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Shoulder Trauma: Bone

Shoulder Trauma: Bone. Department of Orthopaedics, CKUH Sen-Jen Lee Reference: Orthopaedic Knowledge Update 6. Proximal Humeral Fractures. 4% to 5% of all fractures 85% of proximal humeral fractures are minimally displaced Result from falls and involve osteoporotic bone

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Shoulder Trauma: Bone

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  1. Shoulder Trauma: Bone Department of Orthopaedics, CKUH Sen-Jen Lee Reference: Orthopaedic Knowledge Update 6

  2. Proximal Humeral Fractures • 4% to 5% of all fractures • 85% of proximal humeral fractures are minimally displaced • Result from falls and involve osteoporotic bone • The humeral neck is the weakest region of the proximal humerus • Blood supply • Anterior humeral circumflex artery

  3. Proximal Humeral Fracture

  4. Classification of Proximal Humeral Fractures: 4-part System of Neer • Humeral head, greater tuberosity, lesser tuberosity, and humeral shaft • Determination of displacement >1 cm or angulation > 45° • Radiographic imaging, the trauma series: scapular anteroposterior (AP), lateral, and axillary radiographs

  5. The Treatment of Proximal Humeral Fractures • Based on: patient age, bone quality, medical comorbidities, other concurrent injuries, and fracture type • Plate and screw fixation and ender nails with figure-of-8 tension band were the strongest constructs • Tension band with nonabsorbable suture or wire were the weakest fixation

  6. The Treatment of Proximal Humeral Fractures • For minimally or nondisplaced fractures • Nonsurgical treatment • Early passive motion within 14 days is recommended for stable fractures. • Active range of motion is started at 4 to 6 weeks when healing is evident • 77% resulted in good or excellent results

  7. Two-part Fractures of the Surgical Neck • Mode of treatment depends on the stability of the fracture. • CR • CR + percutaneous pins • OR + IF • Ender nails with figure-of-8 tension banding or plate and screw • Surgical reconstruction of nonunions of the surgical neck remains challenging

  8. Two-part Fractures of the Greater tuberosity • Commonly occur • In conjunction with a glenohumeral dislocation. • Rule out an associated surgical neck fracture before attempting reduction • ORIF • Superior or posterior displacement > 5 to 10 mm • Fixation of the tuberosity fragment with repair of the rotator cuff tear • Intraosseous sutures incorporating the cuff insertion • Screw fixation • acromioplasty

  9. Two-part Fractures of the Lesser tuberosity • Rare and can be associated with posterior shoulder dislocations.

  10. Treatment of 3- and 4-part Fractures of Proximal humerus • Controversial • Anatomical reduction > residual displacement. • Techniques: • Ender nails with figure-of-8 tension band • percutaneous reduction and screw fixation • Four-part fractures usually are treated with humeral head replacement. • ORIF: osteonecrosis --9% to 11% • Humeral head replacement • 73% of patients had difficulty with some functional task

  11. Fractures of the Clavicle • 4% to 15% of all fractures and 35% of fractures about the shoulder • 85%: middle third of the clavicle • Associated injuries occur in less than 3% • Direct trauma > indirect mechanism( fall onto the outstretched hand)

  12. Fractures of the M/3 Clavicle • Sternocleidomastoid and trapezius muscles the weight of the arm and pectoralis major • Nonsurgical treatment • Figure-of-8 bandage or sling for 6 weeks • Shortening and a residual painless deformity • Indications for surgical treatment • Open fractures • Neurovascular injury/compromise • Displaced fractures with impending skin compromise

  13. Fractures of the L/3 Clavicle • Coracoclavicular (C-C) ligaments • Type I: minimally displaced • Interligamentous fractures between the conoid and trapezoid • Between the coracoclavicular and coracoacromial ligaments. • Type II: displaced • Lateral to the coracoclavicular ligaments with C-C ligments rupture • Type III fractures involve the articular surface of the lateral clavicle with no ligamentous injury

  14. Treatment of L/3 clavicular fracture • Type I fractures are stable and treated in the same manner as middle third fractures • Treatment for the unstable type II fractures remains controversial. • ORIF for displacement • Type III fractures can be adequately managed nonsurgically • Distal clavicle resection is the procedure of choice if symptomatic degenerative disease occurs.

  15. Complications After clavicular Fractures • The incidence of nonunion • 0.9% to 4.0%. • Acute laceration of the subclavian vessels or brachial plexus injury. • Malunion is common and rarely symptomatic but can cause an unacceptable prominence. Surgical intervention to improve cosmesis may result in an ugly scar or a painful nonunion.

