Fractures of the upper limb In adults Introduction

Fractures of the upper limb are very common injuries in all age groups. In adults, between the ages of 15—49, these injuries are more common in males and are usually due to high-energy mechanisms such as road traffic accidents. Between the ages of 65 and 89 there is a considerable increase in the incidence of fractures, particularly in females. These are associated with osteoporosis and may follow minor trauma such as a fall from a standing height. Many of these injuries are relatively minor, for example clavicle fractures, which usually require no more than symptomatic treatment. Some injuries, such as displaced forearm fractures, require internal fixation but the final result is usually good. Some of the injuries, however, particularly complex fractures of the proximal humerus, often result in poor results despite aggressive management including primary joint replacement.

Specific injuries

Fractures of the clavicle

Fractures of the clavicle are very common, accounting for 5—10 per cent of all fractures. Males are more commonly affected than females (2.5:1) and, in males, the most common age group is the under 20s. The fracture is usually due to sporting injuries or road traffic accidents. In females the elderly are commonly affected, often following a simple fall. The fracture may be caused by direct trauma or indirectly such as a fall on the outstretched hand. The majority of fractures is closed injuries.

Most fractures occur in the midshaft of the bone and are often associated with overlap of the fragments. Fractures of the lateral end of the clavicle may result in superior displacement of bone if the coracoclavicular ligaments are involved. Fractures of the medial end of the clavicle are uncommon.

Treatment. The vast majority of clavicle fractures is treated conservatively with the limb rested in a broad arm sling. Mobilisation can be commenced as comfort allows, with a return to full activities within 3—6 weeks. Attempts at reduction, including bracing back the shoulders with a figure-of-eight bandage, are rarely necessary. Malunion is common but is not usually a functional problem. Nonunion may occur in up to 5 per cent of fractures and is more common after high-energy mechanisms such as road traffic accidents (Fig. 22.21).

Surgery. Open reduction and plate fixation are occasionally required and may be indicated for open fractures associated neurovascular injuries or fractures of the lateral end of the clavicle with significant displacement of the fragments. Internal fixation and bone grafting are indicated for symptomatic nonunions.

Acromioclavicular joint injuries

Disruption of the AC joint is a relatively common injury and is typically seen in young males. It is usually caused by trauma, commonly sporting injuries, and is associated with superior subluxation or dislocation of the lateral end of the clavicle (Fig. 22.22).

Classification.

Type 1 — the capsule and coracoclavicular ligaments are damaged but not ruptured, and no subluxation of the joints occurs.

Type 2 — the joint is subluxed, with some superior displacement of the clavicle; this is associated with increased damage to), but not rupture of, the ligaments

Type 3 — the ligaments are ruptured and the clavicle dislocates superiorly.

Type 4 — the lateral end of the clavicle dislocates and lies subcutaneously due to severe soft tissue injury.

Type 5 — the clavicle dislocates and lies posterior to the acromion (rare).

Type 6 — the clavicle dislocates and lies inferior to the acromion (rare).

 Treatment. Most injuries can be treated conservatively, with good results expected. A broad arm sling can be used, with mobilisation as comfort allows. In certain circum­stances, early surgery may be indicated, especially for the less common type 4—6 injuries. Late reconstruction of the AC joint is occasionally required for persistent displacement of the clavicle associated with pain and functional impairment.

Scapular fractures

These are uncommon injuries and are usually caused by direct trauma, often due to road traffic accidents. Most can he treated conservatively. Internal fixation is indicated for some articular fractures of the glenoid.

A glenoid fracture usually represents a fracture dislocation of the shoulder. The size and displacement of the fragment must be assessed and this can be done by computerised tomography. Conservative treatment with immobilisation will be required for minimally displaced fractures, although rarely for more than 3 weeks. Indications for internal fixation, usually by a lag screw technique, include large displaced fragments and an unstable shoulder. Operative approach, method of fixation and postope­rative mobilisation will be determined by the fracture pattern and fixation achieved at surgery.

Dislocation of the glenohumeral joint

Approximately 45 per cent of all joint dislocations in adults occur at the glenohumeral joint. Most dislocations occur anteriorly and result from a forced abduction/external rotation mechanism, often due to sporting injuries. The injury is therefore more common in males in the age group 21—30, although glenohumeral dislocation does occur in elderly females. In this age group rotator cuff damage may occur in association with the dislocation.

