslab

Gartland 2 Flex elbow

to 90 and repeat X-ray

If no improvement-

Kwire fixation

If flexion type splint in

20 deg flexion


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Type 3

Usually require MUA =/-ORIF

attempts in the ER atpartial reduction anddelays in reduction willonly lead to increasesoft tissue swelling

whichwill complicate thedefinitive reduction inthe OR

Need to monitorcirculation with pulseoxymeter

Elevate

Splint

Definitive treatment inOR


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Lateral condyle # in Kids

common (20% of pediatric elbow)-

6-10 yrs of age;

-

are unstable & tend to become displaced even when immobilized becauseof pull offorearm extensors;

prone to non union since the frx is intra-articular

on exam only lateral sided elbow pain

Classification Milch 1 (SH4)

Milch 2 (SH2 ) Most common


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Lateral condyle # in Kids

Even minimal

displacement requires

ORIF

Fragment is bigger thanit appears on Xray

fractures of shoulder and elbow edited

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