Fractures of the upper extremity in the practice of general practitioners and family medicine.

Fractures of the upper extremity in the practice of general practitioners and family medicine. Features of diagnosis and first aid in outpatient family doctor. Formation route patient with trauma musculoskeletal system. Drug-employment medical and social assessment. Principles of rehabilitation.

 

Clavicle Fractures

EPIDEMIOLOGY

• Clavicle fractures account for 2.6% to 12% of all fractures and for 44% to 66% of fractures about the shoulder.

• Middle third fractures account for 80% of all clavicle fractures, whereas fractures of the lateral and medial third of the clavicle account for 15% and 5%, respectively.

ANATOMY

• The clavicle is the first bone to ossify (fifth week of gestation) and the last ossification center (sternal end) to fuse, at 22 to 25 years of age.

• The clavicle is S-shaped, with the medial end convex forward and the lateral end concave forward.

• It is widest at its medial end and thins laterally.

• The medial and lateral ends have flat expanses that are linked by a tubular middle, which has sparse medullary bone.

• The clavicle functions as a strut, bracing the shoulder from the trunk and allowing the shoulder to function at optimal strength.

• The medial one-third protects the brachial plexus, the subclavian and axillary vessels, and the superior lung. It is strongest in axial load.
• The junction between the two cross-sectional configurations occurs in the middle third and constitutes a vulnerable area to fracture, especially with axial loading. Moreover, the middle third lacks reinforcement by muscles or ligaments distal to the subclavius insertion, resulting in additional vulnerability.

• The distal clavicle contains the coracoclavicular ligaments.

• The two components are the trapezoid and conoid ligaments.

• They provide vertical stability to the acromioclavicular (AC) joint.

• They are stronger than the AC ligaments.

MECHANISM OF INJURY

• Falls onto the affected shoulder account for most (87%) of clavicular fractures, with direct impact accounting for only 7% and falls onto an outstretched hand accounting for 6%.

• Although rare, clavicle fractures can occur secondary to muscle contractions during seizures or atraumatically from pathologic mechanisms or as stress fractures.

CLINICAL EVALUATION

• Patients usually present with splinting of the affected extremity, with the arm adducted across the chest and supported by the contralateral hand to unload the injured shoulder.

• A careful neurovascular examination is necessary to assess the integrity of neural and vascular elements lying posterior to the clavicle.

• The proximal fracture end is usually prominent and may tent the skin. Assessment of skin integrity is essential to rule out open fracture.

• The chest should be auscultated for symmetric breath sounds. Tachypnea may be present as a result of pain with inspiratory effort; this should not be confused with diminished breath sounds, which may be present from an ipsilateral pneumothorax caused by an apical lung injury.

ASSOCIATED INJURIES

• Up to 9% of patients with clavicle fractures have additional fractures, most commonly rib fractures.

• Most brachial plexus injuries are associated with proximal third clavicle fractures.

RADIOGRAPHIC EVALUATION

• Standard anteroposterior radiographs are generally sufficient to confirm the presence of a clavicle fracture and the degree of fracture displacement.

• A 30-degree cephalad tilt view provides an image without the overlap of the thoracic anatomy.

• An apical oblique view can be helpful in diagnosing minimally displaced fractures, especially in children. This view is taken with the involved shoulder angled 45 degrees toward the x-ray source, which is angled 20 degrees cephalad.

• Computed tomography may be useful, especially in proximal third fractures, to differentiate sternoclavicular dislocation from epiphyseal injury, or distal third fractures, to identify articular involvement.

CLASSIFICATION

Descriptive

Clavicle fractures may be classified according to anatomic description, including location, displacement, angulation, pattern (e.g., greenstick, oblique, transverse), and comminution.

Allman

• Group I: fracture of the middle third (80%). This is the most common fracture in both children and adults; proximal and distal segments are secured by ligamentous and muscular attachments.

•  

• Group II: fracture of the distal third (15%). This is subclassified according to the location of the coracoclavicular ligaments relative to the fracture:

 

 

Figure 1. A type I fracture of the distal clavicle (group II). The intact ligaments hold the fragments in place. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:1117.)

 

• Group III: fracture of the proximal third (5%). Minimal displacement results if the costoclavicular ligaments remain intact. It may represent epiphyseal injury in children and teenagers. Subgroups include:

Type I:	Minimal displacement
Type II:	Displaced
Type III:	Intraarticular
Type IV:	Epiphyseal separation
Type V:	Comminuted

•  

Figure 2. A type IIA distal clavicle fracture. In type IIA, both conoid and trapezoid ligaments are on the distal segment, whereas the proximal segment without ligamentous attachments is displaced. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:1118.)

Figure 3. A type IIB fracture of the distal clavicle. The conoid ligament is ruptured, whereas the trapezoid ligament remains attached to the distal segment. The proximal fragment is displaced. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:1118.)

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OTA Classification of Clavicle Fractures

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

 

TREATMENT

Nonoperative

• Most clavicle fractures can be successfully treated nonoperatively with some form of immobilization.

• Comfort and pain relief are the main goals. A sling has been shown to give the same results as a figure-of-eight bandage, providing more comfort and fewer skin problems.

Figure 4. A type III distal clavicle fracture, involving only the articular surface of the acromioclavicular joint. No ligamentous disruption or displacement occurs. These fractures present as late degenerative changes of the joint. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:1119.)

• The goals of the various methods of immobilization are as follows:

• Support the shoulder girdle, raising the lateral fragment in an upward, outward, and backward direction.

• Depress the medial fragment.
• Maintain some degree of fracture reduction.

• Allow for the patient to use the ipsilateral hand and elbow.

• Regardless of the method of immobilization utilized, some degree of shortening and deformity usually result.

• In general, immobilization is used for 4 to 6 weeks.

• During the period of immobilization, active range of motion of the elbow, wrist, and hand should be performed.

Operative

• The surgical indications for midshaft clavicle fractures are controversial.

• The accepted indications for operative treatment of acute clavicle fractures are open fracture, associated neurovascular compromise, and skin tenting with the potential for progression to open fracture.

• Controversy exists over management of midshaft clavicle fractures with substantial displacement and shortening (>1 to 2 cm).

• Although most displaced midshaft fractures will unite, studies have reported shoulder dysfunction and patient dissatisfaction with the resulting cosmetic deformity.

• Controversy also exists over management of type II distal clavicle fractures.

• Some authors have indicated that all type II fractures require operative management.

• Others report that if the bone ends are in contact, healing can be expected even if there is some degree of displacement. In this situation, nonoperative management consists of sling immobilization and progressive range of shoulder motion.

• Operative fixation may be accomplished via the use of:

• Plate fixation: This is placed either on the superior or the anteroinferior aspect of the clavicle.

• Plate and screw fixation requires a more extensive exposure than intramedullary devices but has the advantage of more secure fixation.

• Plate and screw fixation is more likely to be prominent, particularly if placed on the superior aspect of the clavicle.

• Intramedullary pin (Hagie pin, Rockwood pin): This is placed in antegrade fashion through the lateral fragment and then in retrograde fashion into the medial fragment.

• Use of intramedullary fixation requires frequent radiographic follow-up to monitor the possibility of hardware migration and a second procedure for hardware removal.

• Intramedullary pins are prone to skin erosion at the hardware insertion site laterally.

Operative treatment of type II distal clavicle fractures consists of reducing the medial fragment to the lateral fragment. This is accomplished by using either coracoclavicular fixation (Mersilene tape, sutures, wires, or screws) or fixation across the AC joint, through the lateral fragment and into the medial fragment.

COMPLICATIONS

• Neurovascular compromise: This is uncommon and can result from either the initial injury or secondary to compression of adjacent structures by callus and/or residual deformity.

• Malunion: This may cause an unsightly prominence, but operative management may result in an unacceptable scar.

• The effect of malunion on functional outcomes remains controversial.

• Nonunion: The incidence of nonunion following clavicle fractures ranges from 0.1% to 13.0%, with 85% of all nonunions occurring in the middle third.

• Factors implicated in the development of nonunions of the clavicle include (1) severity of initial trauma, (2) extent of displacement of fracture fragments, (3) soft tissue interposition, (4) refracture, (5) inadequate period of immobilization, and (6) primary open reduction and internal fixation.

• Posttraumatic arthritis: This may occur after intraarticular injuries to the sternoclavicular or AC joint

ACROMIOCLAVICULAR (AC) JOINT INJURY

Epidemiology

• Most common in the second decade of life, associated with contact athletic activities

• More common in males (5 to 10:1)

Anatomy (Fig. 5)

• The AC joint is a diarthrodial joint, with fibrocartilage-covered articular surfaces, located between the lateral end of the clavicle and the medial acromion.

• Inclination of the plane of the joint may be vertical or inclined medially 50 degrees.

• The AC ligaments (anterior, posterior, superior, inferior) strengthen the thin capsule. Fibers of the deltoid and trapezius muscles blend with the superior AC ligament to strengthen the joint.

• The AC joint has minimal mobility through a meniscoid, intraarticular disc that demonstrates an age-dependent degeneration until it is essentially nonfunctional beyond the fourth decade.

• The horizontal stability of the AC joint is conferred by the AC ligaments, whereas the vertical stability is maintained by the coracoclavicular ligaments.

• The average coracoclavicular distance is 1.1 to 1.3 cm.

Mechanism of Injury

• Direct: This is the most common mechanism, resulting from a fall onto the shoulder with the arm adducted, driving the acromion medial and inferior.

• Indirect: This is caused by a fall onto an outstretched hand with force transmission through the humeral head and into the AC articulation (Fig. 6).

Associated Fractures and Injuries

• Fractures: clavicle, acromion process, and coracoid process

• Pneumothorax or pulmonary contusion with type VI AC separations

Clinical Evaluation

• The patient should be examined while in the standing or sitting position with the upper extremity in a dependent position, thus stressing the AC joint and emphasizing deformity.

• The characteristic anatomic feature is a downward sag of the shoulder and arm.

A standard shoulder examination should be performed, including assessment of neurovascular status and possible associated upper extremity injuries. Inspection may reveal an apparent step-off deformity of the injured AC joint, with possible tenting of the skin overlying the distal clavicle. Range of shoulder motion may be limited by pain. Tenderness may be elicited over the AC joint.

Figure 5. Normal anatomy of the acromioclavicular joint. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Radiographic Evaluation

• A standard trauma series of the shoulder (anteroposterior [AP], scapular-Y, and axillary views) is usually sufficient for the recognition of AC injury.

Figure 6. An indirect force applied up through the upper extremity (e.g., a fall on the outstretched hand) may superiorly displace the acromion from the clavicle, thus producing injury to the acromioclavicular ligaments. However, stress is not placed on the coracoclavicular ligaments. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Ligamentous injury to the coracoclavicular joints may be assessed via stress radiographs, in which weights (10 to 15 lb) are strapped to the wrists, and an AP radiograph is taken of both shoulders to compare coracoclavicular distances. This can differentiate grade III AC separations from partial grade I to II injuries.

Classification

• This injury is classified depending on the degree and direction of displacement of the distal clavicle (Table 1 and Fig. 7).

Treatment

Type I:	Rest for 7 to 10 days, ice packs, sling. Refrain from full activity until painless, full range of motion (2 weeks).
Type II:	Sling for 1 to 2 weeks, gentle range of motion as soon as possible. Refrain from heavy activity for 6 weeks. More than 50% of patients with type I and II injuries remain symptomatic at long-term follow-up.
Type III:	For inactive, nonlaboring, or recreational athletic patients, especially for the nondominant arm, nonoperative treatment is indicated: sling, early range of motion, strengthening, and acceptance of deformity. Younger, more active patients with more severe degrees of displacement and laborers who use their upper extremity above the horizontal plane may benefit from operative stabilization. Repair is generally avoided in contact athletes because of the risk of reinjury.
Type IV:	Open reduction and surgical repair of the coracoclavicular ligaments are performed for vertical stability.
Type V:	Open reduction and surgical repair of the coracoclavicular ligaments are indicated.
Type VI:	Open reduction and surgical repair of the coracoclavicular ligaments are indicated.

Complications

• Coracoclavicular ossification: not associated with increased disability

• Distal clavicle osteolysis: associated with chronic dull ache and weakness

• AC arthritis

STERNOCLAVICULAR (SC) JOINT INJURY

Epidemiology

• Injuries to the SC joint are rare; Cave et al. reported that of 1,603 shoulder girdle dislocations, only 3% were SC, with 85% glenohumeral and 12% AC dislocations.

Anatomy (Fig. 8)

• The SC joint is a diarthrodial joint, representing the only true articulation between the upper extremity and the axial skeleton.

The articular surface of the clavicle is much larger than that of the sternum; both are covered with fibrocartilage. Less than half of the medial clavicle articulates with the sternum; thus, the SC joint has the distinction of having the least amount of bony stability of the major joints of the body.

Figure 7. Classification of ligamentous injuries to the acromioclavicular (AC) joint. Top left: In the Type I injury, a mild force applied to the point of the shoulder does not disrupt either the AC or the coracoclavicular ligaments. Top right: A moderate to heavy force applied to the point of the shoulder will disrupt the AC ligaments, but the coracoclavicular ligaments remain intact (Type II). Center left: When a severe force is applied to the point of the shoulder, both the AC and the coracoclavicular ligaments are disrupted (Type III). Center right: In a Type IV injury, not only are the ligaments disrupted, but also the distal end of the clavicle is displaced posteriorly into or through the trapezius muscle. Bottom left: A violent force applied to the point of the shoulder not only ruptures the AC and coracoclavicular ligaments but also disrupts the muscle attachments and creates a major separation between the clavicle and the acromion (Type V). Bottom right: This is an inferior dislocation of the distal clavicle in which the clavicle is inferior to the coracoid process and posterior to the biceps and coracobrachialis tendons. The AC and coracoclavicular ligaments are also disrupted (Type VI). (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Figure 8. Cross sections through the thorax at the level of the sternoclavicular joint. (A) Normal anatomic relations. (B) Posterior dislocation of the sternoclavicular joint. (C) Anterior dislocation of the sternoclavicular joint. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Joint integrity is derived from the saddle-like configuration of the joint (convex vertically and concave anteroposteriorly), as well as from surrounding ligaments:

• The intraarticular disc ligament is a checkrein against medial displacement of the clavicle.

• The extraarticular costoclavicular ligament resists rotation and medial-lateral displacement.

• The interclavicular ligament helps to maintain shoulder poise.

• The capsular ligament (anterior, posterior) prevents superior displacement of the medial clavicle.

• Range of motion is 35 degrees of superior elevation, 35 degrees of combined AP motion, 50 degrees of rotation around its long axis. The medial clavicle physis is the last physis to close. It ossifies at 20 years and fuses with the shaft at 25 to 30 years. Therefore, many supposed SC joint dislocations are actually physeal injuries.

Mechanism of Injury (Fig. 9)

Figure 9. Mechanisms that produce anterior or posterior dislocations of the sternoclavicular joint. (A) If the patient is lying on the ground and compression force is applied to the posterolateral aspect of the shoulder, the medial end of the clavicle will be displaced posteriorly. (B) When the lateral compression force is directed from the anterior position, the medial end of the clavicle is dislocated anteriorly. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Direct: Force applied to the anteromedial aspect of the clavicle forces the clavicle posteriorly into the mediastinum to produce posterior dislocation. This may occur when an athlete is in the supine position and another athlete falls on him or her, when an individual is run over by a vehicle, or when an individual is pinned against a wall by a vehicle.

• Indirect: Force can be applied indirectly to the SC joint from the anterolateral (producing anterior SC dislocation) or posterolateral (producing posterior SC dislocation) aspects of the shoulder. This is most commonly seen in football in which an athlete is lying obliquely on his shoulder and force is applied with the individual unable to change position.

Clinical Evaluation

• The patient typically presents supporting the affected extremity across the trunk with the contralateral, uninjured arm. The patient’s head may be tilted toward the side of injury to decrease stress across the joint, and the patient may be unwilling to place the affected scapula flat on the examination table.

• Swelling, tenderness, and painful range of shoulder motion are usually present, with a variable change of the medial clavicular prominence, depending on the degree and direction of injury.

• Neurovascular status must be assessed, because the brachial plexus and major vascular structures are in the immediate vicinity of the medial clavicle.

With posterior dislocations, venous engorgement of the ipsilateral extremity, shortness of breath, painful inspiration, difficulty swallowing, and a choking sensation may be present. The chest must be auscultated to ensure bilaterally symmetric breath sounds.

Radiographic Evaluation

• AP chest radiographs typically demonstrate asymmetry of the clavicles that should prompt further radiographic evaluation. This view should be scrutinized for the presence of pneumothorax if the patient presents with breathing complaints.

• Hobbs view: In this 90-degree cephalocaudal lateral view, the patient leans over the plate, and the radiographic beam is angled behind the neck (Fig. 10).

 

Figure 10. Hobbs view: positioning of the patient for x-ray evaluation of the sternoclavicular joint, as recommended by Hobbs. (Modified from Hobbs DW. Sternoclavicular joint: a new axial radiographic view. Radiology 1968;90:801–802; in Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Greenв’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Serendipity view: This 40-degree cephalic tilt view is aimed at the manubrium. With an anterior dislocation, the medial clavicle lies above the interclavicular line; with a posterior dislocation, the medial clavicle lies below this line (Fig. 11).

Figure 11. Serendipity view: positioning of the patient to take the “serendipity” view of the sternoclavicular joints. The x-ray tube is tilted 40 degrees from the vertical position and is aimed directly at the manubrium. The nongrid cassette should be large enough to receive the projected images of the medial halves of both clavicles. In children, the tube distance from the patient should be 45 inches; in thicker-chested adults, the distance should be 60 inches. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Computed tomography (CT) scan: This is the best technique to evaluate injuries to the SC joint. CT is able to distinguish fractures of the medial clavicle from dislocation as well as delineate minor subluxations that would otherwise go unrecognized.

Classification

Anatomic

• Anterior dislocation: more common
• Posterior dislocation

Etiologic

Sprain or subluxation

• Mild: joint stable, ligamentous integrity maintained

• Moderate: subluxation, with partial ligamentous disruption

• Severe: unstable joint, with complete ligamentous compromise

• Acute dislocation: complete ligamentous disruption with frank translation of the medial clavicle

• Recurrent dislocation: rare
• Unreduced dislocation
• Atraumatic: may occur with spontaneous dislocation, developmental (congenital) dislocation, osteoarthritis, condensing osteitis of the medial clavicle, SC hyperostosis, or infection

Treatment

• Mild sprain: Ice is indicated for the first 24 hours with sling immobilization for 3 to 4 days and a gradual return to normal activities as tolerated.

