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
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).
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.
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
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.
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
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,
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.