Dislocation is frequently associated with damage to the glenoid labrum and detachment of the anteroinferior segment, the Bankart lesion. In addition, damage to the back of the humeral head can occur as a Hill—Sachs lesion (Fig. 22.14). Both of these abnormalities predispose to recurrent dislocation. Less than 5 per cent of primary dislocations are posterior.

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. Following reduction, the arm is rested in a sling for approximately 1 week and mobilisation commenced. Prolonged immobilisation, as previously recommended, does not seem to influence the recurrent dislocation rate.

Hippocratic method. The patient lies supine on a bed, although classically the patient lies on the ground. Traction is applied to the arm with the elbow extended and the arm is flexed and abducted at the shoulder. As traction is continuously applied, the humeral head is eased back into the joint by the surgeon’s stockinged foot.

Kocher’s method. Traction is applied to the arm, with the elbow flexed to 900. The arm is slowly externally rotated, and then internally rotated and flexed across the body to reduce the shoulder. This may be modified by abducting as well as externally rotating the arm, and a collar and cuff bandage can be used to provide counter-traction over the humeral head. All these manoeuvres should be carried out gradually as spiral fractures of the humerus and brachial plexus injuries have been reported.

Hanging-arm method. This method may be tried without sedation. The patient is placed face down on a bed or bent over a chair. The arm is allowed to hang free, with the elbow extended; an intravenous fluid bag can be tied to the arm to provide traction.

Complications. Nerve palsy. Neurological 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, with the axillary nerve, or occasionally the supra­scapular nerve, involved. The majority of palsies recovers with conservative treatment.

Recurrent dislocation. This is age related and is usually due to the presence of a Bankart lesion. In the under 25s approximately 60 per cent will have further instability and approximately half of these will require surgery. Only 25 per cent of the over 34 age group will have further problems. Instability of the glenohumeral joint is considered in more detail in the previous section.

Posterior dislocation of the glenohumeral joint is much less common and has been associated with epilepsy and electrocution. The humeral head appears light-bulb shaped on anteroposterior radiographs, an appearance that is normally seen on a lateral or an axillary view. Reduction is achieved by applying traction to the abducted arm and then gently externally rotating the arm.

Proximal humeral fractures

Fractures of the proximal metaphysis of the humerus are one of the most common fractures in the elderly with a dramatic increase in incidence after the age of 60. They account for approximately 5—7 per cent of adult fractures and are most common in elderly females.

 Classification of fractures. Proximal humeral fractures were classified by Neer in 1970 and this is still an accepted classification. Minimally displaced fractures are ignored, and the fractures are classified by anatomical location and the number of main fragments. The more severe injuries consist of four main parts: the shaft, the articular surface, together with separate, displaced greater and lesser tuberosities (Fig. 22.23).

 

Treatment. Treatment of these injuries is dependent on the severity and displacement of the fractures. The majority of fractures is minimally displaced and treated conservatively with good results expected. Two to three weeks of immobilisation in a sling is recommended. Displaced fractures, particularly in the younger patient, are treated by internal fixation with a plate and screws, multiple pins or an intra­medullary device; again good results can be anticipated.

The treatment of four-part fractures in the elderly osteoporotic patient is still unresolved owing to the unsatisfactory results with all methods of treatment. Conservative treatment can result in a stiff painful shoulder but operative treatment often results in the same outcome. A number of methods of fixation have been described including plates and screws, multiple wires, tension band wiring and intramedullary devices. Insecure fixation in the osteoporotic bone, together with difficulties in reattaching the tuberosities and sub­sequent rotator cuff problems, will produce poor results. Pri­mary replacement of the humeral head, with a metal prosthesis, is frequently performed and was originally recommended by Neer for severe injuries. Unfortunately hemiarthoplasty is also frequently complicated by stiffness or rotator cuff problems.

Avulsion of the greater tuberosity

This fracture is included in the classification described by Neer but should also be considered separately. The injury is often associated with dislocation of the glenohumeral joint and represents a rotator cuff injury. The fracture may appear to be minimally displaced after reduction of the dislocation.

Treatment. Displaced fractures should be anatomically fixed with screws through a lateral approach. Undisplaced fractures may be treated conservatively but regular review, initially with weekly radiographs, is required. Malunited fractures will lead to impingement symptoms which do not respond as well to later decompression.