• Moderate sprain or subluxation: Ice is indicated for the first 24 hours with a clavicle strap, sling and swathe, or figure-of-eight bandage for 1 week, then sling immobilization for 4 to 6 weeks.

• Severe sprain or dislocation (Fig. 12).

• Anterior: As for nonoperative treatment, it is controversial whether one should attempt closed reduction because it is usually unstable; a sling is used for comfort. Closed reduction may be accomplished using general anesthesia, or narcotics and muscle relaxants for the stoic patient. The patient is placed supine with a roll between the scapulae. Direct, posteriorly directed pressure usually results in reduction. Postreduction care consists of a clavicle strap, sling and swathe, or figure-of-eight bandage for 4 to 6 weeks. Some advocate a bulky anterior dressing with elastic tape to maintain reduction.

Figure 12. Technique for closed reduction of the sternoclavicular joint. (A) The patient is positioned supine with a sandbag placed between the two shoulders. Traction is then applied to the arm against countertraction in an abducted and slightly extended position. In anterior dislocations, direct pressure over the medial end of the clavicle may reduce the joint. (B) In posterior dislocations, in addition to the traction it may be necessary to manipulate the medial end of the clavicle with the fingers to dislodge the clavicle from behind the manubrium. (C) In stubborn posterior dislocations, it may be necessary to prepare the medial end of the clavicle in sterile fashion and to use a towel clip to grasp around the medial clavicle to lift it back into position. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Greenв’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Posterior: A careful history and physical examination are necessary to rule out associated pulmonary or neurovascular problems. Prompt closed or open reduction is indicated, usually under general anesthesia. Closed reduction is often successful and remains stable. The patient is placed supine with a roll between the scapulae. Closed reduction may be obtained with traction with the arm in abduction and extension. Anteriorly directed traction on the clavicle with a towel clip may be required. A clavicle strap, sling and swathe, or figure-of-eight bandage is used for immobilization for 4 to 6 weeks. A general or thoracic surgeon should be available in the event that the major underlying neurovascular structures are inadvertently damaged.

• Medial physeal injury: Closed reduction is usually successful, with postreduction care consisting of a clavicle strap, sling and swathe, or figure-of-eight bandage immobilization for 4 to 6 weeks.

• Operative management of SC dislocation may include fixation of the medial clavicle to the sternum using fascia lata, subclavius tendon, or suture, osteotomy of the medial clavicle, or resection of the medial clavicle. The use of Kirschner wires or Steinmann pins is discouraged, because migration of hardware may occur.

Complications

• Poor cosmesis is the most common complication with patients complaining of an enlarged medial prominence.

• Complications are more common with posterior dislocations and reflect the proximity of the medial clavicle to mediastinal and neurovascular structures. The complication rate has been reported to be as high as 25% with posterior dislocation. Complications include the following:
• Pneumothorax
• Laceration of the superior vena cava

• Venous congestion in the neck
• Esophageal rupture
• Subclavian artery compression
• Carotid artery compression
• Voice changes
• Severe thoracic outlet syndrome

Scapula Fractures

EPIDEMIOLOGY

• This relatively uncommon injury represents only 3% to 5% of all shoulder fractures and 0.5% to 1% of all fractures.

• The mean age of patients with fracture of the scapula is 35 to 45 years.

ANATOMY

• This flat, triangular bone links the upper extremity to the axial skeleton.

• Protection from impact is provided by the large surrounding muscle mass as well as the mobility of the scapula on the chest wall, further aiding in force dissipation.

MECHANISM OF INJURY

• Significant trauma is required to fracture the scapula, as is evidenced by the common cause of injury motor vehicle accident in approximately 50% of cases and motorcycle accident in 11% to 25%.

• Indirect injury occurs through axial loading on the outstretched arm (scapular neck, glenoid, intraarticular fracture).

• Direct trauma, often high energy, occurs from a blow or fall (scapula body fracture) or through direct trauma to the point of the shoulder (acromion, coracoid fracture).

• Shoulder dislocation may cause a glenoid fracture.

• Muscles or ligaments may cause an avulsion fracture.

ASSOCIATED INJURIES

• The presence of a scapula fracture should raise suspicion of associated injuries, because 35% to 98% of scapula fractures occur in the presence of comorbid injuries including:

• Ipsilateral upper torso injuries: fractured ribs, clavicle, sternum, shoulder trauma.

• Pneumothorax: seen in 11% to 55% of scapula fractures.

• Pulmonary contusion: present in 11% to 54% of scapula fractures.

• Injuries to neurovascular structures: brachial plexus injuries, vascular avulsions.

• Spine injuries: 20% lower cervical spine, 76% thoracic spine, 4% lumbar spine.

• Others: concomitant skull fracture, blunt abdominal trauma, pelvic fracture, and lower extremity injuries. These are all seen with higher incidences in the presence of a scapula fracture.

CLINICAL EVALUATION

• A full trauma evaluation is indicated, with attention to airway, breathing, circulation, disability, and exposure.

The patient typically presents with the upper extremity supported by the contralateral hand in an adducted and immobile position, with painful range of motion, especially shoulder abduction.

• A careful examination for associated injures should be performed, with a thorough neurovascular assessment.

• Compartment syndrome overlying the scapula is uncommon, but it must be ruled out in the presence of pain out of proportion to the apparent injury. Comolli sign is triangular swelling of the posterior thorax overlying the scapula and is suggestive of hematoma resulting in increased compartment pressures.

RADIOGRAPHIC EVALUATION

• Initial radiographs should include a trauma series of the shoulder, consisting of a true anteroposterior view, an axillary view, and a scapular-Y view (true scapular lateral); these generally are able to demonstrate most glenoid, scapular neck, body, and acromion fractures.

• The axillary view may be used to delineate acromial and glenoid rim fractures further.

• An acromial fracture should not be confused with an os acromiale, which is a rounded, unfused apophysis and is present in approximately 3% of the population. When present, it is bilateral in 60% of cases.
• Glenoid hypoplasia, or scapular neck dysplasia, is an unusual abnormality that may resemble glenoid impaction and may be associated with humeral head or acromial abnormalities. It has a benign course and is usually noted incidentally.

• A 45-degree cephalic tilt (Stryker notch) radiograph is helpful to identify coracoid fractures.

• Computed tomography may be useful for further characterizing intraarticular glenoid fractures.

• Because of the high incidence of associated injuries, especially to thoracic structures, a chest radiograph is an essential part of the evaluation.

CLASSIFICATION

Anatomic Classification (Zdravkovic and Damholt) (Fig. 13)

Figure 13. Anatomic classification. (A) scapula body; (B,C) glenoid; (D) scapula neck; (E) acromion; (F) scapula spine; (G) coracoid.
Type I:	Scapula body
Type II:	Apophyseal fractures, including the acromion and coracoid
Type III:	Fractures of the superolateral angle, including the scapular neck and glenoid

 

Ideberg Classification of Intraarticular Glenoid Fractures (Fig. 14)

Type I:	Avulsion fracture of the anterior margin
Type IIA:	Transverse fracture through the glenoid fossa exiting inferiorly
Type IIB:	Oblique fracture through the glenoid fossa exiting inferiorly
Type III:	Oblique fracture through the glenoid exiting superiorly and often associated with an acromioclavicular joint injury
Type IV:	Transverse fracture exiting through the medial border of the scapula
Type V:	Combination of a type II and type IV pattern
Type VI:	Comminuted glenoid fracture

Classification of Acromial Fractures (Kuhn et al.) (Fig. 15)

Type I:	Minimally displaced
Type II:	Displaced but does not reduce the subacromial space
Type III:	Displaced with narrowing of the subacromial space

Classification of Coracoid Fractures (Ogawa et al.) (Fig. 16)

Type I:	Proximal to the coracoclavicular ligament.
Type II:	Distal to the coracoclavicular ligament

OTA Classification of Scapula Fractures

• See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

TREATMENT

Nonoperative

Most scapula fractures are amenable to nonoperative treatment, consisting of sling use and early range of shoulder motion.

Operative

• Surgical indications are controversial, but include:

• Displaced intraarticular glenoid fractures involving greater than 25% of the articular surface.

• Scapular neck fractures with greater than 40-degree angulation or 1-cm medial translation.

• Scapular neck fractures with an associated displaced clavicle fracture.

• Fractures of the acromion that impinge on the subacromial space.

• Fractures of the coracoid process that result in a functional acromioclavicular separation.

• Comminuted fractures of the scapular spine.

Figure 14. Ideberg classification of glenoid fractures into five types, with the comminuted Type VI of Goss added. The classification is historical, because decision making is based on displacement of the articular component. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Greenв’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Figure 15. Type I acromion fractures are nondisplaced and include Type IA (avulsion) and Type IB (complete fracture). Type II fractures are displaced, but they do not reduce the subacromial space. Type III fractures cause a reduction in subacromial space. (Modified from Kuhn JE, Blasier RB, Carpenter JE. Fractures of the acromion process: a proposed classification system. J Orthop Trauma 1994;8:6–13.)

•  

Figure 16. Classification of coracoid fractures: Type I is proximal to the coracoclavicular ligament attachment and Type II is distal. (Modified from Ogawa K, Yoshida A, Takahashi M, Ui M. Fractures of the coracoid process. J Bone Joint Surg Br 1979;79:17–19.)

• Specific treatment options include:
• Glenoid fractures (Ideberg classification):

Type I:	Fractures involving greater than one fourth of the glenoid fossa that result in instability may be amenable to open reduction and internal fixation with screw fixation using an anterior or posterior approach.
Type II:	Inferior subluxation of the humeral head may result, necessitating open reduction, especially when associated with a greater than 5-mm articular step-off. An anterior approach typically provides adequate exposure.
Type III:	Reduction is often difficult and may require superior exposure for superior to inferior screw placement, partial-thickness clavicle removal, or distal clavicle resection in addition to anterior exposure for reduction. Additional stabilization of the superior suspensory shoulder complex (SSSC) may be necessary.
Type IV:	Open reduction should be considered for displaced fractures, especially those in which the superior fragment of the glenoid displaces laterally.
Type V:	Operative management does not necessarily result in improved functional results as compared with nonoperative treatment with early motion, but it should be considered for articular step-off greater than 5 mm.

• Scapular body fractures: Operative fixation is rarely indicated, with nonoperative measures generally effective. Open reduction may be considered when neurovascular compromise is present and exploration is required.

• Glenoid neck fractures: These generally may be treated symptomatically, with early range-of-motion exercises. If the injury is accompanied by a displaced clavicle fracture, an unstable segment may exist, including the glenoid, acromion, and lateral clavicle. Internal fixation of the clavicular fracture generally results in adequate stabilization for healing of the glenoid fracture.

• Acromion fractures: Os acromiale must first be ruled out, as well as concomitant rotator cuff injuries. Displaced acromion fractures may be stabilized by dorsal tension banding, if displacement causes subacromial impingement.

• Coracoid fractures: Complete third-degree acromioclavicular separation accompanied by a significantly displaced coracoid fracture is an indication for open reduction and internal fixation of both injuries.

• Floating shoulder: This consists of double disruptions of the superior shoulder suspensory complex (SSSC).

• The SSSC is a bone-soft tissue ring that includes the glenoid process, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromial process (Fig. 17).

• The superior strut is the middle third clavicle.

• The inferior strut is the lateral scapular body and spine.

• Traumatic disruption of two or more components of the SSSC usually secondary to high-energy injury is frequently described as a floating shoulder.

Figure 17. Superior shoulder suspensory complex anatomy. (A) Anteroposterior view. (B) True lateral view. (Modified from Goss TP. Double disruption of the superior shoulder suspensory complex. J Orthop Trauma 1993;7:99–106.)

• Historically, operative management has been recommended because of potential instability and displacement of the glenoid.

• Recent series of nonoperative treatment of floating shoulders reported good results.

COMPLICATIONS

• Associated injuries: These account for most serious complications, because of the high-energy nature of these injuries. Increased mortality is associated with concomitant first rib fracture.
• Malunion: Fractures of the scapula body generally unite with nonoperative treatment; when malunion occurs, it is generally well tolerated but may result in painful scapulothoracic crepitus.

• Nonunion: This is extremely rare, but when present and symptomatic it may require open reduction and internal fixation.

• Suprascapular nerve injury: This may occur in association with scapula body, neck, or coracoid fractures that involve the suprascapular notch (Fig. 18).

Scapulothoracic Dissociation

• This injury is a traumatic disruption of the scapula from the posterior chest wall.

• This rare, life-threatening injury, is essentially a subcutaneous forequarter amputation.

• The mechanism is a violent traction and rotation force, usually as a result of a motor vehicle or motorcycle accident.

• Neurovascular injury is common:
• Complete brachial plexopathy: 80%
• Partial plexopathy: 15%
• Subclavian or axillary artery: 88%
• It can be associated with fracture or dislocation about the shoulder or without obvious bone injury.

Figure 18. Schematic diagram showing the positions of the brachial plexus relative to the scapula. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Greenв’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Diagnosis includes:
• Massive swelling of shoulder region.

• A pulseless arm.
• A complete or partial neurologic deficit.

• Lateral displacement of the scapula on a nonrotated chest radiograph, which is diagnostic (Fig. 19).

• Classification

Type I:	Musculoskeletal injury alone
Type IIA:	Musculoskeletal injury with vascular disruption
Type IIB:	Musculoskeletal injury with neurologic impairment
Type III:	Musculoskeletal injury with both neurologic and vascular injury

• Initial treatment
• Patients are often polytraumatized.
• Advanced trauma life support protocols should be followed.

• Angiography of the limb with vascular repair and exploration of brachial plexus are performed as indicated.

• Stabilization of associated bone or joint injuries is indicated.

• Later treatment
• Neurologic
• At 3 weeks, electromyography is indicated.

• At 6 weeks, cervical myelography or magnetic resonance imaging is performed.

Shoulder arthrodesis and/or above elbow amputation may be necessary if the limb is flail.

Figure 19. Diagram of scapulothoracic dissociation, demonstrating lateral displacement of the scapula on the injured side (left) compared with the normal side (right) on a nonrotated chest radiograph. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Greenв’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Nerve root avulsions and complete deficits have a poor prognosis.

• Partial plexus injuries have good prognosis, and functional use of the extremity is often regained.

• Osseous
• If initial exploration of the brachial plexus reveals a severe injury, primary above elbow amputation should be considered.

• If cervical myelography reveals three or more pseudomeningoceles, the prognosis is similarly poor.

• This injury is associated with a poor outcome including flail extremity in 52%, early amputation in 21%, and death in 10%.

Intrathoracic Dislocation of the Scapula

• This is extremely rare.
• The inferior angle of the scapula is locked in the intercostal space.

• Chest computed tomography may be needed to confirm the diagnosis.

• Treatment consists of closed reduction and immobilization with a sling and swathe for 2 weeks, followed by progressive functional use of the shoulder and arm.

Proximal Humerus Fractures

EPIDEMIOLOGY

• Proximal humerus fractures comprise 4% to 5% of all fractures and represent the most common humerus fracture (45%).

• The increased incidence in the older population is thought to be related to osteoporosis.

• The 2:1 female-to-male ratio is likely related to issues of bone density.

ANATOMY

• The shoulder has the greatest range of motion of any articulation in the body; this is due to the shallow glenoid fossa that is only 25% the size of the humeral head and the fact that the major contributor to stability is not bone, but a soft tissue envelope composed of muscle, capsule, and ligaments.

• The proximal humerus is retroverted 35 to 40 degrees relative to the epicondylar axis.

• The four osseous segments (Neer) (Fig. 20) are:

• The humeral head.
• The lesser tuberosity.
• The greater tuberosity.
• The humeral shaft.
• Deforming muscular forces on the osseous segments (Fig. 20):

• The greater tuberosity is displaced superiorly and posteriorly by the supraspinatus and external rotators.

• The lesser tuberosity is displaced medially by the subscapularis.

• The humeral shaft is displaced medially by the pectoralis major.

• The deltoid insertion causes abduction of the proximal fragment.

• Neurovascular supply:
• The major blood supply is from the anterior and posterior humeral circumflex arteries.

• The arcuate artery is a continuation of the ascending branch of the anterior humeral circumflex. It enters the bicipital groove and supplies most of the humeral head. Small contributions to the humeral head blood supply arise from the posterior humeral circumflex, reaching the humeral head via tendo-osseous anastomoses through the rotator cuff. Fractures of the anatomic neck are uncommon, but they have a poor prognosis because of the precarious vascular supply to the humeral head.

• The axillary nerve courses just anteroinferior to the glenohumeral joint, traversing the quadrangular space. It is at particular risk for traction injury owing to its relative rigid fixation at the posterior cord and deltoid, as well as its proximity to the inferior capsule where it is susceptible to injury during anterior dislocation and anterior fracture-dislocation.

Figure 20. Displacement of the fracture fragments depends on the pull of the muscles of the rotator cuff and the pectoralis major. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

MECHANISM OF INJURY

• Most common is a fall onto an outstretched upper extremity from a standing height, typically in an older, osteoporotic woman.

• Younger patients typically present with proximal humeral fractures following high-energy trauma, such as a motor vehicle accident. These usually represent more severe fractures and dislocations, with significant associated soft tissue disruption and multiple injuries.

• Less common mechanisms include:
• Excessive shoulder abduction in an individual with osteoporosis, in which the greater tuberosity prevents further rotation.

• Direct trauma, usually associated with greater tuberosity fractures.

• Electrical shock or seizure.
• Pathologic processes: malignant or benign processes in the proximal humerus.

CLINICAL EVALUATION

• Patients typically present with the upper extremity held closely to the chest by the contralateral hand, with pain, swelling, tenderness, painful range of motion, and variable crepitus.

• Chest wall and flank ecchymosis may be present and should be differentiated from thoracic injury.

• A careful neurovascular examination is essential, with particular attention to axillary nerve function. This may be assessed by the presence of sensation on the lateral aspect of the proximal arm overlying the deltoid. Motor testing is usually not possible at this stage because of pain. Inferior translation of the distal fragment may result from deltoid atony; this usually resolves by 4 weeks after fracture, but if it persists, it must be differentiated from a true axillary nerve injury.

RADIOGRAPHIC EVALUATION

• Trauma series, consisting of AP and lateral views in the scapular plane as well as an axillary view.

• Axillary is the best view for evaluation of glenoid articular fractures and dislocations, but it may be difficult to obtain because of pain.

• Velpeau axillary: If a standard axillary cannot be obtained because of pain or fear of fracture displacement, the patient may be left in the sling and leaned obliquely backward 45 degrees over the cassette. The beam is directed caudally, orthogonal to the cassette, resulting in an axillary view with magnification (Fig. 21).

