Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 The humeral neck is the weakest region of the proximal humerus Blood supply Anterior humeral circumflex artery Proximal Humeral Fracture 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 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 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 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 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 Two-part Fractures of the Lesser tuberosity Rare and can be associated with posterior shoulder dislocations. 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 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) 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 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 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. 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. 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%) 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 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. Glenoid Fracture (Ideberge Classifi.) 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 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 Shoulder Girdle Unstable: Complexity of Scapular Fractures 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." 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 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 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 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 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 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