Humeral shaft fractures

These injuries account for approximately 3 per cent of adult fractures and are most common in patients in their 70s, usually as a result of a simple fall; approximately 80 per cent of the patients are female. A second, slightly smaller peak in incidence occurs in patients in their 20s. In this group 80 per cent of the patients are male and the injury is due to a road traffic accident or sport. The majority of humeral shaft fractures is closed injuries, with open fractures and associated injuries being more common in the younger age group (Fig. 22.24).

Treatment. The majority of humeral fractures can be treat­ed conservatively, particularly in the elderly, with good return of function anticipated. A sling or splintage is employed for 2—3 weeks, at which time mobilisation can be commenced. Hanging casts have been recommended, but can result in distraction of the fracture site and increased risk of nonunion.

Surgery. Operative treatment is indicated in patients with open fractures, associated vascular injuries and particularly in patients with multiple injuries. Open reduction and plate fixation is the most common method of stabilisation, although intramedullary nailing from either a proximal or distal entry point is commonly used. External fixation is occasionally indicated for associated severe soft tissue problems.

Complications. Nonunion. Up to 10 per cent of humeral fractures will be complicated by nonunion, particularly transverse fractures of the midshaft of the bone. Treatment is usually internal fixation and bone grafting of the nonunion site with subsequent healing in most cases.

Nerve palsy. Radial nerve palsy can also occur in up to 10 per cent of patients, with a wrist drop and loss of extension of the fingers. The majority will recover and therefore the injury is treated conservatively, with the patient managed with physiotherapy and a radial nerve splint. Up to 10 per cent of these patients will have no recovery of function and may require exploration of the nerve at about 3 months after the injury. Early exploration is indicated if the nerve is initially intact but dysfunction occurs after closed or open management.

Distal humeral fractures

These are the least common of the metaphyseal fractures of the upper limb, and commonly require internal fixation and early mobilisation to produce good results. As with clavicle fractures, the injury is more common in young males and is usually due to 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.

Anatomy and classification of fractures. The elbow consists of a medial and lateral column, with an articular surface at the distal end. The trochlea at the end of the medial column articulates with the ulna and contributes to flexion and extension at the elbow. The capitellum, the articular surface of the lateral column, articulates with the radial head and contributes to pronation and supination at the elbow.

Anatomically the fractures may involve the medial or the lateral column in isolation, with separation of the condyle from the rest of the humerus. These are relatively uncommon, accounting for only 5 per cent of elbow fractures in adults. The more complex injuries involve both columns, with complete separation of the articular surface from the diaphysis, together with a fracture through the articular surface. It is these T- or Y-shaped fractures that can be particularly difficult to treat.

Treatment. Minimally displaced fractures can be treated conservatively with splintage followed by gentle mobilisation as comfort allows. In adults immobilisation of the elbow for longer than 2—3 weeks should be avoided as stiffness and functional restriction can occur. This is particularly true for complex injuries, or following operative management of the fractures.

For displaced fractures internal fixation is recommended for all age groups; stable fixation with plates and/or screws should be used to allow early mobilisation. Single column fractures can usually be stabilised through a limited approach but the complex T- or Y-fractures require a wide exposure of the joint to ensure accurate reduction, and usually two plates are necessary for stable fixation to the humeral shaft. In order to gain the necessary access, osteotomy of the ulna is usually required and these injuries require surgical skill and experience to achieve good results.

In the elderly osteoporotic patient, especially with very distal fractures, stable internal fixation is not possible. In these patients primary elbow replacement has been carried out with good results. This avoids the need for an osteotomy, with its risk of nonunion and implant problems, and allows immediate mobilisation of the elbow.

Radial head fractures

  These are relatively common fractures; the majority occurs in females, in the age group 20—50, after a fall on the out­stretched hand.

Approximately 40 per cent of fractures are undisplaced, involving only part of the articular surface. In a further 40 per cent a fragment of the radial head is displaced, with depression of the articular surface. The remainder of the fractures involves all of the articular surface, either as a single fragment with a fracture of the radial neck 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 injury should be suspected in patients with a typical history, pain over the radial head and restricted movement of the elbow

Classification. A number of classifications has been described but one of the most commonly used is that described by Mason (Fig. 22.25):

  type 1 — undisplaced partial articular (marginal) fractures;

  type 2 — displaced marginal fractures;

  type 3 — comminuted fractures of the radial head.