• Computed tomography is helpful in evaluating articular involvement, degree of fracture displacement, impression fractures, and glenoid rim fractures.

• Magnetic resonance imaging is generally not indicated for fracture management, but it may be used to assess rotator cuff integrity.

CLASSIFICATION

Neer (Fig. 22)

• Four parts: These are the greater and lesser tuberosities, humeral shaft, and humeral head.

• A part is defined as displaced if >1 cm of fracture displacement or >45 degrees of angulation.

• Fracture types include:
• One-part fractures: no displaced fragments regardless of number of fracture lines.

• Two-part fractures:
• Anatomic neck.
• Surgical neck.
• Greater tuberosity.
• Lesser tuberosity.
• Three-part fractures:
• Surgical neck with greater tuberosity.

• Surgical neck with lesser tuberosity.

• Four-part fractures.
• Fracture dislocation.
• Articular surface fracture.

Figure 21. A Velpeau axillary view can be obtained without abducting the shoulder. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

OTA Classification of Proximal Humerus Fractures

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

TREATMENT

• Minimally displaced fractures
• Up to 85% of proximal humerus fractures are minimally displaced or nondisplaced.

• Sling immobilization or swathe for comfort.

• Frequent radiographic follow-up is important to detect loss of fracture reduction.

• Early shoulder motion may be instituted at 7 to 10 days if the patient has a stable or impacted fracture.

• Pendulum exercises are instructed initially followed by passive range-of-motion exercises.

• At 6 weeks, active range-of-motion exercises are started.

• Resistive exercises are started at 12 weeks.

• Two-part fractures

Anatomic neck fractures: These are rare and difficult to treat by closed reduction. They require open reduction and internal fixation (ORIF) (younger patients) or prosthesis (e.g., shoulder hemiarthroplasty) and are associated with a high incidence of osteonecrosis.

Figure 22. The Neer classification of proximal humerus fractures. (Reprinted with permission from Neer CS. Displaced proximal humeral fractures: I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077–1089.).)

• Surgical neck fractures
• If the fracture is reducible and the patient has good-quality bone, one can consider fixation with percutaneously inserted terminally threaded pins.

• Problems associated with multiple pin fixation include nerve injury (axillary), pin loosening, pin migration, and inability to move the arm.

• Irreducible fractures (usually interposed soft tissue) and fractures in osteopenic bone require ORIF with pins, intramedullary nails with or without a supplemental tension band, or plate and screws.

• Greater tuberosity fractures: If they are displaced more than 5 to 10 mm (5 mm for superior translation), they require ORIF with or without rotator cuff repair; otherwise, they may develop nonunion and subacromial impingement. A greater tuberosity fracture associated with anterior dislocation may reduce on reduction of the glenohumeral joint and be treated nonoperatively.

• Lesser tuberosity fractures: They may be treated closed unless displaced fragment blocks internal rotation; one must rule out associated posterior dislocation.

• Three-part fractures
• These are unstable due to opposing muscle forces; as a result, closed reduction and maintenance of reduction are often difficult.

• Displaced fractures require operative fixation, except in severely debilitated patients or those who cannot tolerate surgery.

• Younger individuals should have an attempt at ORIF; preservation of the vascular supply is of paramount importance with minimization of soft tissue devascularization.

• Older patients may benefit from primary prosthetic replacement (hemiarthroplasty).

• Four-part fractures
• Incidence of osteonecrosis ranges from 13% to 35%.

• ORIF may be attempted in young patients if the humeral head is located within the glenoid fossa and there appears to be soft tissue continuity. Fixation may be achieved with multiple Kirschner wire, screw fixation, suture or wire fixation, or plate and screws.

• Primary prosthetic replacement of the humeral head (hemiarthroplasty) is the procedure of choice in the elderly.

• Hemiarthroplasty is associated with unpredictable results from the standpoint of function.

• Four-part valgus impacted proximal humerus fractures represent variants that are associated with lower rate of osteonecrosis and have had better reported results with ORIF (Fig. 23).

• Fracture-dislocations
• Two-part fracture-dislocations: may be treated closed after shoulder reduction unless the fracture fragments remain displaced.

• Three- and four-part fracture-dislocations: ORIF is used in younger individuals and hemiarthroplasty in the elderly. The brachial plexus and axillary artery are in proximity to the humeral head fragment with anterior fracture-dislocations.

• Recurrent dislocation is rare following fracture union.

• Hemiarthroplasty for anatomic neck fracture-dislocation is recommended because of the high incidence of osteonecrosis.

• They may be associated with increased incidence of myositis ossificans with repeated attempts at closed reduction.

• Articular surface fractures
• These are most often associated with posterior dislocations.

• Patients with >40% of humeral head involvement may require hemiarthroplasty; ORIF should initially be considered in patients <40 years of age, if possible.

COMPLICATIONS

Figure 23. Drawing showing the anatomy of a valgus-impacted four-part fracture. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Vascular injury: This is infrequent (5% to 6%); the axillary artery is the most common site (proximal to anterior circumflex artery). The incidence is increased in older individuals with atherosclerosis because of the loss of vessel wall elasticity.

• Neural injury
• Brachial plexus injury: This is infrequent (6%).

• Axillary nerve injury: This is particularly vulnerable with anterior fracture-dislocation because the nerve courses on the inferior capsule and is prone to traction injury or laceration. Complete axillary nerve injuries that do not improve within 2 to 3 months may require electromyographic evaluation and exploration.

• Chest injury: Intrathoracic dislocation may occur with surgical neck fracture-dislocations; pneumothorax and hemothorax must be ruled out in the appropriate clinical setting.

• Myositis ossificans: This is uncommon and is associated with chronic unreduced fracture-dislocations and repeated attempts at closed reduction.

• Shoulder stiffness: It may be minimized with an aggressive, supervised physical therapy regimen and may require open lysis of adhesions for recalcitrant cases.

• Osteonecrosis: This may complicate 3% to 14% of three-part proximal humeral fractures, 13% to 34% of four-part fractures, and a high rate of anatomic neck fractures.

• Nonunion: This occurs particularly in displaced two-part surgical neck fractures with soft tissue interposition. Other causes include excessive traction, severe fracture displacement, systemic disease, poor bone quality, inadequate fixation, and infection. It may be addressed with ORIF with or without bone graft or prosthetic replacement.

• Malunion: This occurs after inadequate closed reduction or failed ORIF and may result in impingement of the greater tuberosity on the acromion, with subsequent restriction of shoulder motion.

Humeral Shaft Fractures

EPIDEMIOLOGY

• Common injury, representing 3% to 5% of all fractures.

ANATOMY

• The humeral shaft extends from the pectoralis major insertion to the supracondylar ridge. In this interval, the cross-sectional shape changes from cylindric to narrow in the anteroposterior direction.

• The vascular supply to the humeral diaphysis arises from perforating branches of the brachial artery, with the maiutrient artery entering the medial humerus distal to the midshaft (Fig. 24).

• The musculotendinous attachments of the humerus result in characteristic fracture displacements (Table 2).

Table 2. Position of fracture fragments

Fracture Location Proximal Fragment Distal Fragment Above pectoralis major insertion Abducted, rotated externally by rotator cuff Medial, proximal by deltoid and pectoralis major Between pectoralis major and deltoid tuberosity Medial by pectoralis, teres major, and latissimus dorsi Lateral, proximal by deltoid Distal to deltoid tuberosity Abducted by deltoid Medial, proximal by biceps and triceps

MECHANISM OF INJURY

• Direct (most common): Direct trauma to the arm from a blow or motor vehicle accident results in transverse or comminuted fractures.

• Indirect: A fall on an outstretched arm results in spiral or oblique fractures, especially in elderly patients. Uncommonly, throwing injuries with extreme muscular contraction have been reported to cause humeral shaft fractures.

• Fracture pattern depends on the type of force applied:

• Compressive: proximal or distal humeral fractures

• Bending: transverse fractures of the humeral shaft

• Torsional: spiral fractures of the humeral shaft

• Torsional and bending: oblique fracture, often accompanied by a butterfly fragment

CLINICAL EVALUATION

• Patients with humeral shaft fractures typically present with pain, swelling, deformity, and shortening of the affected arm.

• A careful neurovascular examination is essential, with particular attention to radial nerve function. In cases of extreme swelling, serial neurovascular examinations are indicated with possible measurement of compartment pressures.

• Physical examination frequently reveals gross instability with crepitus on gentle manipulation.

• Soft tissue abrasions and minor lacerations must be differentiated from open fractures.

• Intraarticular extensions of open fractures may be determined by intraarticular injection of saline distant from the wound site and noting extravasation of fluid from the wound.

RADIOGRAPHIC EVALUATION

AP and lateral radiographs of the humerus should be obtained, including the shoulder and elbow joints on each view. To obtain views at 90В° from each other, the patient, NOT the arm, should be rotated, as manipulation of the injured extremity will typically result in distal fragment rotation only.

Figure 24. The neurovascular anatomy of the upper arm. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Traction radiographs may aid in fracture definition in cases of severely displaced or comminuted fracture patterns.

• Radiographs of the contralateral humerus may aid in preoperative planning.

• Computed tomography, bone scans, and MRI are rarely indicated except in cases in which pathologic fracture is suspected.

CLASSIFICATION

Descriptive

• Open vs. closed.
• Location: proximal third, middle third, distal third.

• Degree: nondisplaced, displaced.
• Direction and character: transverse, oblique, spiral, segmental, comminuted.

• Intrinsic condition of bone.
• Articular extension.

OTA Classification

• See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

TREATMENT

• The goal is to establish union with an acceptable humeral alignment and to restore the patient to preinjury level of function.

• Both patient and fracture characteristics, including patient age and functional level, presence of associated injuries, soft tissue status, and fracture pattern, need to be considered when selecting an appropriate treatment option.

Nonoperative

• Nonoperative treatment requirements are:
• An understanding by the treating physician of the postural and muscular forces that must be controlled.

• Dedication to close patient supervision and follow-up.

• A cooperative and preferably upright and mobile patient.

• An acceptable reduction.
• Most humeral shaft fractures (>90%) will heal with nonsurgical management.

• Twenty degrees of anterior angulation, 30 degrees of varus angulation, and up to 3 cm of bayonet apposition are acceptable and will not compromise function or appearance.

• Hanging cast: This utilizes dependency traction by the weight of the cast and arm to effect fracture reduction.

• Indications include displaced midshaft humeral fractures with shortening, particularly spiral or oblique patterns. Transverse or short oblique fractures represent relative contraindications because of the potential for distraction and healing complications.

• The patient must remain upright or semiupright at all times with the cast in a dependent position for effectiveness.

• It is frequently exchanged for functional bracing 1 to 2 weeks after injury.

• More than 95% union is reported.

• Coaptation splint: This utilizes dependency traction to effect fracture reduction, but with greater stabilization and less distraction than a hanging arm cast. The forearm is suspended in a collar and cuff.
• It is indicated for the acute treatment of humeral shaft fractures with minimal shortening and for short oblique or transverse fracture patterns that may displace with a hanging arm cast.

• Disadvantages include irritation of the patient’s axilla and the potential for splint slippage.

• It is frequently exchanged for functional bracing 1 to 2 weeks after injury.

• Thoracobrachial immobilization (Velpeau dressing): This is used in elderly patients or children who are unable to tolerate other methods of treatment and in whom comfort is the primary concern.

• It is indicated for minimally displaced or nondisplaced fractures that do not require reduction.

• Passive shoulder pendulum exercises may be performed within 1 to 2 weeks after injury.

• It may be exchanged for functional bracing 1 to 2 weeks after injury.

• Shoulder spica cast: This has limited application, because operative management is typically performed for the same indications.

• It is indicated when the fracture patterecessitates significant abduction and external rotation of the upper extremity.

• Disadvantages include difficulty of cast application, cast weight and bulkiness, skin irritation, patient discomfort, and inconvenient upper extremity position.

• Functional bracing: This utilizes hydrostatic soft tissue compression to effect and maintain fracture alignment while allowing motion of adjacent joints.

• It is typically applied 1 to 2 weeks after injury, after the patient has been placed in a hanging arm cast or coaptation splint and swelling has subsided.

• It consists of an anterior and posterior shell held together with Velcro straps.

• Success depends on an upright patient and brace tightening daily.

• Contraindications include massive soft tissue injury, an unreliable patient, and an inability to obtain or maintain acceptable fracture reduction.

• A collar and cuff may be used to support the forearm, but sling application may result in varus angulation.

• The functional brace is worn for a minimum of 8 weeks after fracture or until radiographic evidence of union.

Operative

• Indications for operative treatment are:

• Multiple trauma
• Inadequate closed reduction or unacceptable malunion

• Pathologic fracture
• Associated vascular injury
• “Floating elbow”
• Segmental fracture
• Intraarticular extension
• Bilateral humeral fractures
• Open fracture
• Neurologic loss following penetrating trauma
• Radial nerve palsy after fracture manipulation (controversial)

• Nonunion
• Surgical approaches to the humeral shaft include:

• Anterolateral approach: preferred for proximal third humeral shaft fractures; radial nerve identified in the interval between the brachialis and brachioradialis and traced proximally. This can be extended proximally to the shoulder or distally to the elbow.

• Anterior approach: muscular interval between the biceps and brachialis muscles.

• Posterior approach: provides excellent exposure to most of the humerus, but cannot be extended proximally to the shoulder; muscular interval between the lateral and long heads of the triceps.

Surgical Techniques

OPEN REDUCTION AND PLATE FIXATION

• This is associated with the best functional results. It allows direct fracture reduction and stable fixation of the humeral shaft without violation of the rotator cuff.

• Radiographs of the uninjured, contralateral humerus may be used for preoperative templating.

• A 4.5-mm dynamic compression plate with fixation of eight to ten cortices proximal and distal to the fracture is used.

• Lag screws should be utilized wherever possible.

• One should preserve soft tissue attachments to butterfly fragments.

INTRAMEDULLARY FIXATION

• Indications include:
• Segmental fractures in which plate placement would require considerable soft tissue dissection.

• Humerus fractures in extremely osteopenic bone.

• Pathologic humerus fractures.
• It is associated with a high incidence of shoulder pain following antegrade humeral nailing.

• Two types of intramedullary nails are available for use in the humeral shaft: flexible nails and interlocked nails.

• Flexible nails
• Rationale: Fill the canal with multiple nails to achieve an interference fit.

• These nails have relatively poor stability.

• Use should be reserved for humeral shaft fractures with minimal comminution.

• Interlocked nails
• These nails have proximal and distal interlocking capabilities and are able to provide rotational and axial fracture stability.

• With antegrade nailing, the axillary nerve is at risk for injury during proximal locking screw insertion. Screws protruding beyond the medial cortex may potentially impinge on the axillary nerve during internal rotation. Anterior to posterior screws are avoided because of the potential for injury to the main trunk of the axillary nerve.

• Distal locking usually consists of a single screw in the anteroposterior plane. Distal locking screw can be inserted anterior to posterior or posterior to anterior via an open technique to minimize the risk of neurovascular injury. Lateral to medial screws risk injury to lateral antebrachial cutaneous nerve.

• Either type of nails can be inserted through antegrade or retrograde techniques.

• If antegrade technique is elected, most methods attempt to avoid the rotator cuff to minimize postoperative shoulder problems.

• The proximal aspect of the nail should be countersunk to prevent subacromial impingement.

EXTERNAL FIXATION

• Indications include:
• Infected nonunions.
• Burn patients with fractures.
• Open fractures with extensive soft tissue loss.

• Complications include pin tract infection, neurovascular injury, and nonunion.

Postoperative Rehabilitation

Range-of-motion exercises for the hand and wrist should be started immediately after surgery; shoulder and elbow range of motion should be instituted as pain subsides.

COMPLICATIONS

• Radial nerve injury occurs in up to 18% of cases.

• It is most common with middle third fractures, although best known for its association with Holstein-Lewis type distal third fracture, which may entrap or lacerate the nerve as it passes through the intermuscular septum.

• Most injuries are neurapraxias or axonotmesis; function will return within 3 to 4 months; laceration is more common in open fractures or gunshot injuries.

• With secondary palsies that occur during fracture reduction, it has not been clearly established that surgery will improve the ultimate recovery rate compared with nonsurgical management.

• Delayed surgical exploration should be done after 3 to 4 months if there is no evidence of recovery by electromyography or nerve conduction velocity studies.

• Advantages of late over early nerve exploration:

• Enough time will have passed for recovery from neurapraxia or neurotmesis.

• Precise evaluation of a nerve lesion is possible.

• The associated fracture may have united.

• The results of secondary nerve repair are as good as those of primary repair.

• Vascular injury: This is uncommon but may be associated with fractures of the humeral shaft lacerating or impaling the brachial artery or with penetrating trauma.

• The brachial artery has the greatest risk for injury in the proximal and distal third of arm.

• It constitutes an orthopaedic emergency; arteriography is controversial because may prolong time to definitive treatment for an ischemic limb.

• Arterial inflow should be established within 6 hours.

• At surgery, the vessel should be explored and repaired and the fracture stabilized.

• If limb viability is not in jeopardy, bone repair may precede vascular repair.

• External fixation should be considered an option.

• Nonunion occurs in up to 15% of cases.

• Risk factors include fracture at the proximal or distal third of the humerus, transverse fracture pattern, fracture distraction, soft tissue interposition, and inadequate immobilization.

• It may necessitate open reduction and internal fixation with bone grafting

• Malunion: This may be functionally inconsequential; arm musculature and shoulder, elbow, and trunk range of motion can compensate for angular, rotational, and shortening deformities.

Distal Humerus

EPIDEMIOLOGY

• Fractures of the adult distal humerus are relatively uncommon, comprising approximately 2% of all fractures and one-third of all humerus fractures.

• Intercondylar fractures of the distal humerus are the most common fracture pattern.

• Extension-type supracondylar fractures of the distal humerus account for >80% of all supracondylar fractures in adults.

ANATOMY

• The distal humerus may be conceptualized as medial and lateral “columns,” each of which is roughly triangular and is composed of an epicondyle, or the nonarticulating terminal of the supracondylar ridge, and a condyle, which is the articulating unit of the distal humerus (Fig. 25).

• The articulating surface of the capitellum and trochlea projects distally and anteriorly at an angle of 40 to 45 degrees. The centers of the arcs of rotation of the articular surfaces of each condyle lie on the same horizontal axis; thus, malalignment of the relationships of the condyles to each other changes their arc of rotation, thus limiting flexion and extension (Fig. 26).