  16. Fractures of the Scapula • 0.5% to 1% of all fractures and 3% to 5% of shoulder fracture • High-energy trauma • Associated injuries: severe and life-threatening • Ipsilateral rib fracture with • Hemopneumothorax (27% to 54%) • Clavicular fracture (17% to 38%) • Closed head injury (11% to 57%) • Injury to the face and skull (10% to 24%) • Brachial plexus disruption (3% to 8%)

  17. Fractures of the Scapula • True scapular AP and lateral views and an axillary view (trauma series) • West point axillary view • Stryker notch view • CT scan

  18. Classification of Scapular Fractures • Fractures of the body and spine (50%) • Short-term immobilization in a sling and swathe bandage • Scapular neck (25%) • ORIF: if the glenoid fragment is displaced > 1 cm or angulated > / = 40° • Acromion (7%) • ORIF: encroach on the subacromial space and interfere with rotator cuff function • coracoid process (3%) fractures.

  19. Glenoid Fracture (Ideberge Classifi.)

  20. Intra-articular glenoid Fractures • Type I fractures involve the glenoid rim. • ORIF: 25% of the anterior glenoid or 33% of the posterior glenoid with fracture displacement > 10 mm • Types II through VI • ORIF: • Subluxation of the humeral head with a major fragment • > / = 5 mm intra-articular step-off • Severe separation between the glenoid fragments

  21. Shoulder Girdle Unstable: Complexity of Scapular Fractures • Superior shoulder suspensory complex (SSSC): • Glenoid process, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromial process • ORIF is indicated for double disruption • Often surgical stabilization at 1 site • “Floating shoulder”: M/3 clavicle and glenoid neck • Treated by surgical stabilization of the clavicle or acromioclavicular joint

  22. Shoulder Girdle Unstable: Complexity of Scapular Fractures

  23. Scapulothoracic Dissociation • A rare, often fatal, closed injury manifested by lateral displacement of the scapula with associated neurovascular injury and either acromioclavicular or sternoclavicular separation or clavicular fracture • A severe direct force over the shoulder accompanied by traction applied to the upper extremity is the mechanism of injury • As a "closed, traumatic forequarter amputation."

  24. Humeral Shaft Fractures • 3% of all fractures • Direct load : • Short / long oblique fracture ± butterfly fragment • Indirect torque • A spiral fracture • The neurovascular status of the limb must be assessed

  25. Nonsurgical Treatment of Humeral Shaft Fractures • CR and immobilization with splint or hanging arm cast followed by a functional brace at 1 to 2 weeks • 20° of anterior or posterior angulation, • 30° of varus or valgus angulation, and • 3 cm of shortening • Contraindications to use of the functional brace • Massive soft-tissue or bone loss • An unreliable or uncooperative patient • An inability to obtain or maintain acceptable fracture alignment • Range of motion (ROM) exercises

  26. Surgical Treatment of Humeral Shaft Fractures • Indications • Open fracture, except low-energy handgun wound • Associated vascular injury • Floating elbow • Segmental fracture • Pathologic fracture • Bilateral humeral fractures • Humeral fracture in polytrauma patient • Neurologic loss after lacerating injury • Neurologic loss during closed fracture alignment inability to maintain acceptable alignment • Displaced intra-articular fracture extension

  27. Surgical Treatment of Humeral Shaft Fractures • Surgical fixation using plates and screws • Dynamic compression plate • Reconstruction plates, T plates • The surgeon should obtain 5 to 6 cortices of fixation both proximal and distal to the fracture • Intramedullary fixation • Flexible IM devices: ender pins, and rush rods • Locked IM nails • Results and outcomes • 96% united with an average time to union of 9.5 weeks for closed fractures and 13.6 weeks for open fractures

  28. Results and Outcomes • CR & immobilization with functional brace: 96% united • Varus deformity: average, 9° • External rotation: lost between 5° and 45° • ORIF with plates and screws: 87% (102 p’ts) • 5 early failures of internal fixation, 2 nonunions, and 4 postoperative infections • ORIF with IM flexible rods or nails: 94% (58 p’ts) • Antegrade nailing: excellent results • Retrograde nailing: poor results • ORIF with an interlocked IM nail: 100% (51 p’ts) • 3 transient brachial plexus neurapraxias, 2 infections, 3 cases of nail impingement, and 2 intraoperative fractures

  29. Complications of Humeral Shaft Fractures • Radial nerve injury: up to 18% • Most commonly associated with M/3 fracture • Neurapraxia or axonotmesis; 90% will resolve in 3 to 4 months • Vascular injury • Nonunion: 7% • Pathologic fractures • Interlocked nail is the implant of choice for these fractures

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