shoulder/ humerus fractures - orlando hand surgery · fractures of the humeral shaft (consider...
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Shoulder/ HumerusFractures
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Let’s recall anatomy!
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Let’s recall anatomy!
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The Hand to Shoulder Center
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The Hand to Shoulder Center
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The Hand to Shoulder Center
PHF: Epidemiology
• Majority of patients older– Osteoporotic fracture– Low energy– Younger
patient is high energy
• 2:1 female to male• 4% of all fractures in adults
– 85% of Fx�s one-part (non- displaced)
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The Hand to Shoulder Center
Neerclassification
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The Hand to Shoulder Center
• Codman: 4 distinctepiphyseal fragments
Codman EA. The shoulder; 1934.
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The Hand to Shoulder Center
Greater Tuberosity Fx
Posterior-superior displacement causes impingement
•Associated with RCT
Traditional criteria for ORIF- 1 cm (Neer)
• Deltoid split for small fragments
– Limit to 5 cm distal
– Axillary nerve
• Large fragments use deltopectoral
approach
• Suture fixation reduces recurrence, better
fixation, and avoids fragmentation
• Screws, Plating techniques may be
needed
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The Hand to Shoulder Center
Surgical Neck Fracture
• Medial comminution– Varus malalignment
Prominent tuberosities
Requires fixation
Stable reduction impossible
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The Hand to Shoulder Center
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The Hand to Shoulder Center
3-Part Fractures
• Issues:– Malrotation
• Version
– Head-height relationshipVarus or valgus
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The Hand to Shoulder Center
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The Hand to Shoulder Center
3-part fracture
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The Hand to Shoulder Center
Classic 4-Part Fx
ORIF?•Young•AVN•Often Hemi•? Reverse
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The Hand to Shoulder Center
Assessment: CT
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The Hand to Shoulder Center
Predicting humeral head ischemia
Hertel et al. JSES. 13. 2004•Combination of 3: 97% predictive AVN–Length of medial calcar segment (< 8mm)–Loss of integrity of medial hingeAnatomic neck fracture
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The Hand to Shoulder Center
Nerve Injury
• Frequency (electromyogram)– 67% (96/143) all comers
– 82% (41/50) displaced fxs59% (55/93) non-displaced fxs
• All nerves recovered• Nondisplaced fxs
– Recovery of shoulder fxn took 2 mos longer
• Displaced fxsDifficult to know
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The Hand to Shoulder Center
• Displaced Fx�s– Distorted Anatomy
• Not a “healing issue”• Options:
– ORIF• Perc Pinning• Locking Plate
– Hemiarthroplasty– ? Reverse– Rod
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The Hand to Shoulder Center
Current Indications for Locking Plate
Fx Pattern
Displaced 2, 3 and 4-parts
– Varus Fx�s– Valgus Impacted
• Too late for pinning• Osteoporotic Fxs• ComminutionFailed Nonop Tx
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The Hand to Shoulder Center
Beware of the Varus Fracture
• Calcar comminution– Deforming forces– Pinning not a good option– Higher Failure Rate!!!
• Varus Collapse• Screw Cutout
Requires Locking Plate
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Fractures of the clavicle
Mechanism of injury:
Most (94%) clavicular injuries result from a direct blow on the point of the shoulder, generally from a fall on the side (A). Less commonly, force may be transmitted up the arm from a fall on the outstretched hand (B).Under the age of 30 road traffic and sporting injuries are the commonest causes.
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Fractures of the clavicle (in children)
Greenstick fractures are common, particularly at the junction between the middle and outer thirds. Fractures may not be particularly obvious on the radiographs and it is often helpful in children to have both shoulders included for comparison..
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Fractures of the clavicle
In the adult, undisplaced fractures are also common, and are comparatively stable injuries. Late slipping is rare.Symptoms settle rapidly and minimal treatment is required.
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Fractures of the clavicle
With greater violence, there is separation of the bone ends. The proximal end, under the pull of sternomastoid, often becomes elevated (1). The shoulder loses the prop-like effect of the clavicle, so that it tends to sag downwards and forwards (2). Note (3) the glenoid, (4) the coracoid,(5) the acromion.
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Fractures of the clavicle
Figure-of- eightbandage:
Pads of gamgee or cotton wool alone are carefully positioned round both shoulders (1). The patient, who should be sitting on a stool, is asked to brace back the shoulders; a wool roll bandage is then applied in a figure-of-eight fashion (2). For added security the layers may be lightly stitched together at the crossover (3).
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Fractures of the clavicle
Operative treatment
Internal fixation of fractures of the clavicle in the acute situation may be considered in cases of so-called 'floating shoulder', where there is a fracture of the clavicle associated with a fracture of the proximal humerus or of the glenoid.Good fixation reduces pain, improves patient mobility, and may facilitate union at each site. New evidence suggests faster return to function but higher risk of nonunion.
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Scapularfractures
( Fractures of the scapular neck lead to much bruising and swelling. Comminution is common. In spite of frequently daunting radiographs, a good outcome usually follows conservative management with early mobilisation.
( Fractures of the scapular spine or coracoid may usually be treated conservatively.
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Fractures of the humeral shaft( Consider internal fixation if there is a
segmental fracture, two fractures in the same limb; multiple injuries, fractures of both arms, a significant head injury, pathological fracture, a radial nerve palsy in an open and otherwise suitable fracture, or after failed manipulation.
( The most reliable method is to use a plate (1) applied to the posterior surface with an interfragmental screw (2).
( Alternatively, an intramedullary nail with interlocking screws may be used.
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The Hand to Shoulder Center
Better Education,
Better care, Better
Outcomes