• The trochlear axis compared with the longitudinal axis is 4 to 8 degrees of valgus.

• The trochlear axis is 3 to 8 degrees externally rotated.

• The intramedullary canal ends 2 to 3 cm above the olecranon fossa.

MECHANISM OF INJURY

• Most low-energy distal humeral fractures result from a simple fall in middle-aged and elderly women in which the elbow is either struck directly or is axially loaded in a fall onto the outstretched hand.

• Motor vehicle and sporting accidents are more common causes of injury in younger individuals.

CLINICAL EVALUATION

• Signs and symptoms vary with degree of swelling and displacement; considerable swelling frequently occurs, rendering landmarks difficult to palpate. However, the normal relationship of the olecranon, medial, and lateral condyles should be maintained, roughly delineating an equilateral triangle.

• Crepitus with range of motion and gross instability may be present; although this is highly suggestive of fracture, no attempt should be made to elicit it because neurovascular compromise may result.

• A careful neurovascular evaluation is essential because the sharp, fractured end of the proximal fragment may impale or contuse the brachial artery, mediaerve, or radial nerve.

Figure 25. The distal most part of the lateral column is the capitellum, and the distal most part of the medial column is the nonarticular medial epicondyle. The trochlea is the medial most part of the articular segment and is intermediate in position between the medial epicondyle and capitellum. The articular segment functions architecturally as a  arch.

Figure 26. The joint surface to shaft axis is 4 to 8 degrees of valgus the A-carrying angle (A). The articular segment juts forward from the line of the shaft at 40 degrees and functions architecturally as the tie arch at the point of maximum column divergence distally. The medial epicondyle is on the projected axis of the shaft, whereas the lateral epicondyle is projected slightly forward from the axis (B,C).

• Serial neurovascular examinations with compartment pressure monitoring may be necessary with massive swelling; cubital fossa swelling may result in vascular impairment or the development of a volar compartment syndrome resulting in Volkmann ischemia.

RADIOGRAPHIC EVALUATION

• Standard anteroposterior (AP) and lateral views of the elbow should be obtained. Oblique radiographs may be helpful for further fracture definition.
• Traction radiographs may better delineate the fracture pattern and may be useful for preoperative planning.

• In nondisplaced fractures, an anterior or posterior fat pad sign may be present on the lateral radiograph, representing displacement of the adipose layer overlying the joint capsule in the presence of effusion or hemarthrosis.

• Minimally displaced fractures may result in a decrease in the normal condylar shaft angle of 40 degrees seen on the lateral radiograph.

• Because intercondylar fractures are much more common than supracondylar fractures in adults, the AP (or oblique) radiograph should be scrutinized for evidence of a vertical split in the intercondylar region of the distal humerus.

• Computed tomography may be utilized to delineate fracture fragments further.

CLASSIFICATION

Descriptive

• Supracondylar fractures
• Extension-type
• Flexion-type
• Transcondylar fractures
• Intercondylar fractures
• Condylar fractures
• Capitellum fractures
• Trochlea fractures
• Lateral epicondylar fractures
• Medial epicondylar fractures
• Fractures of the supracondylar process

OTA Classification of Fractures of the Distal Humerus

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

GENERAL TREATMENT PRINCIPLES

• Anatomic articular reduction
• Stable internal fixation of the articular surface

• Restoration of articular axial alignment
• Stable internal fixation of the articular segment to the metaphysis and diaphysis

• Early range of elbow motion

SPECIFIC FRACTURE TYPES

Extension-type Supracondylar Fracture

• This results from a fall onto an outstretched hand with or without an abduction or adduction force.

Treatment

NONOPERATIVE

• This is indicated for nondisplaced or minimally displaced fractures, as well as for severely comminuted fractures in elderly patients with limited functional ability.

• Posterior long arm splint is placed in at least 90 degrees of elbow flexion if swelling and neurovascular status permit, with the forearm ieutral.

• Posterior splint immobilization is continued for 1 to 2 weeks, after which range-of-motion exercises are initiated. The splint may be discontinued after approximately 6 weeks, when radiographic evidence of healing is present.

• Frequent radiographic evaluation is necessary to detect loss of fracture reduction.

OPERATIVE

• Indications
• Displaced fracture
• Vascular injury
• Open fracture
• Open reduction and internal fixation: Plate fixation is used on each column, either in parallel or preferably set at 90 degrees. Plate fixation is the procedure of choice, because this allows for early range of elbow motion.

• Total elbow replacement may be considered in elderly patients who otherwise are active with good preinjury function in whom a severely comminuted fracture of the distal humerus is deemed unreconstructable. The medial, triceps-sparing approach should be utilized, rather than an olecranon osteotomy, for exposure of the elbow joint.

• Range-of-motion exercises should be initiated as soon as the patient is able to tolerate therapy.

Complications

• Volkmann ischemic contracture: This may result from unrecognized compartment syndrome with subsequent neurovascular compromise. A high index of suspicion accompanied by aggressive elevation and serial neurovascular examinations with or without compartment pressure monitoring must be maintained.

• Stiffness: Up to a 20-degree decrease in the condylar-shaft angle may be tolerated owing to compensatory motion of the shoulder.

• Heterotopic bone formation may occur.

Flexion-type Supracondylar Fracture

• This uncommon injury is frequently associated with open lesions as the sharp, proximal fragment pierces the triceps tendon and overlying skin.

• Associated vascular injuries are rare, accounting for 2% to 4% of supracondylar fractures.

Mechanism of Injury

• Force is directed against the posterior aspect of a flexed elbow.

Treatment

NONOPERATIVE

• Nondisplaced or minimally displaced fractures may be immobilized in a posterior elbow splint in relative extension. Elbow flexion may result in fracture displacement.

OPERATIVE

• Open reduction and internal fixation: Plate fixation is used in each column, either in parallel or preferably set at 90 degrees.

• Range-of-motion exercises should be initiated as soon as the patient is able to tolerate therapy.

• Total elbow replacement may be considered in elderly patients who otherwise are active with good preinjury function in whom a severely comminuted fracture of the distal humerus is deemed unreconstructable.

Transcondylar Fractures

• These occur primarily in elderly patients with osteopenic bone.

Mechanism of Injury

• Mechanisms that produce supracondylar fractures may also result in transcondylar fractures: a fall onto an outstretched hand with or without an abduction or adduction component or a force applied to a flexed elbow.

Treatment

NONOPERATIVE

• This is indicated for nondisplaced or minimally displaced fractures or in elderly patients who are debilitated and functioning poorly.

• Range-of-motion exercises should be initiated as soon as the patient is able to tolerate therapy.

OPERATIVE

• Operative treatment should be undertaken for open fractures, unstable fractures, or displaced fractures.

• Open reduction and plate fixation are the preferred treatment.

• Total elbow arthroplasty (semiconstrained) may be considered in the elderly patient with good preinjury functional status if fixation cannot be obtained.

Intercondylar Fracture

• This is the most common distal humeral fracture.

• Comminution is common.
• Fracture fragments are often displaced by unopposed muscle pull at the medial (flexor mass) and lateral (extensor mass) epicondyles, which rotate the articular surfaces.

Mechanism of Injury

• Force is directed against the posterior aspect of an elbow flexed >90 degrees, thus driving the ulna into the trochlea.

RISEBOROUGH AND RADIN

Type I:	Nondisplaced
Type II:	Slight displacement with no rotation between the condylar fragments
Type III:	Displacement with rotation
Type IV:	Severe comminution of the articular surface (Fig. 27)

Classification

OTA CLASSIFICATION

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

Figure 27. Riesborough and Radin classification. (A) Type I undisplaced condylar fracture of the elbow. (B) Type II displaced but not rotated T-condylar fracture. (C) Type III displaced and rotated T-condylar fracture. (D) Type IV displaced, rotated, and comminuted condylar fracture. (From Bryan RS. Fractures about the elbow in adults. AAOS Instr Course Lect 1981;30:200–223.)

 

Treatment

• Treatment must be individualized according to patient age, bone quality, and degree of comminution.

NONOPERATIVE

• This is indicated for nondisplaced fractures, elderly patients with displaced fractures and severe osteopenia and comminution, or patients with significant comorbid conditions precluding operative management. Nonoperative options for displaced fractures include:
• Cast immobilization: This has few advocates; it represents the worst of both worlds inadequate fracture reduction and prolonged immobilization.

• Traction with an olecranon pin: This is placed overhead to reduce swelling; it is problematic in that longitudinal traction alone will not derotate the intercondylar fragments in the axial plane, and this leads to malunion.

• The arm is placed in a collar and cuff with as much flexion as possible after initial reduction is attempted; gravity traction helps effect reduction.

OPERATIVE

• Open reduction and internal fixation
• The indication is a displaced reconstructible fracture.

• Goals of fixation are to restore articular congruity and to secure the supracondylar component.

• Methods of fixation
• Interfragmentary screws
• Dual plate fixation: one plate medially and another plate placed posterolaterally, 90 degrees from the medial plate

• Total elbow arthroplasty (semiconstrained): This may be considered in markedly comminuted fractures and with fractures in osteoporotic bone.

• Surgical exposures
• Tongue of triceps
• Does not allow full exposure of joint.

• Deters early active motion for fear of triceps rupture.

• Olecranon osteotomy: intraarticular; A chevron is best for rotational stability.

• A triceps-sparing extensile posterior approach (Bryan and Morrey) can be used.

• Postoperative care: Early range of motion of the elbow is essential unless fixation is tenuous.

Complications

• Posttraumatic arthritis: This results from articular injury at time of trauma as well as a failure to restore articular congruity.

• Failure of fixation: Postoperative collapse of fixation is related to the degree of comminution, the stability of fixation, and protection of the construct during the postoperative course.

• Loss of motion (extension): This is increased with prolonged periods of immobilization. Range-of-motion exercises should be instituted as soon as the patient is able to tolerate therapy, unless fixation is tenuous.

• Heterotopic bone.
• Neurologic injury: The ulnar nerve is most commonly injured during surgical exposure.

Condylar Fractures

• These are rare in adults and are much more common in the pediatric age group.

• Less than 5% of all distal humerus fractures are condylar; lateral fractures are more common than medial.

• Medial condyle fractures: These include the trochlea and medial epicondyle and are less common than medial epicondylar fractures.

• Lateral condyle fractures: These include the capitellum and lateral epicondyle.

Mechanism of Injury

• Abduction or adduction of the forearm with elbow extension.

Classification

MILCH

Two types are designated for medial and lateral condylar fractures; the key is the lateral trochlear ridge (Fig. 28):

 

Type I:	Lateral trochlear ridge left intact
Type II:	Lateral trochlear ridge part of the condylar fragment (medial or lateral)

• These are less stable.
• They may allow for radioulnar translocation if capsuloligamentous disruption occurs on the contralateral side.

 

Figure 28. Classification of condylar fractures according to Milch and the location of the common fracture lines seen in Type I and II fractures of the lateral (B) and medial (C) condyles. (A) Anterior view of the anatomy of the distal articular surface of the humerus. The capitellotrochlear sulcus divides the capitellar and trochlear articular surfaces. The lateral trochlear ridge is the key to analyzing humeral condyle fractures. In Type I fractures, the lateral trochlear ridge remains with the intact condyle, providing medial to lateral elbow stability. In Type II fractures, the lateral trochlear ridge is a part of the fractured condyle, which may allow the radius and ulna to translocate in a medial to lateral direction with respect to the long axis of the humerus. (B) Fractures of the lateral condyle. In Type I fractures, the lateral trochlear ridge remains intact, therefore preventing dislocation of the radius and ulna. In Type II fractures, the lateral trochlear ridge is a part of the fractured lateral condyle. With capsuloligamentous disruption medially, the radius and ulna may dislocate. (C) Fractures of the medial condyle. In Type I fractures, the lateral trochlear ridge remains intact to provide medial-to-lateral stability of the radius and ulna. In Type II fractures, the lateral trochlear ridge is a part of the fractures medial condyle. With lateral capsuloligamentous disruption, the radius and ulna may dislocate medially on the humerus. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:954.)

 

JUPITER

This is low or high, based on proximal extension of fracture line to supracondylar region:

 

OTA CLASSIFICATION

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

• Low: equivalent to Milch type I fracture

• High: equivalent to Milch type II fracture

Treatment

• Anatomic restoration of articular congruity is essential to maintain the normal elbow arc of motion and to minimize the risk of posttraumatic arthritis.

NONOPERATIVE

• Indicated for nondisplaced or minimally displaced fractures or for patients with displaced fractures who are not considered candidates for operative treatment.

• It consists of posterior splinting with the elbow flexed to 90 degrees and the forearm in supination or pronation for lateral or medial condylar fractures, respectively.

OPERATIVE

• Indicated for open or displaced fractures.

• Consists of screw fixation with or without collateral ligament repair if necessary, with attention to restoration of the rotational axes.

• Prognosis depends on:
• The degree of comminution.
• The accuracy of reduction.
• The stability of internal fixation.

• Range-of-motion exercises should be instituted as soon as the patient can tolerate therapy.

Complications

• Lateral condyle fractures: Improper reduction or failure of fixation may result in cubitus valgus and tardy ulnar nerve palsy requiring nerve transposition.

• Medial condyle fractures: Residual incongruity is more problematic owing to involvement of the trochlear groove. These may result in:
• Posttraumatic arthritis, especially with fractures involving the trochlear groove.

• Ulnar nerve symptoms with excess callus formation or malunion.

• Cubitus varus with inadequate reduction or failure of fixation.

Capitellum Fractures

• These represent <1% of all elbow fractures.

• They occur in the coronal plane, parallel to the anterior humerus.

• Little or no soft tissue attachments result in a free articular fragment that may displace.

• Anterior displacement of the articular fragment into the coronoid or radial fossae may result in a block to flexion.

Mechanism of Injury

• A fall onto an outstretched hand with the elbow in varying degrees of flexion; force is transmitted through the radial head the capitellum. Fracture occurs secondary to shear.
• These are occasionally associated with radial head fractures.

Classification

OTA CLASSIFICATION

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

ADDITIONAL CLASSIFICATION (FIG. 29)

Type I:	Hahn-Steinthal fragment: large osseous component of capitellum, sometimes with trochlear involvement
Type II:	Kocher-Lorenz fragment: articular cartilage with minimal subchondral bone attached: uncapping of the condyle
Type III:	Markedly comminuted

Treatment

NONOPERATIVE

• This is primarily used for nondisplaced fractures.

• It consists of immobilization in a posterior splint for 3 weeks followed by range of elbow motion.

Figure 29. (A) Type I (Hahn-Steinthal) capitellar fracture. A portion of the trochlea may be involved in this fracture. (B) Type II (Kocher-Lorenz) capitellar fracture. Very little subchondral bone is attached to the capitellar fragment. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:960.)

 

OPERATIVE

• The goal is anatomic restoration.

• Open reduction and internal fixation
• This technique is indicated for displaced type I fractures.

• Via a posterolateral or posterior approach, screws may be placed from a posterior to anterior direction; alternatively, headless screws may be placed from anterior to posterior.

• Fixation should be stable enough to allow early range of elbow motion.

• Excision
• This is indicated for severely comminuted type I fractures and most type II fractures.

• Proximal migration of the radius with distal radioulnar joint pain is uncommon.

• This is relatively contraindicated in the presence of associated elbow fractures owing to compromise of elbow stability.

• This is the recommended treatment in chronic missed fractures with limited range of elbow motion.

Complications

• Osteonecrosis: This is relatively uncommon.

• Posttraumatic arthritis: The risk is increased with failure to restore articular congruity and excision of the articular fragment.

• Cubitus valgus: This may result after excision of articular fragment or with an associated lateral condylar or radial head fracture. It is associated with tardy ulnar nerve palsy.
• Loss of motion (flexion): This is associated with retained chondral or osseous fragments that may become entrapped in the coronoid or radial fossae.

Trochlea Fractures (Laugier’s Fracture)

• Extremely rare.
• It is associated with elbow dislocation.

Mechanism of Injury

• Tangential shearing force resulting from elbow dislocation.

Treatment

• Nondisplaced fractures may be managed with posterior splinting for 3 weeks followed by range-of-motion exercises.

• Displaced fractures should receive open reduction and internal fixation with Kirschner wire or screw fixation.

• Fragments not amenable to internal fixation should be excised.

Complications

• Posttraumatic arthritis may result with retained osseous fragments within the elbow joint or incongruity of the articular surface.

• Restricted range of motion may result from malunion of the trochlear fragment.

Lateral Epicondylar Fractures

• Extremely rare.

Mechanism of Injury

• Direct trauma is the mechanism in adults.

• Prepubescent patients may experience avulsion fractures.

Treatment

• Symptomatic immobilization is followed by early range of elbow motion.

Complications

• Nonunion may result in continued symptoms of pain exacerbated by wrist or elbow motion.

Medial Epicondylar Fractures

• These are more common than lateral epicondylar fractures owing to the relative prominence of the epicondyle on the medial side of the elbow.

Mechanism of Injury

• In children and adolescents, the medial epicondyle may be avulsed during a posterior elbow dislocation.

• In adults, it is most commonly the result of direct trauma, although it can occur as an isolated fracture or associated with elbow dislocation.

Treatment

• Nondisplaced or minimally displaced fractures may be managed by short-term immobilization for 10 to 14 days in a posterior splint with the forearm pronated and the wrist and elbow flexed.

• Operative indications
• Relative indications include displaced fragments in the presence of ulnar nerve symptoms, elbow instability to valgus stress, wrist flexor weakness, and symptomatic nonunion of the displaced fragment.

• Open reduction and internal fixation versus excision: Excision is indicated for fragments not amenable to internal fixation or are incarcerated within the joint space.

Complications

• Posttraumatic arthritis: This may result from osseous fragments retained within the joint space.

• Weakness of the flexor mass: This may result from nonunion of the fragment or malunion with severe distal displacement.

Fractures of the Supracondylar Process

• The supracondylar process is a congenital osseous or cartilaginous projection that arises from the anteromedial surface of the distal humerus.

• The ligament of Struthers is a fibrous arch connecting the supracondylar process with the medial epicondyle, from which fibers of the pronator teres or the coracobrachialis may arise.

• Through this arch traverse the mediaerve and the brachial artery.

• Fractures are rare, with a reported incidence between 0.6% and 2.7%, but they may result in pain and mediaerve or brachial artery compression.

Mechanism of Injury

• Direct trauma to the anterior aspect of the distal humerus.

Treatment

• Most of these fractures are amenable to nonoperative treatment with symptomatic immobilization in a posterior elbow splint in relative flexion until pain free, followed by range-of-motion and strengthening exercises.