 

Treatment. Undisplaced fractures are treated by a temporary collar and cuff support, followed by early mobilisation. If the elbow is particularly painful, aspiration of the haemarthrosis can be carried out followed by intra-articular injection of local anaesthetic. Aspiration can be safely carried out through the centre of the triangle formed by the lateral epicondyle, radial head and the olecranon.

The treatment of displaced, partial articular fractures is dependent on the size and displacement of the fragment. Small fragments (<25 per cent of the articular surface) are treated conservatively, unless the range of motion is significantly restricted. In these circumstances aspiration of the joint and injection of local anaesthetic is carried out. If there is still a block to extension, and particularly full supination, exploration of the elbow via a lateral incision is indicated. Large fragments are treated by open reduction and internal fixation with small screws if possible; smaller fragments can be excised.

More complex injuries are treated by internal fixation, although this may not be possible if significant comminution is present. In these circumstances excision of the radial head can be carried out. If, however, there is any damage to the collateral ligaments of the elbow or the interosseous membrane of the forearm, prosthetic replacement may be indicated. This is seen in patients sustaining high-energy injuries, such as road traffic accidents or falls from a height. In these patients radiographs of the entire forearm including wrist should be obtained, and the distal examined carefully, both clinically and radiologically.

Olecranon fractures

These are common injuries and are usually due to indirect trauma such as a fall on the outstretched hand. The injury is

 (c) A grossly displaced fracture of the radial head and neck.

essentially an avulsion fracture due to the pull of the triceps muscle. Most fractures are intra-articular, although extra­articular fractures do occur with a small bony fragment avulsed (Fig. 22.26).

Classification. A 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. Undisplaced fractures can be treated conservatively, but late displacement can occur and regular review is necessary. Most fractures are displaced and internal fixation is indicated. Extra-articular and two-part intra-articular fractures can be treated with a tension band wiring system, using a figure-of-eight wire and intramedullary wires or screws. Stable internal fixation should be achieved to allow early mobilisation of the elbow. A tension band wire is not suitable for comminuted articular fractures or more distal fractures, and plate fixation is recommended.

The prognosis for this injury is good, with 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.

Elbow dislocation

Approximately 20 per cent of all dislocations occur at the elbow and most occur in children and young adults. The elbow usually dislocates posteriorly and is due to axial loading on a slightly flexed elbow. Fractures of the distal humerus, radial head and coronoid may be associated with the injury (Fig. 22.27).

Treatment. The elbow should be reduced as soon as possible and this is usually accomplished by closed means. Traction is applied with the arm slightly flexed and the olecranon can usually be pushed over the distal humerus, reducing with a definite clunk. Postoperatively the arm is immobilised in a collar and cuff, and mobilisation commenced after 1 week. Prolonged immobilisation should be avoided as the elbow often becomes stiff.

Complications.

  Instability. In most cases the elbow is stable after reduction but occasionally there is a tendency for the elbow to redislocate in extension. In these circumstances, after reduction, the elbow is managed in a cast brace preventing full extension initially. The extension block can be gradually reduced over 2—3 weeks. Late instability is rarely a problem after simple dislocation and is more usually associated with complex fracture dislocations.

Stiffness. Some loss of extension is not uncommon after elbow dislocation but is rarely a functional problem unless the arm has been immobilised for long periods.

Forearm fractures

These account for approximately 5 per cent of adult fractures and the majority 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.

Most of these fractures involve both bones and result from indirect trauma. Single bone injuries can occur and are usually caused by direct violence, such as a blow with a stick. Single bone fractures can also occur in association with a joint injury of the other forearm bone, and this injury must be considered. Radiographs of the elbow and wrist joints should be obtained in all forearm fractures.

Treatment. The vast majority of these fractures is displaced, and open reduction and internal fixation with plates is indicated. Both bones are usually plated, through separate incisions, with early postoperative mobilisation. Conservative treatment is not usually recommended as rotation at the fracture site is difficult to correct or control in plaster. Full 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 injuries. Montalgia fractures. Proximal ulna fractures may be associated with dislocation of the radial head but these account for only 1 per cent of forearm fractures. If the ulna fracture is reduced accurately, the radial head usually reduces and no specific treatment is necessary (Fig. 22.28).

Galeazzi fractures. Again these are relatively uncommon and consist of a distal radial fracture with disruption of the distal radio-ulnar joint.

Open reduction of the distal radius is carried out and the reduction of the distal ulna confirmed. If this is unstable, immobilisation in suppination or even cross pinning to the radius is carried out.