• Median nerve or brachial artery compression may require surgical exploration and release.

Complications

• Myositis ossificans: The risk is increased with surgical exploration.

• Recurrent spur formation: This may result in recurrent symptoms of neurovascular compression, necessitating surgical exploration and release, with excision of the periosteum and attached muscle fibers to prevent recurrence.

Olecranon

EPIDEMIOLOGY

• Bimodal distribution is seen, with younger individuals as a result of high-energy trauma and older individuals as a result of a simple fall.

ANATOMY

• The coronoid process delineates the distal border of the greater sigmoid (semilunar) notch of the ulna, which articulates with the trochlea. This articulation allows motion only about the flexion-extension axis, thus providing intrinsic stability to the elbow joint.

• The articular cartilage surface is interrupted by a transverse ridge known as the “bare area.”

• Posteriorly, the triceps tendon envelops the articular capsule before it inserts onto the olecranon. A fracture of the olecranon with displacement represents a functional disruption of the triceps mechanism, resulting in loss of active extension of the elbow.

• The ossification center for the olecranon appears at 10 years and is fused by about age 16. There can be persistent epiphyseal plates in adults; these are usually bilateral and demonstrate familial inheritance.

• The subcutaneous position of the olecranon makes it vulnerable to direct trauma.

MECHANISM OF INJURY

Two common mechanisms are seen, each resulting in a predictable fracture pattern:

• Direct: A fall on the point of the elbow or direct trauma to the olecranon typically results in a comminuted olecranon fracture.

• Indirect: A fall onto the outstretched upper extremity accompanied by a strong, sudden contraction of the triceps typically results in a transverse or oblique fracture.

• A combination of these may produce displaced, comminuted fractures, or, in cases of extreme violence, fracture-dislocation with anterior displacement of the distal ulnar fragment and radial head.

CLINICAL EVALUATION

• Patients typically present with the upper extremity supported by the contralateral hand with the elbow in relative flexion. Abrasions over the olecranon or hand can be indicative of the mechanism of injury.

• Physical examination may demonstrate a palpable defect at the fracture site. An inability to extend the elbow actively against gravity indicates discontinuity of the triceps mechanism.

• A careful neurosensory evaluation should be performed, because associated ulnar nerve injury is possible, especially with comminuted fractures resulting from high-energy injuries.

RADIOGRAPHIC EVALUATION

• Standard anteroposterior and lateral radiographs of the elbow should be obtained. A true lateral radiograph is imperative, because this will demonstrate the extent of the fracture, the degree of comminution, the degree of articular surface involvement, and displacement of the radial head, if present.

• The anteroposterior view should be evaluated to exclude associated fractures or dislocations. The distal humerus may obscure osseous details of the olecranon fracture.

CLASSIFICATION

Mayo Classification (Fig. 30)

This distinguishes three factors that have a direct influence on treatment: (1) fracture displacement, (2) comminution, and (3) ulnohumeral stability.

• Type I fractures are nondisplaced or minimally displaced and are subclassified as either noncomminuted (type 1A) or comminuted (type 1B). Treatment is nonoperative.
• Type II fractures have displacement of the proximal fragment without elbow instability; these fractures require operative treatment.

• Type IIA fractures, which are noncomminuted, can be treated by tension band wire fixation.

• Type IIB fractures are comminuted and require plate fixation.

• Type III fractures feature instability of the ulnohumeral joint and require surgical treatment.

Figure 30. The Mayo classification of olecranon fractures divides fractures according to displacement, comminution, and subluxation/ dislocation. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

 

Schatzker (Based on Fracture Pattern) (Fig. 31)

• Transverse: This occurs at the apex of the sigmoid notch and represents an avulsion fracture from a sudden, violent pull of both triceps and brachialis, and uncommonly from direct trauma.

• Transverse-impacted: A direct force leads to comminution and depression of the articular surface.

• Oblique: This results from hyperextension injury; it begins at midpoint of the sigmoid notch and runs distally.

• Comminuted fractures with associated injuries: These result from direct high-energy trauma; fractures of the coronoid process may lead to instability.

• Oblique-distal: Fractures extend distal to the coronoid and compromise elbow stability.

• Fracture-dislocation: It is usually associated with severe trauma.

 

Figure 31. Schatzker classification of olecranon fractures. (From Browner BD, Jupiter JB, Levine AM, eds. Skeletal Trauma. Philadelphia: WB Saunders, 1992:1137, with permission.)

 

OTA Classification of Proximal Radius/Ulna Fractures

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

 

TREATMENT OBJECTIVES

• Restoration of the articular surface

• Restoration and preservation of the elbow extensor mechanism

• Restoration of elbow motion and prevention of stiffness

• Prevention of complications

TREATMENT

 

Nonoperative

• This is indicated for nondisplaced fractures and displaced fractures in poorly functioning older individuals.

• Immobilization in a long arm cast with the elbow in 45 to 90 degrees of flexion is favored by many authors, although in reliable patients a posterior splint or orthosis with gradual initiation of range of motion after 5 to 7 days may be used.

• Follow-up radiographs should be obtained within 5 to 7 days after treatment to rule out fracture displacement. Osseous union is usually not complete until 6 to 8 weeks.

In general, there is adequate fracture stability at 3 weeks to remove the cast and to allow protected range-of-motion exercises, avoiding flexion past 90 degrees.

 

Operative

• Indications for surgery
• Disruption of extensor mechanism (any displaced fracture)

• Articular incongruity
• Types of operative treatment:
• Intramedullary fixation: 6.5-mm cancellous lag screw fixation. The screw must be of sufficient length to engage the distal intramedullary canal for adequate fixation. This may be used in conjunction with tension band wiring (described later).

• With screw techniques, beware of bowing of the ulna intramedullary canal that may shift the fracture with screw advancement.

• Tension band wiring in combination with two parallel Kirschner wires: This counteracts the tensile forces and converts them to compressive forces and is indicated for avulsion-type olecranon fractures (Fig. 32).

• Plate and screws: They are used for comminuted olecranon fractures, Monteggia fractures, and olecranon fracture-dislocations. A plate should also be for oblique fractures and for fractures that extend distal to the coronoid.

• No mechanical difference exists between posterior or lateral placement.

• Fewer problems with plate prominence are noted when it is placed laterally.

Excision (with repair of the triceps tendon): This is indicated for nonunited fractures, extensively comminuted fractures, fractures in elderly individuals with severe osteopenia and low functional requirements, and extraarticular fractures.

Figure 32. The Kirschner wires are then bent 180 degrees and are impacted into the olecranon beneath the triceps insertion. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Wolfgang et al. reported that excision of as much as 50% of the olecranon is effective in treating comminuted fractures.

• Morrey et al. demonstrated decreasing elbow stability with increasingly larger fragment excision.

• This is contraindicated in fracture-dislocations of the elbow or fractures of the radial head, because excision results in compromised elbow stability.

• Postoperative management: the patient should be placed in a posterior elbow splint. With a stable repair, one should initiate early range-of-motion exercises.

COMPLICATIONS

• Hardware symptoms occur in 22% to 80% of patients.

• From 34% to 66% require hardware removal.

• Hardware failure occurs in 1% to 5%.

• Infection occurs in 0% to 6%.
• Pin migration occurs in 15%.
• Ulnar neuritis occurs in 2% to 12%.

• Heterotopic ossification occurs in 2% to 13%.

• Nonunion occurs in 5%.
• Decreased range of motion: This may complicate up to 50% of cases, particularly loss of elbow extension, although most patients note little if any functional limitation.

Radial Head

ANATOMY

• The capitellum and the radial head are reciprocally curved.

• Force transmission across the radiocapitellar articulation takes place at all angles of elbow flexion and is greatest in full extension.

• Full rotation of the head of the radius requires accurate anatomic positioning in the lesser sigmoid notch.

• The radial head plays a role in valgus stability of the elbow, but the degree of conferred stability remains disputed.

• The radial head is a secondary restraint to valgus forces and seems to function by shifting the center of varus-valgus rotation laterally, so the moment arm and forces on the medial ligaments are smaller.

• Clinically, the radial head is most important when there is injury to both the ligamentous and muscle-tendon units about the elbow.

• The radial head acts in concert with the interosseous ligament of the forearm to provide longitudinal stability.

• Proximal migration of the radius can occur after radial head excision if the interosseous ligament is disrupted.

MECHANISM OF INJURY

• Most of these injuries are the result of a fall onto the outstretched hand, the higher-energy injuries representing falls from a height or during sports.

• The radial head fractures when it collides with the capitellum. This can occur with a pure axial load, with a posterolateral rotatory force, or as the radial head dislocates posteriorly as part of a posterior Monteggia fracture or posterior olecranon fracture-dislocation.

• It is frequently associated with injury to the ligamentous structures of the elbow.

• It is less commonly associated with fracture of the capitellum.

CLINICAL EVALUATION

• Patients typically present with limited elbow and forearm motion and pain on passive rotation of the forearm.

• Well-localized tenderness overlying the radial head may be present, as well as an elbow effusion.

• The ipsilateral distal forearm and wrist should be examined. Tenderness to palpation or stress may indicate the presence of an Essex-Lopresti lesion (radial head fracture-dislocation with associated interosseous ligament and distal radioulnar joint disruption).

• Medial collateral ligament competence should be tested, especially with type IV radial head fractures in which valgus instability may result.

• Aspiration of the hemarthrosis through a direct lateral approach with injection of lidocaine will decrease acute pain and allow evaluation of passive range of motion. This can help identify a mechanical block to motion.

RADIOGRAPHIC EVALUATION

• Standard anteroposterior (AP) and lateral radiographs of the elbow should be obtained, with oblique views (Greenspan view) for further fracture definition or in cases in which fracture is suspected but not apparent on AP and lateral views.

• A Greenspan view is taken with the forearm ieutral rotation and the radiographic beam angled 45 degrees cephalad; this view provides visualization of the radiocapitellar articulation (Fig. 33).

• Nondisplaced fractures may not be readily appreciable, but they may be suggested by a positive fat pad sign (posterior more sensitive than anterior) on the lateral radiograph, especially if clinically suspected.

• Complaints of forearm or wrist pain should be assessed with radiographic evaluation.

• Computed tomography may be utilized for further fracture definition for preoperative planning, especially in cases of comminution or fragment displacement.

Figure 33. Schematic and radiograph demonstrating the radial head-capitellum view (Reproduced with permission from Greenspan A. Orthopedic Imaging. Philadelphia: Lippincott Williams Wilkins, 2004.)

CLASSIFICATION

Mason (Fig. 34)

Type I:	Nondisplaced fractures
Type II:	Marginal fractures with displacement (impaction, depression, angulation)
Type III:	Comminuted fractures involving the entire head
Type IV:	Associated with dislocation of the elbow (Johnston)

OTA Classification of Proximal Radius/Ulna Fractures

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

 

Figure 34. Mason classification of radial head and neck fractures. (From Broberg MA, Morrey BF. Results of treatment of fracture- dislocations to the elbow. Clin Orthop 1987;216:109.)

 

TREATMENT GOALS

• Correction of any block to forearm rotation

• Early range of elbow and forearm motion

• Stability of the forearm and elbow

• Limitation of the potential for ulnohumeral and radiocapitellar arthrosis, although the latter seems uncommon

TREATMENT

Nonoperative

• Most isolated fractures of the radial head can be treated nonoperatively.

• Symptomatic management consists of a sling and early range of motion 24 to 48 hours after injury as pain subsides.

• Aspiration of the radiocapitellar joint with or without injection of local anesthesia has been advocated by some authors for pain relief.

• Persistent pain, contracture, and inflammation may represent capitellar fracture (possibly osteochondral) that was not appreciated on radiographs and can be assessed by magnetic resonance imaging.

Operative

 

 

Isolated Partial Radial Head Fractures

• The one accepted indication for operative treatment of a displaced partial radial head fracture (Mason II) is a block to motion. This can be assessed by lidocaine injection into the elbow joint.

• A relative indication is displacement of a large fragment greater than 2 mm without a block to motion.

• A Kocher exposure can be used to approach the radial head; one should take care to protect the uninjured lateral collateral ligament complex.

• The anterolateral aspect of the radial head is usually involved and is readily exposed through these intervals.

• After the fragment has been reduced, it is stabilized using one or two small screws.

Partial Radial Head Fracture as Part of a Complex Injury

• Partial head fragments that are part of a complex injury are often displaced and unstable with little or no soft tissue attachments.

• Open reduction and internal fixation is performed when stable, reliable fixation can be achieved.

• For an unstable elbow or forearm injury, it may be preferable to resect the remaining intact radial head and replace it with a metal prosthesis.

Fractures Involving the Entire Head of the Radius

When treating a fracture-dislocation of the forearm or elbow with an associated fracture involving the entire head of the radius, open reduction and internal fixation should only be considered a viable option if stable, reliable fixation can be achieved. Otherwise, prosthetic replacement is indicated.

• The optimal fracture for open reduction and internal fixation has three or fewer articular fragments without impaction or deformity, each should be of sufficient size and bone quality to accept screw fixation, and there should be little or no metaphyseal bone loss.

• Once reconstructed with screws, the radial head is secured to the radial neck with a plate.

• The plate should be placed posteriorly with the forearm supinated; otherwise, it may impinge on the ulna and restrict forearm rotation (Fig. 35).

Figure 35. The nonarticular area of the radial head or the so-called safe zone for the application of internal fixation devices has been defined in various ways. Smith and Hotchkiss defined it based on lines bisecting the radial head made in full supination, full pronation, and neutral. Implants can be placed as far as halfway between the middle and posterior lines and a few millimeters beyond halfway between the middle and anterior lines. Caputo and colleagues recommended using the radial styloid and Lister tubercle as intraoperative guides to this safe zone, but this describes a slightly different zone. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

 

 

Prosthetic Replacement

• The rationale for use is to prevent proximal migration of the radius.

• Long-term studies of fracture-dislocations and Essex-Lopresti lesions demonstrated poor function with silicone implants. Metallic (titanium, vitallium) radial head implants have been used with increasing frequency and are the prosthetic implants of choice in the unstable elbow.

• The major problem with a metal radial head prosthesis is “overstuffing” the joint.

Radial Head Excision

• The level of excision should be just proximal to the annular ligament.

• A direct lateral approach is preferred; the posterior interosseous nerve is at risk with this approach.

• Patients generally have few complaints, mild occasional pain, and nearly normal range of motion; the distal radioulnar joint is rarely symptomatic, with proximal migration averaging 2 mm (except with associated Essex-Lopresti lesion). Symptomatic migration of the radius may necessitate radioulnar synostosis.
• Late excision for Mason type II and III fractures produces good to excellent results in 80% of cases.

Essex-Lopresti Lesion

• This is defined as longitudinal disruption of forearm interosseous ligament, usually combined with radial head fracture and/or dislocation plus distal radioulnar joint injury.

• It is difficult to diagnose; wrist pain is the most sensitive sign of distal radioulnar joint injury.

• One should assess the distal radioulnar joint on the lateral x-ray view.

• Treatment requires restoring stability of both elbow and distal radioulnar joint components of injury.

• Radial head excision in this injury will result in proximal migration of the radius.

• Treatment is repair or replacement of the radial head with evaluation of the distal radioulnar joint.

Postoperative Care

• With stable fixation, it is essential to begin early active flexion-extension and pronation-supination exercises.

COMPLICATIONS

Contracture: This may occur secondary to prolonged immobilization or in cases with unremitting pain, swelling, and inflammation, even after seemingly minimal trauma. These may represent unrecognized capitellar osteochondral injuries. After a brief period of immobilization, the patient should be encouraged to do flexion-extension and supination-pronation exercises. The outcome may be maximized by a formal, supervised therapy regimen.

• Chronic wrist pain may represent an unrecognized interosseous ligament, distal radioulnar joint, or triangular fibrocartilage complex injury. Recognition of such injuries is important, especially in Mason type III or IV fractures in which radial head excision is considered. Proximal migration of the radius may require radioulnar synostosis to prevent progressive migration.

• Posttraumatic osteoarthritis: This may occur especially in the presence of articular incongruity or with free osteochondral fragments.

• Reflex sympathetic dystrophy: This may occur following surgical management of radial head fractures.

• Missed fracture-dislocation: Unrecognized (occult) fracture-dislocation of the elbow may result in a late dislocation owing to a failure to address associated ligamentous injuries of the elbow.

 

Radius and Ulna Shaft

EPIDEMIOLOGY

• Forearm fractures are more common in men than women; secondary to the higher incidence in men of motor vehicle accidents, contact athletic participation, altercations, and falls from a height.

• The ratio of open fractures to closed fractures is higher for the forearm than for any other bone except the tibia.

ANATOMY

• The forearm acts as a ring; a fracture that shortens either the radius or the ulna results either in a fracture or a dislocation of the other forearm bone at the proximal or distal radioulnar joint. Nightstick injuries are an exception.
• The ulna, which is relatively straight, acts as an axis around which the laterally bowed radius rotates in supination and pronation. A loss of supination and pronation may result from radial shaft fractures in which the lateral curvature has not been restored.

• The interosseous membrane occupies the space between the radius and ulna. The central band is approximately 3.5 cm wide running obliquely from its proximal origin on the radius to its distal insertion on the ulna. Sectioning of the central band alone reduces stability by 71% (Fig. 36).

• Fracture location dictates deforming forces:

• Radial fractures distal to the supinator muscle insertion but proximal to the pronator teres insertion tend to result in supination of the proximal fragment owing to unopposed pull of the supinator and biceps brachii muscles.

• Radial fractures distal to the supinator and pronator teres muscles tend to result ieutral rotational alignment of the proximal fragment.

FRACTURES OF BOTH THE RADIUS AND ULNA SHAFTS

Mechanism of Injury

• These are most commonly associated with motor vehicle accidents, although they are also commonly caused by direct trauma (while protecting one’s head), gunshot wounds, and falls either from a height or during athletic competition.

• Pathologic fractures are uncommon.

Clinical Evaluation

• Patients typically present with gross deformity of the involved forearm, pain, swelling, and loss of hand and forearm function.

• A careful neurovascular examination is essential, with assessment of radial and ulnar pulses, as well as median, radial, and ulnar nerve function.

• One must carefully assess open wounds because the ulna border is subcutaneous, and even superficial wounds can expose the bone.

Figure 36. Line diagram showing the soft tissue connections of the radius and the ulna to each other. The proximal radioulnar joint is stabilized by the annular ligament. The distal radioulnar joint is stabilized by the dorsal and volar radioulnar ligaments and the triangular fibrocartilage complex. (From Richards RR. Chronic disorders of the forearm. J Bone Joint Surg 1996;78A:916–930.)

• Excruciating, unremitting pain, tense forearm compartments, or pain on passive stretch of the fingers should raise suspicions of impending or present compartment syndrome. Compartment pressure monitoring should be performed, with emergency fasciotomy indicated for diagnosed compartment syndrome.

Radiographic Evaluation

Anteroposterior (AP) and lateral views of the forearm should be obtained, with oblique views obtained as necessary for further fracture definition.

• Radiographic evaluation should include the ipsilateral wrist and elbow to rule out the presence of associated fracture or dislocation.

• The radial head must be aligned with the capitellum on all views.

Classification

Descriptive

• Closed versus open
• Location
• Comminuted, segmental, multifragmented
• Displacement
• Angulation
• Rotational alignment

OTA Classification of Fractures of the Radial and Ulna Shaft

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

Treatment

Nonoperative

• The rare, nondisplaced fracture of both the radius and the ulna may be treated with a well-molded, long arm cast ieutral rotation with the elbow flexed to 90 degrees.

• The patient should have frequent follow-up to evaluate for possible loss of fracture reduction.

Operative

• Open reduction and internal fixation is the procedure of choice for displaced forearm fractures involving the radius and ulna in adults.

• Internal fixation involves use of compression plating (3.5-mm dynamic compression plate) with or without bone grafting.

• Principles of plate fixation:
• Restore ulnar and radial length (prevents subluxation of either the proximal or distal radioulnar joint).

• Restore rotational alignment.
• Restore radial bow (essential for rotational function of the forearm).

• A volar Henry approach may be used for fixation of the distal one-third of the radius with plate placement on the flat volar surface. Midshaft fractures may be approached and stabilized via a dorsal or volar approach.

• The ulna may be plated on either the volar or dorsal aspect, depending on the location of the fragments and contour of the ulna surrounding the fracture site. Using two separate incisions decreases the incidence of radioulnar synostosis.

• One should consider bone grafting if substantial comminution or bone loss exists.

Open fractures may receive primary open reduction and internal fixation after debridement, except in severe open injuries. This approach restores stability, limits dead space, and improves wound care. The timing of bone grafting of open fractures is controversial; it can be performed at the time of delayed primary closure or at 6 weeks after injury.

• External fixation may be used in cases with severe bone or soft tissue loss, gross contamination, infected nonunion, or in cases of open elbow fracture-dislocations with soft tissue loss.

• Good results have been reported with locked intramedullary nail fixation. However, the indications for intramedullary nailing over plate and screws have not been clearly defined. Some of the reported indications are segmental fractures, open fractures with bone or soft tissue loss, pathologic fractures, and failed plate fixation.

Complications

• Nonunion and malunion: These are uncommon, most often related to infection and errors of surgical technique. Patients may require removal of hardware, bone grafting, and repeat internal fixation.

• Infection: The incidence is only 3% with open reduction and internal fixation. It necessitates surgical drainage, debridement, copious irrigation, wound cultures, and antibiotics. If internal fixation is found to be stable, it does not necessarily need to be removed because most fractures will unite despite infection. Massive infections with severe soft tissue and osseous compromise may necessitate external fixation with wounds left open and serial debridements.

• Neurovascular injury: This is uncommon, associated with gunshot injury or iatrogenic causes. Nerve palsies can generally be observed for 3 months, with surgical exploration indicated for failure of return of nerve function. Injuries to the radial or ulnar arteries may be addressed with simple ligation if the other vessel is patent.

• Volkmann ischemia: This devastating complication follows compartment syndrome. Clinical suspicion should be followed by compartment pressure monitoring with emergency fasciotomy if a compartment syndrome is diagnosed.

• Posttraumatic radioulnar synostosis: This is uncommon (3% to 9% incidence); the risk increases with massive crush injuries or closed head injury. It may necessitate surgical excision if functional limitations of supination and pronation result, although a nonarticular synostosis excision is rarely successful in the proximal forearm. Postoperative low-dose radiation may decrease the incidence of recurrence.

FRACTURES OF THE ULNA SHAFT

• These include nightstick and Monteggia fractures, as well as stress fractures in athletes.

• A Monteggia lesion denotes a fracture of the proximal ulna accompanied by radial head dislocation.

Mechanism of Injury

• Ulna nightstick fractures result from direct trauma to the ulna along its subcutaneous border, classically as a victim attempts to protect the head from assault.

• Monteggia fractures are produced by various mechanisms (by Bado classification) (Fig. 37):

Type I:	Forced pronation of the forearm
Type II:	Axial loading of the forearm with a flexed elbow
Type III:	Forced abduction of the elbow
Type IV:	Type I mechanism in which the radial shaft additionally fails

 

Figure 37. The Bado classification of Monteggia fractures. (A) Type I. An anterior dislocation of the radial head with associated anteriorly angulated fracture of the ulna shaft. (B) Type II. Posterior dislocation of the radial head with a posteriorly angulated fracture of the ulna. (C) Type III. A lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysic. (D) Type IV. Anterior dislocation of the radial head with a fracture of the radius and ulna. (From Bado JL. The Monteggia lesion. Clin Orthop 1967;50:70–86..)

 

Clinical Evaluation

• Patients with a nightstick fracture typically present with focal swelling, pain, tenderness, and variable abrasions at the site of trauma.

• Patients with Monteggia fractures present with elbow swelling, deformity, crepitus, and painful range of elbow motion, especially supination and pronation.

• A careful neurovascular examination is essential, because nerve injury, especially to the radial or posterior interosseous nerve, is common. Most nerve injuries have been described with Type II Bado fractures.

Radiographic Evaluation

• AP and lateral views of the elbow and forearm (to include the wrist) should be obtained.

• Oblique views may aid in fracture definition.

• Normal radiographic findings:
• A line drawn through the radial head and shaft should always line up with the capitellum.

• Supinated lateral: Lines drawn tangential to the radial head anteriorly and posteriorly should enclose the capitellum.

Bado Classification of Monteggia Fractures (Fig. 37)

Type I:	Anterior dislocation of the radial head with fracture of ulnar diaphysis at any level with anterior angulation
Type II:	Posterior/posterolateral dislocation of the radial head with fracture of ulnar diaphysis with posterior angulation
Type III:	Lateral/anterolateral dislocation of the radial head with fracture of ulnar metaphysis
Type IV:	Anterior dislocation of the radial head with fractures of both radius and ulna within proximal third at the same level

Classification

OTA Classification of Fractures of the Ulna Shaft

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

Treatment

Nightstick Fractures

• Nondisplaced or minimally displaced ulna fractures may be treated with plaster immobilization in a sugar-tong splint for 7 to 10 days. Depending on the patient’s symptoms, this may be followed by functional bracing for 8 weeks with active range-of-motion exercises for the elbow, wrist, and hand, or simple immobilization in a sling with a compression wrap.

• Displaced fractures (>10-degree angulation in any plane or >50% displacement of the shaft) should be treated with open reduction and internal fixation using a 3.5-mm dynamic compression plate.

Monteggia Fractures

• Closed reduction and casting of Monteggia fractures should be reserved only for the pediatric population.

• Monteggia fractures require operative treatment, with closed reduction of the radial head with the patient under anesthesia, and open reduction and internal fixation of the ulna shaft with a 3.5-mm dynamic compression plate or reconstruction plate.

• After fixation of the ulna, the radial head is usually stable (>90%).

• Failure of the radial head to reduce with ulna reduction and stabilization is usually the result of an interposed annular ligament or rarely the radial nerve.

• If open reduction is required for the radial head, the annular ligament should be repaired.

• Associated radial head fractures may require fixation.

• Postoperatively, the patient is placed in a posterior elbow splint for 5 to 7 days. With stable fixation, physical therapy can be started with active flexion-extension and supination-pronation exercises. If fixation or radial head stability is questionable, the patient may be placed in a long arm cast with serial radiographic evaluation to determine healing, followed by a supervised physical therapy regimen.

Complications

• Nerve injury: most commonly associated with Bado Type II and III injuries involving the radial and/or mediaerves, as well as their respective terminal branches, the posterior and anterior interosseous nerves. These may also complicate open reduction owing to overzealous traction or reduction maneuvers. Surgical exploration is indicated for failure of nerve palsy recovery after a 3-month period of observation.

• Radial head instability: uncommon following anatomic reduction of the ulna. If redislocation occurs <6 weeks postoperatively with a nonanatomic reduction of the ulnar, repeat reduction and fixation of the ulna with an open reduction of the radial head may be considered. Dislocation of the radial head >6 weeks postoperatively is best managed by radial head excision.

FRACTURES OF THE RADIAL SHAFT

• Fractures of the proximal two-thirds of the radius without associated injuries may be considered to be truly isolated. However, radial fractures involving the distal third involve the distal radioulnar joint until proven otherwise.

• A Galeazzi or Piedmont fracture refers to a fracture of the radial diaphysis at the junction of the middle and distal thirds with associated disruption of the distal radioulnar joint. It has also been referred to as the “fracture of necessity,” because it requires open reduction and internal fixation to achieve a good result. This lesion is approximately three times as common as Monteggia fractures.

• Variants: Fracture can occur anywhere along the radius or associated with fractures of both radius and ulna with distal radioulnar joint disruption.

• Four major deforming forces contribute to a loss of reduction if the fracture is treated by nonoperative means:

• Weight of the hand: This results in dorsal angulation of the fracture and subluxation of the distal radioulnar joint.

• Pronator quadratus insertion: This tends to pronate the distal fragment with proximal and volar displacement.

• Brachioradialis: This tends to cause proximal displacement and shortening.

• Thumb extensors and abductors: They result in shortening and relaxation of the radial collateral ligament, allowing displacement of the fracture despite immobilization of the wrist in ulnar deviation.

• A reverse Galeazzi fracture denotes a fracture of the distal ulna with associated disruption of the distal radioulnar joint.

Mechanism of Injury

• Radial diaphyseal fractures may be caused by direct trauma or indirect trauma, such as a fall onto an outstretched hand.

• The radial shaft in the proximal two thirds is well padded by the extensor musculature; therefore, most injuries severe enough to result in proximal radial shaft fractures typically result in ulna fracture as well. In addition, the anatomic position of the radius in most functional activities renders it less vulnerable to direct trauma than the ulna.

• Galeazzi fractures may result from direct trauma to the wrist, typically on the dorsolateral aspect, or a fall onto an outstretched hand with forearm pronation.

• Reverse Galeazzi fractures may result from a fall onto an outstretched hand with forearm supination.

Clinical Evaluation

• Patient presentation is variable and is related to the severity of the injury and the degree of fracture displacement. Pain, swelling, and point tenderness over the fracture site are typically present.

• Elbow range of motion, including supination and pronation, should be assessed; rarely, limited forearm rotation may suggest a radial head dislocation in addition to the diaphyseal fracture.

• Galeazzi fractures typically present with wrist pain or midline forearm pain that is exacerbated by stressing of the distal radioulnar joint in addition to the radial shaft fracture.

• Neurovascular injury is rare.

Radiographic Evaluation

• AP and lateral radiographs of the forearm, elbow, and wrist should be obtained.

• Radiographic signs of distal radioulnar joint injury are:

• Fracture at base of the ulnar styloid.

• Widened distal radioulnar joint on AP x-ray.

• Subluxed ulna on lateral x-ray.

• >5 mm radial shortening.

Classification

OTA Classification of Fractures of the Radial Shaft

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

Treatment

Proximal Radius Fracture

• Nondisplaced fractures may be managed in a long arm cast. Any evidence of loss of radial bow is an indication for open reduction and internal fixation. The cast is continued until radiographic evidence of healing occurs.

• Displaced fractures are best managed by open reduction and plate fixation using a 3.5-mm dynamic compression plate.

Galeazzi Fractures

• Open reduction and internal fixation comprise the treatment of choice, because closed treatment is associated with a high failure rate.

• Plate and screw fixation is the treatment of choice.

• An anterior Henry approach (interval between the flexor carpi radialis and the brachioradialis) typically provides adequate exposure of the radius fracture, with plate fixation on the flat, volar surface of the radius.

• The distal radioulnar joint injury typically results in dorsal instability; therefore, a dorsal capsulotomy may be utilized to gain access to the distal radioulnar joint if it remains dislocated after fixation of the radius. Kirschner wire fixation may be necessary to maintain reduction of the distal radioulnar joint if unstable. If the distal radioulnar joint is believed to be stable, however, postoperative plaster immobilization may suffice.

• Postoperative management:
• If the distal radioulnar joint is stable: Early motion is recommended.

• If the distal radioulnar joint is unstable: Immobilize the forearm in supination for 4 to 6 weeks in a long arm splint or cast.

• Distal radioulnar joint pins, if needed, are removed at 6 to 8 weeks.

Complications

• Malunion: Nonanatomic reduction of the radius fracture with a failure to restore rotational alignment or lateral bow may result in a loss of supination and pronation, as well as painful range of motion. This may require osteotomy or distal ulnar shortening for cases in which symptomatic shortening of the radius results in ulnocarpal impaction.

• Nonunion: This is uncommon with stable fixation, but it may require bone grafting.

• Compartment syndrome: Clinical suspicion should be followed by compartment pressure monitoring with emergency fasciotomy if a compartment syndrome is diagnosed.

• One should assess all three forearm compartments and the carpal tunnel.

• Neurovascular injury:
• This is usually iatrogenic.
• Superficial radial nerve injury (beneath the brachioradialis) is at risk with anterior radius approaches.

• Posterior interosseous nerve injury (in the supinator) is at risk with proximal radius approaches.

• If no recovery occurs, explore the nerve at 3 months.

• Radioulnar synostosis: This is uncommon (3% to 9.4% incidence).

• Risk factors include:
• Fracture of both bones at the same level (11% incidence).

• Closed head injury.
• Surgical delay >2 weeks.
• Single incision for fixation of both bone forearm fractures.

• Penetration of the interosseous membrane by bone graft or screws, bone fragments, or surgical instruments.

• Crush injury.
• Infection.
• The worst prognosis is with distal synostosis, and the best is with diaphyseal synostosis.

• Recurrent dislocation: This may arise as a result of radial malreduction. It emphasizes the need for anatomic restoration of the radial fracture to ensure adequate healing and biomechanical function of the distal radioulnar joint.

Distal Radius

EPIDEMIOLOGY

• Distal radius fractures are among the most common fractures of the upper extremity.

• More than 450,000 occur annually in the United States.

• Fractures of the distal radius represent approximately one-sixth of all fractures treated in emergency departments.

• The incidence of distal radius fractures in the elderly correlates with osteopenia and rises in incidence with increasing age, nearly in parallel with the increased incidence of hip fractures.

• Risk factors for fractures of the distal radius in the elderly include decreased bone mineral density, female sex, white race, family history, and early menopause.

ANATOMY

• The metaphysis of the distal radius is composed primarily of cancellous bone. The articular surface has a biconcave surface for articulation with the proximal carpal row (scaphoid and lunate fossae), as well as a notch for articulation with the distal ulna.

• 80% of axial load is supported by the distal radius and 20% by the ulna and the triangular fibrocartilage complex (TFCC).

• Reversal of the normal palmar tilt results in load transfer onto the ulna and TFCC; the remaining load is then borne eccentrically by the distal radius and is concentrated on the dorsal aspect of the scaphoid fossa.

• Numerous ligamentous attachments exist to the distal radius; these often remain intact during distal radius fracture, facilitating reduction through “ligamentotaxis.”

• The volar ligaments are stronger and confer more stability to the radiocarpal articulation than the dorsal ligaments.

MECHANISM OF INJURY

• Common mechanisms in younger individuals include falls from a height, motor vehicle accident, or injuries sustained during athletic participation. In elderly individuals, distal radial fractures may arise from low-energy mechanisms, such as a simple fall from a standing height.

• The most common mechanism of injury is a fall onto an outstretched hand with the wrist in dorsiflexion.

• Fractures of the distal radius are produced when the dorsiflexion of the wrist varies between 40 and 90 degrees, with lesser degrees of force required at smaller angles.

• The radius initially fails in tension on the volar aspect, with the fracture propagating dorsally, whereas bending moment forces induce compression stresses resulting in dorsal comminution. Cancellous impaction of the metaphysis further compromises dorsal stability. Additionally, shearing forces influence the injury pattern, often resulting in articular surface involvement.

• High-energy injuries (e.g., vehicular trauma) may result in significantly displaced or highly comminuted unstable fractures to the distal radius.

CLINICAL EVALUATION

• Patients typically present with variable wrist deformity and displacement of the hand in relation to the wrist (dorsal in Colles or dorsal Barton fractures and volar in Smith-type fractures). The wrist is typically swollen with ecchymosis, tenderness, and painful range of motion.

• The ipsilateral elbow and shoulder should be examined for associated injuries.

• A careful neurovascular assessment should be performed, with particular attention to mediaerve function. Carpal tunnel compression symptoms are common (13% to 23%) owing to traction during forced hyperextension of the wrist, direct trauma from fracture fragments, hematoma formation, or increased compartment pressure.

RADIOGRAPHIC EVALUATION

• Posteroanterior and lateral views of the wrist should be obtained, with oblique views for further fracture definition, if necessary. Shoulder or elbow symptoms should be evaluated radiographically.
• Contralateral wrist views may help to assess the patient’s normal ulnar variance and scapholunate angle.

• Computed tomography scan may help to demonstrate the extent of intraarticular involvement.

• Normal radiographic relationships (Fig. 38).
• Radial inclination: averages 23 degrees (range, 13 to 30 degrees)

• Radial length: averages 11 mm (range, 8 to 18 mm).

• Palmar (volar) tilt: averages 11 to 12 degrees (range, 0 to 28 degrees).

CLASSIFICATION

Descriptive

• Open versus closed
• Displacement
• Angulation
• Comminution
• Loss of radial length

Frykman Classification of Colles Fractures

This is based on the pattern of intraarticular involvement (Fig. 39).

Figure 38. The normal radiographic measurements of the distal radius. (Reproduced with permission from the Orthopaedic Trauma Association).

Figure 39. Frykman classification of distal radius fractures. (A) Frykman Type I/II, extraarticular. (B) Frykman Type III/IV, intraarticular radiocarpal joint. (C) Frykman Type V/VI, intraarticular distal radioulnar joint. (D) Frykman Type VII/VIII, intraarticular radiocarpal and distal radioulnar joints. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:771..)

 

Melone Classification of Intraarticular Fractures

This is based on a consistent mechanism (lunate impaction injury) (Fig. 40).

Type I:	Stable, without comminution
Type II:	Unstable die-punch, dorsal or volar
IIA:	Reducible
IIB:	Irreducible
Type III:	Spike fracture; contused volar structures
Type IV:	Split fracture; medial complex fractured with dorsal and palmar fragments displaced separately
Type V:	Explosion fracture; severe comminution with major soft tissue injury

 

Figure 40. Intraarticular distal radius fractures. (From Melone CP Jr. Open treatment for displaced articular fractures of the distal radius. Clin Orthop 1986;202:103..)

Fernandez Classification

This is a mechanism-based classification system.

Type I:	Metaphyseal bending fracture with the inherent problems of loss of palmar tilt and radial shortening relative to the ulna (DRUJ injury)
Type II:	Shearing fracture requiring reduction and often buttressing of the articular segment
Type III:	Compression of the articular surface without the characteristic fragmentation; also the potential for significant interosseous ligament injury
Type IV:	Avulsion fracture or radiocarpal fracture dislocation
Type V:	Combined injury with significant soft tissue involvement owing to high-energy injury

OTA Classification of Fractures of the Distal Radius and Ulna

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

 

Eponyms (Fig. 41)

• Colles fracture

• The original description was for extraarticular fractures. Present usage of eponym includes both extraarticular and intraarticular distal radius fractures demonstrating various combinations of dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortening.

• Clinically, it has been described as a “dinner fork” deformity.

• More than 90% of distal radius fractures are of this pattern.

• The mechanism of injury is a fall onto a hyperextended, radially deviated wrist with the forearm in pronation.

• Intraarticular fractures are generally seen in the younger age group secondary to higher-energy forces; concomitant injuries (i.e., to nerve, carpus, and distal ulna) are more frequent, as is involvement of both the radiocarpal joint and the DRUJ.

• Smith fracture (reverse Colles fracture)

• This describes a fracture with volar angulation (apex dorsal) of the distal radius with a “garden spade” deformity or volar displacement of the hand and distal radius.

• The mechanism of injury is a fall onto a flexed wrist with the forearm fixed in supination.

• This is a notoriously unstable fracture pattern; it often requires open reduction and internal fixation because of difficulty in maintaining adequate closed reduction.

• Barton fracture

• This is a fracture-dislocation or subluxation of the wrist in which the dorsal or volar rim of the distal radius is displaced with the hand and carpus. Volar involvement is more common.
• The mechanism of injury is a fall onto a dorsiflexed wrist with the forearm fixed in pronation. Fracture occurs secondary to shear.
• Most fractures are unstable and require open reduction and internal fixation with a buttress plate to achieve stable, anatomic reduction.

• Radial styloid fracture (chauffeur’s fracture, backfire fracture, Hutchinson fracture)

• This is an avulsion fracture with extrinsic ligaments remaining attached to the styloid fragment.

• The mechanism of injury is compression of the scaphoid against the styloid with the wrist in dorsiflexion and ulnar deviation.

• It may involve the entire styloid or only the dorsal or volar portion.

• It is often associated with intercarpal ligamentous injuries (i.e., scapholunate dissociation, perilunate dislocation).

• Open reduction and internal fixation are ofteecessary.

Figure 41. Eponymic classification of five basic types of distal radius fractures: four classic (Colles, Barton, Smith, and Chauffeur’s) fracture descriptions, and the Malone four-part fracture, which was described more recently and represents an increasing understanding of the importance of the distal radioulnar joint and the ulnar column of the radius.

 

TREATMENT

• Factors affecting treatment include:
• Fracture pattern.
• Local factors: bone quality, soft tissue injury, fracture comminution, fracture displacement, and energy of injury.

• Patient factors: physiologic patient age, lifestyle, occupation, hand dominance, associated medical conditions, associated injuries, and compliance.

• Acceptable radiographic parameters for a healed radius in an active, healthy patient include:

• Radial length: within 2 to 3 mm of the contralateral wrist.

• Palmar tilt: neutral tilt (0 degrees).

• Intraarticular step-off: <2 mm.
• Radial inclination: <5-degree loss.
• McQueen has reported that the carpal alignment after distal radius fracture is the main influence on outcome.

• Carpal alignment is measured by the intersection of two lines on the lateral radiograph: one parallel and through the middle of the radial shaft and the other through and parallel to the capitate. If the two lines intersect within the carpus, then the carpus is aligned. If the two lines intersect out with the carpus, then the carpus is malaligned.

• Several factors have been associated with redisplacement following closed manipulation of a distal radius fracture:

• The initial displacement of the fracture: The greater the degree of displacement (particularly radial shortening), the more energy is imparted to the fracture resulting in a higher likelihood that closed treatment will be unsuccessful.

• The age of the patient: Elderly patients with osteopenic bones tend to displace, particularly late.

• The extent of metaphyseal comminution (the metaphyseal defect), as evidenced by either plain radiograph or computerized tomography.

• Displacement following closed treatment is a predictor of instability, and repeat manipulation is unlikely to result in a successful radiographic outcome.

Nonoperative

• All fractures should undergo closed reduction, even if it is expected that surgical management will be needed.

• Fracture reduction helps to limit postinjury swelling, provides pain relief, and relieves compression on the mediaerve.

• Cast immobilization is indicated for:

• Nondisplaced or minimally displaced fractures.

• Displaced fractures with a stable fracture pattern which can be expected to unite within acceptable radiographic parameters.

• Low-demand elderly patients in whom future functional impairment is less of a priority than immediate health concerns and/or operative risks.

• Hematoma block with supplemental intravenous sedation, Bier block, or conscious sedation can be used to provide analgesia for closed reduction.

• Technique of closed reduction (dorsally tilted fracture):

• The distal fragment is hyperextended.

• Traction is applied to reduce the distal to the proximal fragment with pressure applied to the distal radius.

• A well-molded long arm (sugar-tong) splint is applied, with the wrist in neutral to slight flexion.

• One must avoid extreme positions of the wrist and hand.

• The cast should leave the metacarpophalangeal joints free.

• Once swelling has subsided, a well-molded cast is applied.

• The ideal forearm position, duration of immobilization, and need for a long arm cast remain controversial; no prospective study has demonstrated the superiority of one method over another.

• Extreme wrist flexion should be avoided, because it increases carpal canal pressure (and thus mediaerve compression) as well as digital stiffness. Fractures that require extreme wrist flexion to maintain reduction may require operative fixation.

• The cast should be worn for approximately 6 weeks or until radiographic evidence of union has occurred.

• Frequent radiographic examination is necessary to detect loss of reduction.

Operative

• Indications
• High-energy injury
• Secondary loss of reduction
• Articular comminution, step-off, or gap

• Metaphyseal comminution or bone loss
• Loss of volar buttress with displacement

• DRUJ incongruity

Operative Techniques

• Percutaneous pinning: This is primarily used for extraarticular fractures or two-part intraarticular fractures.

• It may be accomplished using two or three Kirschner wires placed across the fracture site, generally from the radial styloid, directed proximally and from the dorsoulnar side of the distal radial fragment directed proximally. Transulnar pinning with multiple pins has also been described.
• Percutaneous pinning is generally used to supplement short arm casting or external fixation. The pins may be removed 3 to 4 weeks postoperatively, with the cast maintained for an additional 2 to 3 weeks.

• Kapandji Intrafocal pinning.
• This is a technique of trapping the distal fragment by buttressing to prevent displacement.

• The wires are inserted both radially and dorsally directly into the fracture site. The wires are then levered up and then directed into the proximal intact opposite cortex.

• The fragments are thus buttressed from displacing dorsally or proximally.

• In addition to being relatively simple and inexpensive, this technique has been shown to be very effective, particularly in elderly patients.

• External fixation: Its use has grown in popularity based on studies yielding relatively low complication rates.

• Spanning external fixation
• Ligamentotaxis is used to restore radial length and radial inclination, but it rarely restores palmar tilt.

• External fixation alone may not be sufficiently stable to prevent some degree of collapse and loss of palmar tilt during the course of healing.

• Overdistraction should be avoided because it may result in finger stiffness and may be recognized by increased intercarpal distance on intraoperative fluoroscopy.

• It may be supplemented with percutaneous pinning of comminuted or articular fragments.

• Pins may be removed at 3 to 4 weeks, although most recommend 6 to 8 weeks of external fixation.

• Nonspanning external fixation
• A nonspanning fixator is one that stabilizes the distal radius fracture by securing pins in the radius alone, proximal to and distal to the fracture site.

• It requires a sufficiently large intact segment of intact distal radius.

• McQueen reported that nonspanning better preserved volar tilt, prevented carpal malalignment, and gave better grip strength and hand function than spanning external fixation.

• Open reduction and internal fixation
• Dorsal plating: This has several theoretic advantages.

• It is technically familiar to most surgeons, and the approach avoids the neurovascular structures on the palmar side.

• The fixation is on the compression side of the fracture and provides a buttress against collapse.

• Initial reports of the technique demonstrated successful outcomes with the theoretic advantages of earlier return of function and better restoration of radial anatomy than seen with external fixation.

• Dorsal plating has been associated with extensor tendon complications.

• Volar nonlocked plating
• The primary indication is a shear fracture of the volar lip.

• It may be unable to maintain fracture reduction in the presence of dorsal comminution.

• Volar locked plating
• Locked volar plating has increased in popularity because this implant has been shown to stabilize distal radius fractures with dorsal comminution.

• The interval is between the flexor carpi radialis and the radial artery.

• Adjunctive fixation
• Supplemental graft may be autograft, allograft, or synthetic graft.

• Adjunctive Kirschner wire fixation may be helpful with smaller fragments.

• Arthroscopically assisted intraarticular fracture reduction

Although arthroscopy has been invaluable at enhancing existing knowledge of associated soft tissue lesions in distal radius fractures, it is controversial whether this technique provides outcomes superior to those of conventional techniques.

• Fractures that may benefit most from adjunctive arthroscopy are: (1) complex articular fractures without metaphyseal comminution, particularly those with central impaction fragments; and (2) fractures with evidence of substantial interosseous ligament or TFCC injury without large ulnar styloid base fracture.

• Ulna styloid fractures: Indications for fixation of ulna styloid are controversial. Some authors have advocated fixation for displaced fractures at the base of the ulna styloid.

COMPLICATIONS

• Mediaerve dysfunction: Management is controversial, although there is general agreement about the following:

• A complete mediaerve lesion with no improvement following fracture reduction requires surgical exploration.

• Mediaerve dysfunction developing after reduction mandates release of the splint and positioning of the wrist ieutral position; if there is no improvement, exploration and release of the carpal tunnel should be considered.

• An incomplete lesion in a fracture requiring operative intervention is a relative indication for carpal tunnel release.

• Malunion or nonunion: This typically results from inadequate fracture reduction or stabilization; it may require internal fixation with or without osteotomy with bone graft.

• Complications of external fixation include reflex sympathetic dystrophy, pin tract infection, wrist and finger stiffness, fracture through a pin site, and radial sensory neuritis. Open pin placement is advisable to allow visualization of the superficial radial nerve.

• Posttraumatic osteoarthritis: This is a consequence of radiocarpal and radioulnar articular injury, thus emphasizing the need for anatomic restoration of the articular surface.

• Finger, wrist, and elbow stiffness: This occurs especially with prolonged immobilization in a cast or with external fixation; it emphasizes the need for aggressive occupational therapy to mobilize the digits and elbow while wrist immobilization is in place, as well as a possible supervised therapy regimen once immobilization has been discontinued.

• Tendon rupture, most commonly extensor pollicis longus, may occur as a late complication of distal radius fractures, even in cases of minimally displaced injuries. Degeneration of the tendon, owing to vascular disruption of the tendon sheath as well as mechanical impingement on the callus, results in attrition of tendon integrity. Dorsal plating has been most often associated with extensor tendon complications.

• Midcarpal instability (i.e., dorsal or volar intercalated segmental instability) may result from radiocarpal ligamentous injury or a dorsal or volar rim distal radius disruption.

Wrist

EPIDEMIOLOGY

• Although wrist injuries are fairly common, especially with athletic participation, the true incidence is unknown owing to a failure to recognize carpal injuries in the presence of associated, more obvious injuries.

ANATOMY

• The distal radius has articular facets for the scaphoid and lunate separated by a ridge. The sigmoid notch articulates with the distal ulna.
• The distal ulna articulates with the sigmoid notch of the distal radius. The ulna styloid process serves as the attachment for the triangular fibrocartilage complex (TFCC).

• Carpal bones (Fig. 42)

• Proximal row: This consists of the scaphoid (an oblique strut that spans both rows), lunate, triquetrum, and pisiform.

• Distal row: The trapezium, trapezoid, capitate, and hamate are connected to one another and to the base of the metacarpals by strong ligaments, making the distal row relatively immobile.

• The lunate is the key to carpal stability.

• It is connected to both scaphoid and triquetrum by strong interosseous ligaments.

• Injury to the scapholunate or lunotriquetral ligaments leads to asynchronous motion of the lunate to dissociative carpal instability patterns.

• Joints: These are the distal radioulnar, radiocarpal, and midcarpal.

• Normal anatomic relationships (see Fig. 42)

• Radial inclination: averages 23 degrees (range, 13 to 30 degrees)

• Radial length: averages 11 mm (range, 8 to 18 mm)

• Palmar (volar) tilt: averages 11 to 12В° (range, 0 to 28 degrees)

• The 0-degree capitolunate angle: a straight line drawn down the third metacarpal shaft, capitate, lunate, and shaft of radius with wrist ieutral position

• The 47-degree scapholunate angle (normal range, 30 to 70 degrees); less than 2 mm scapholunate space

Figure 42. The wrist is composed of two rows of bones that provide motion and transfer forces: scaphoid (S), lunate (L), triquetrum (T), pisiform (P), trapezium (Tm), trapezoid (Td), capitate (C), hamate (H). (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Wrist ligaments (Figs. 43 and 44)
• Extrinsic ligaments connect the radius to the carpus and the carpus to the metacarpals.

• Intrinsic ligaments connect carpal bone to carpal bone (e.g., scapholunate and lunotriquetral ligaments).

• In general, the volar ligaments are stronger than the dorsal ligaments.

• Important volar ligaments include:
• The radioscaphocapitate (guides scaphoid kinematics).

• The radioscapholunate (stabilizes the scapholunate articulation).

The radiolunate.

The radiolunotriquetral (supports the proximal row, stabilizes the radiolunate and lunotriquetral joints).

• The proximal and distal carpal rows are attached by capsular ligaments on each side of the lunocapitate joint.

• Injury to these ligaments leads to abnormal motion between the two rows and to nondissociative wrist instability patterns.

• Space of Poirier: This ligament-free area in the capitolunate space is an area of potential weakness.

• The TFCC is a major stabilizer of the ulnar carpus and distal radioulnar joint.

• The TFCC absorbs about 20% of the axial load across the wrist joint.

• It consists of several components, including the radiotriquetral ligament (meniscal homologue), articular disc, ulnolunate ligament, and ulnar collateral ligament.

Figure 43. The palmar capsule consists of two major ligamentous inclusions: the radiolunate ligament is the deeper of the two, which proceeds to the triquetrum and composes in effect the radiolunotriquetral ligament. The more distal and superficial component is often referred to as the arcuate ligament or distal V. The radial component of this ligament is the radioscaphocapitate ligament. The ulnar component of the arcuate ligament is the triquetrocapitate ligament. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

 

Figure 44. The intraarticular intrinsic ligaments connect adjacent carpal bones. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

 

• Vascular supply (Fig. 45)
• The radial, ulnar, and anterior interosseous arteries combine to form a network of transverse arterial arches both dorsal and volar to the carpus.

• The blood supply to the scaphoid is derived primarily from the radial artery, both dorsally and volarly. The volar scaphoid branches supply the distal 20% to 30% of the scaphoid, whereas branches entering the dorsal ridge supply the proximal 70% to 80%.

• The lunate receives blood supply from both its volar and dorsal surfaces in most cases (80%). About 20% of lunates have only a volar blood supply.

 

Figure 45. Schematic drawing of the arterial supply of the palmar aspect of the carpus. Circulation of the wrist is obtained through the radial, ulnar, and anterior interosseous arteries and the deep palmar arch: 1, palmar radiocarpal arch; 2, palmar branch of anterior interosseous artery; 3, palmar intercarpal arch; 4, deep palmar arch; and 5, recurrent artery. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Kinematics
• The global motion of the wrist is composed of flexion and extension, radioulnar deviation at the radiocarpal joint, and axial rotation around the distal radioulnar joint.

• The radiocarpal articulation acts as a universal joint allowing a small degree of intercarpal motion related to rotation of individual carpal bones.

• The forearm accounts for about 140 degrees of rotation.

• Radiocarpal joint motion is primarily flexion and extension of nearly equal proportions (70 degrees), and radial and ulnar deviation of 20 and 40 degrees, respectively.

• The scaphoid rests on the radioscaphocapitate ligament at its waist. Using the ligament as an axis, it rotates from a volar flexed perpendicular position to a dorsiflexed longitudinal position. Pathomechanics (Fig. 46)
• Classically, the radius, lunate, and capitate have been described as a central “link” that is colinear in the sagittal plane.

• The scaphoid serves as a connecting strut. Any flexion moment transmitted across the scaphoid is balanced by an extension moment at the triquetrum.

• When the scaphoid is destabilized by fracture or scapholunate ligament disruption, the lunate and triquetrum assume a position of excessive dorsiflexion (dorsal intercalated segmental instability [DISI]) and the scapholunate angle becomes abnormally high (>70 degrees).

• When the triquetrum is destabilized (usually by disruption of the lunotriquetral ligament complex) the opposite pattern (volar intercalated segmental instability [VISI]) is seen as the intercalated lunate segment volarflexes.

MECHANISM OF INJURY

• The most common mechanism of carpal injury is a fall onto the outstretched hand, resulting in an axial compressive force with the wrist in hyperextension. The volar ligaments are placed under tension with compression and shear forces applied dorsally, especially when the wrist is extended beyond its physiologic limits.

Excessive ulnar deviation and intercarpal supination result in a predictable pattern of injury, progressing from the radial side of the carpus to the mid carpus and finally to the ulnar carpus.

 

 CLINICAL EVALUATION

• The clinical presentation of individual carpal injuries is variable, but in general, the most consistent sign of carpal injury is well-localized tenderness.

• Gross deformity may be present, ranging from displacement of the carpus to prominence of individual carpal bones.

• Provocative tests may reproduce or exacerbate pain, crepitus, or displacement indicative of individual carpal injuries (see specific carpal injuries).

RADIOGRAPHIC EVALUATION

• Posteroanterior (PA) and lateral x-rays are each taken in the neutral position.

• Gilula lines (three smooth radiographic arcs) should be examined on the PA view. Disruption of these arcs indicates ligamentous instability.
• For further diagnosis of carpal and mainly scaphoid fractures.

• A scaphoid view (anteroposterior [AP] x-ray with wrist supinated 30 degrees and in ulnar deviation) is obtained.

Figure 46. Schematic drawing of carpal instability. (A) Normal longitudinal alignment of the carpal bones with the scaphoid axis at a 47-degree angle to the axes of the capitate, lunate, and radius. (B) A volar intercalated segmental instability (VISI) deformity is usually associated with disruption of the lunatotriquetral ligament. (C) A dorsal intercalated segmental instability (DISI) deformity is associated with scapholunate ligament disruption or a displaced scaphoid fracture. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Baltimore: Lippincott Williams & Wilkins, 2005.)

• A pronated oblique view is indicated.

• If there is the suspicion of carpal instability, additional views in maximal radial and ulnar deviation are recommended as well as a clenched-fist PA.

• Further views can be done in maximal flexion and extension.

• Arthrography, magnetic resonance (MR), wrist arthrography, videoradiography, and arthroscopy can assist in the diagnosis of carpal ligament injuries.

• Computed tomography (CT) scans are helpful in evaluating carpal fractures, malunion, nonunion, and bone loss.

• MRI scans are sensitive to detect occult fractures and osteonecrosis of the carpal bones as well as detecting soft tissue injury, including ruptures of the scapholunate ligament and TFCC.

CLASSIFICATION

OTA Classification of Carpal Fractures and Fracture-Dislocations

See Fracture and Dislocation Compendium at http://www.ota.org/.compendium/index.htm.

SPECIFIC FRACTURES

 

Scaphoid

• Fractures of the scaphoid are common and account for about 50% to 80% of carpal injuries.

• Anatomically, the scaphoid is divided into proximal and distal poles, a tubercle, and a waist; 80% of the scaphoid is covered with articular cartilage (Fig. 47).

• Ligamentous attachments to the scaphoid include the radioscaphocapitate ligament, which variably attaches to the ulnar aspect of the scaphoid waist, and the dorsal intercarpal ligament, which provides the primary vascular supply to the scaphoid.

• The major vascular supply is derived from scaphoid branches of the radial artery, entering the dorsal ridge and supplying 70% to 80% of the scaphoid, including the proximal pole. The remaining distal aspect is supplied through branches entering the tubercle. Fractures at the scaphoid waist or proximal third depend on fracture union for revascularization (Fig. 48).

• The most common mechanism is a fall onto the outstretched hand that imposes a force of dorsiflexion, ulnar deviation, and intercarpal supination.

• Clinical evaluation

Figure 47. Types of scaphoid fractures. The scaphoid is susceptible to fractures at any level. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 4th ed., vol. 1. Philadelphia: Lippincott-Raven, 1996:826.)

Figure 48. The vascular supply of the scaphoid is provided by two vascular pedicles. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Patients present with wrist pain and swelling, with tenderness to palpation overlying the scaphoid in the anatomic snuffbox. Provocative tests include:

• The scaphoid lift test: reproduction of pain with dorsal-volar shifting of the scaphoid.

• The Watson test: painful dorsal scaphoid displacement as the wrist is moved from ulnar to radial deviation with compression of the tuberosity.

• Differential diagnoses
• Scapholunate instability
• Lunate dislocation
• Flexor carpus radialis tendon rupture
• Radial styloid fracture
• Trapezium fracture
• De Quervain disease
• Carpometacarpal (basal) joint arthrosis
• Radiographic evaluation
• This includes a PA view with the hand clenched in a fist to extend the scaphoid, a lateral, a radial oblique (supinated AP) and an ulnar oblique view.

• Initial films are nondiagnostic in up to 25% of cases.

• If the clinical examination suggests fracture but radiographs are not diagnostic, a trial of immobilization with follow-up radiographs 1 to 2 weeks after injury may demonstrate the fracture.

• Technetium bone scan, MRI, CT, and ultrasound evaluation may be used to diagnose occult scaphoid fractures.

• Classification
• Based on fracture pattern (Russe)

• Horizontal oblique
• Transverse
• Vertical oblique
• Based on displacement
• Stable: nondisplaced fractures with no step-off in any plane

• Unstable: displacement with 1 mm or more step-off scapholunate angulation >60 degrees or radiolunate angulation >15 degrees

• Based on location
• Tuberosity: 17% to 20%
• Distal pole: 10% to 12%
• Waist: 66% to 70%
• Horizontal oblique: 13% to 14%
• Vertical oblique: 8% to 9%
• Transverse: 45% to 48%
• Proximal pole: 5% to 7%

Treatment

• Indications for nonoperative treatment
• Nondisplaced distal third fracture
• Tuberosity fractures
• Nonoperative treatment
• Long arm thumb spica cast for 6 weeks

• Immobilization in slight flexion and slight radial deviation

• Replacement with short arm thumb spica cast at 6 weeks until united

• Expected time to union:
• Distal third: 6 to 8 weeks
• Middle third: 8 to 12 weeks
• Proximal third: 12 to 24 weeks
• Management of suspected scaphoid fractures
• In patients with an injury and positive examination findings but normal x-rays, immobilization for 1 to 2 weeks (thumb spica) is indicated.

• Repeat x-rays if the patient is still symptomatic.

• If pain is still present but x-rays continue to be normal, consider MRI (or bone scan).

• If an acute diagnosis is necessary, consider MRI or CT immediately.

• Healing rates with nonoperative treatment depends on fracture location:

• Operative treatment
• Indications for surgery
• Fracture displacement >1 mm
• Radiolunate angle >15 degrees
• Scapholunate angle >60 degrees
• Humpback deformity
• Nonunion
• Surgical techniques
• Most involve the insertion of screws.

• Controversy exists about open versus percutaneous techniques.

• Open techniques are needed for nonunions and fractures with unacceptable displacement.

• Closed techniques are appropriate for acute fractures with minimal displacement.

• The volar approach between the flexor carpi radialis and the radial artery provides good exposure for open reduction and internal fixation and repair of the radioscapholunate ligament. The volar approach is the least damaging to the vascular supply of the vulnerable proximal pole.

• Postoperative immobilization consists of a long arm thumb spica cast for 6 weeks.

• Complications
• Delayed union, nonunion, and malunion: These are reported to occur with greater frequency when a short arm cast is used as compared with a long arm cast, as well as with proximal scaphoid fractures. They may necessitate operative fixation with bone grafting to achieve union.

• Osteonecrosis: This occurs especially with fractures of the proximal pole, owing to the tenuous vascular supply.

Lunate

• The lunate is the fourth most fractured carpal bone after the scaphoid, triquetrum, and trapezium.

• Fractures of the lunate are often unrecognized until they progress to osteonecrosis, at which time they are diagnosed as Kienboeck disease.

• The lunate has been referred to as the “carpal keystone,” because it rests in the well-protected concavity of the lunate fossa of the distal radius, anchored by interosseous ligaments to the scaphoid and triquetrum, and distally is congruent with the convex head of the capitate.

• Its vascular supply is derived from the proximal carpal arcade dorsally and volarly, with three variable intralunate anastomoses.

• The mechanism of injury is typically a fall onto an outstretched hand with the wrist in hyperextension, or a strenuous push with the wrist in extension.

• Clinical evaluation reveals tenderness to palpation on the volar wrist overlying the distal radius and lunate, with painful range of motion.

• Radiographic evaluation: PA and lateral views of the wrist are often inadequate to establish the diagnosis of lunate fracture because osseous details are frequently obscured by overlapping densities.

Oblique views may be helpful, but CT, MRI, and technetium bone scanning best demonstrate fracture.

• MRI has been used with increasing frequency to appreciate the vascular changes associated with injury and healing and is the imaging test of choice for evaluation of Kienboeck disease.

• Classification: Acute fractures of the lunate can be classified into five groups:

• Frontal fractures of the palmar pole with involvement of the palmar nutrient arteries

• Osteochondral fractures of the proximal articular surface without substantial damage to the nutrient vessels

• Frontal fractures of the dorsal pole

• Transverse fractures of the body
• Transarticular frontal fractures of the body of the lunate

• Treatment
• Nondisplaced fractures should be treated in a short or long arm cast or splint with follow-up at close intervals to evaluate progression of healing.

• Displaced or angulated fractures should be treated surgically to allow adequate apposition for formation of vascular anastomoses.

• Complications
• Osteonecrosis: Established Kienboeck disease represents the most devastating complication of lunate fractures, with advanced collapse and radiocarpal degeneration. This may require further operative intervention for pain relief, including radial shortening, radial wedge osteotomy, ulnar lengthening, or salvage procedures such as proximal row carpectomy, wrist denervation, or arthrodesis.

Triquetrum

• The triquetrum is the carpal bone that is most commonly fractured after the scaphoid.

• Most fractures of the triquetrum are avulsion injuries that may be associated with ligament damage.

• Most commonly, injury occurs with the wrist in extension and ulnar deviation, resulting in an impingement shear fracture by the ulnar styloid against the dorsal triquetrum.

• Clinical evaluation reveals tenderness to palpation on the dorsoulnar aspect of the wrist as well as painful range of wrist motion.

• Radiographic evaluation
• Transverse fractures of the body can generally be identified on the PA view.

• Dorsal triquetral fractures are not easily appreciated on AP and lateral views of the wrist owing to superimposition of the lunate. An oblique, pronated lateral view may help to visualize the dorsal triquetrum.

• Treatment
• Nondisplaced fractures of the body or dorsal chip fractures may be treated in a short arm cast or ulnar gutter splint for 6 weeks.

• Displaced fractures may be amenable to open reduction and internal fixation.

Pisiform

• Fractures of the pisiform are rare.

• The mechanism of injury is either a direct blow to the volar aspect of the wrist or a fall onto an outstretched, dorsiflexed hand.

• Clinical evaluation demonstrates tenderness on the volar ulnar aspect of the ulnar wrist with painful passive extension of the wrist as the flexor carpi ulnaris is placed under tension.

• Radiographic evaluation: Pisiform fractures are not well visualized on standard views of the wrist; special views include a lateral view of the wrist with forearm supination of 20 to 45 degrees or a carpal tunnel view (20-degree supination oblique view demonstrating an oblique projection of the wrist in radial deviation and semisupination).

• Treatment of nondisplaced or minimally displaced fractures consists of an ulnar gutter splint or short arm cast for 6 weeks. Displaced fractures may require fragment excision, either early, in the case of a severely displaced fragment, or late, in the case of a pisiform fracture that has resulted in painful nonunion.

Trapezium

• Fractures of the trapezium comprise approximately 3% to 5% of all carpal bone fractures.

• About 60% of the reported cases have an unsatisfactory outcome secondary to degenerative changes.

• Most are ridge avulsion fractures or vertical fractures of the body.

• The mechanism of injury is axial loading of the adducted thumb, driving the base of the first metacarpal onto the articular surface of the trapezium.

• Avulsion fractures may occur with forceful deviation, traction, or rotation of the thumb.

• Direct trauma to the palmar arch may result in avulsion of the trapezial ridge by the transverse carpal ligament.

• Clinical evaluation reveals tenderness to palpation of the radial wrist, accompanied by painful range of motion at the first carpometacarpal joint.

• Radiographic evaluation: Fractures are usually identifiable on standard PA and lateral views.

• Superimposition of the first metacarpal base may be eliminated by obtaining a Robert view, or a true PA view of the first carpometacarpal joint and trapezium, taken with the hand in maximum pronation.

• A carpal tunnel view may be necessary for adequate visualization of dorsal ridge fractures.

• Treatment
• Nondisplaced fractures are generally amenable to thumb spica splinting or casting to immobilize the first carpometacarpal joint for 6 weeks.

• Indications for open reduction and internal fixation include articular involvement of the carpometacarpal articulation, comminuted fractures, and displaced fractures.

• Comminuted fractures may require supplemental bone grafting.

• Complications
• Posttraumatic osteoarthritis may result in decreased or painful range of motion at the first carpometacarpal joint. Irreparable joint damage may necessitate fusion or excisional arthroplasty.

Trapezoid

• Because of the shape and position of the trapezoid, fractures are rare. An axial load transmitted through the second metacarpal may lead to dislocation, more often dorsal, with associated capsular ligament disruption.

• Direct trauma from blast or crush injuries may cause trapezoid fracture, although this is often in conjunction with other injuries.

• Clinical evaluation demonstrates tenderness proximal to the base of the second metacarpal with a variable dorsal prominence representing a dislocated trapezoid. Range of motion of the second carpometacarpal joint is painful and limited.

• Radiographic evaluation: fractures can be identified on the PA radiograph based on a loss of the normal relationship between the second metacarpal base and the trapezoid. Comparison with the contralateral, uninjured wrist may aid in the diagnosis. The trapezoid, or fracture fragments, may be superimposed over the trapezium or capitate, and the second metacarpal may be proximally displaced.

• Oblique views or CT may aid in the diagnosis if osseous details are obscured by overlap.

• Treatment
• Nondisplaced fractures may be treated with a splint or short arm cast for 6 weeks.

• Indications for open reduction and internal fixation include displaced fractures, especially those involving the carpometacarpal articulation. These may be addressed with open reduction and internal fixation with Kirschner wires with attention to restoration of articular congruity.

• Complications
• Posttraumatic osteoarthritis may result at the second carpometacarpal articulation if joint congruity is not restored.

Capitate

• This is uncommon as an isolated injury owing to its relatively protected position.

• A fracture of the capitate is more commonly associated with greater arc injury pattern (transscaphoid, transcapitate perilunate fracture-dislocation). A variation of this is the “naviculocapitate syndrome, in which the capitate and scaphoid are fractured without associated dislocation.

• The mechanism of injury is typically direct trauma or a crushing force that results in associated carpal or metacarpal fractures.

• Clinical evaluation reveals point tenderness as well as variable painful dorsiflexion of the wrist as the capitate impinges on the dorsal rim of the radius.

• Fractures of the capitate can usually be identified on standard scaphoid views, although motion studies are recommended to look for displacement.

• Diagnosis may require an MRI scan.

• Treatment: Capitate fractures require reduction to diminish the risk of osteonecrosis. If closed reduction is unattainable, open reduction and internal fixation are indicated, usually with Kirschner wires or lag screws, to restore normal anatomy.

• Complications
• Midcarpal arthritis: This is caused by capitate collapse as a result of displacement of the proximal pole.

• Osteonecrosis: This is rare but results in functional impairment; it emphasizes need for accurate diagnosis and stable reduction.

Hamate

• Hamate fractures are quite rare.

• The hamate may be fractured through its distal articular surface, through other articular surfaces, or through its hamulus, or hook.

• A distal articular fracture accompanied by fifth metacarpal subluxation may occur when axial force is transmitted down the shaft of the metacarpal, such as with a fist strike or a fall.

• Fractures of the body of the hamate generally occur with direct trauma or crush injuries to the hand.

• Fracture of the hook of the hamate is a frequent athletic injury sustained when the palm of the hand is struck by an object (e.g., baseball bat, golf club, hockey stick), and it generally occurs at the base of the hook, although avulsion fractures of the tip may occur.

• Clinical evaluation: Patients typically present with pain and tenderness over the hamate. Ulnar and mediaeuropathy can also be seen, as well as rare injuries to the ulnar artery.

• Radiographic evaluation: The diagnosis of hamate fracture can usually be made on the basis of the PA view of the wrist. Fracture of the hamate is best visualized on the carpal tunnel or a 20-degree supination oblique view (oblique projection of the wrist in radial deviation and semisupination). CT and bone scan are sometimes necessary to visualize the fracture. A hamate fracture should not be confused with an os hamulus proprium, which represents an ossification center that has failed to fuse.

• Classification of hamate fractures is descriptive.

• Treatment
• Nondisplaced hamate fractures may be treated with immobilization in a short arm splint or cast for 6 weeks.

• Displaced fractures of the body may be amenable to Kirschner wire or screw fixation. Fractures of the hook of the hamate may be treated with excision of the fragment for displaced fragments or in cases of symptomatic nonunion.

• Complications
• Symptomatic nonunion: This may be treated with excision of the nonunited fragment.

• Ulnar or mediaeuropathy: This is related to the proximity of the hamate to these nerves and may require surgical exploration and release.

• Ruptures of the flexor tendons to the small finger: They result from attritional wear at the fracture site.

PERILUNATE DISLOCATIONS AND FRACTURE-DISLOCATIONS

• The lunate, which is normally securely attached to the distal radius by ligamentous attachments, is commonly referred to as the “carpal keystone.”

• Greater arc injury: This passes through the scaphoid, capitate, and triquetrum and often results in transscaphoid or transscaphoid transcapitate perilunate fracture-dislocations (Fig. 49).

• Lesser arc injury: This follows a curved path through the radial styloid, midcarpal joint, and lunatotriquetral space and results in perilunate and lunate dislocations.

• The most common injury is transscaphoid perilunate fracture-dislocation (de Quervain injury).

• Mechanism of injury
• Perilunate injuries: Load is applied to the thenar eminence, forcing the wrist into extension.

• Injury progresses through several stages (Mayfield progression):

• It usually begins radially through the body of scaphoid (fracture) or thru scapholunate interval (dissociation).

• The scaphoid bridges the proximal and distal carpal rows.

• With dislocation between these rows, the scaphoid must either rotate or fracture.

• Force is transmitted ulnarly through the space of Poirier (between the lunate and capitate).

• Finally, force transmission disrupts the lunotriquetral articulation (Fig. 50).

• Clinical evaluation: Scapholunate or perilunate injuries typically cause tenderness just distal to Lister tubercle. Swelling is generalized about the wrist with variable dorsal prominence of the entire carpus in cases of frank perilunate dislocation.

Figure 49. Vulnerable zones of the carpus. (A) A lesser arch injury follows a curved path through the radial styloid, midcarpal joint, and the lunatotriquetral space. A greater arc injury passes through the scaphoid, capitate, and triquetrum. (B) Lesser and greater arc injuries can be considered as three stages of the perilunate fracture or ligament instabilities. (From Johnson RP. The acutely injured wrist and its residuals. Clin Orthop 1980;149:33–44.)

Figure 50. Mayfield stages of progressive perilunate instability. Stage I results in scapholunate instability. Stages II to IV result in progressively worse perilunate instability. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Radiographic evaluation: Diagnosis can often be made without accompanying radiographs, but PA and lateral views should be obtained to confirm the diagnosis and rule out associated injuries. CT, MRI, and arthrography are generally unnecessary but may be useful in further defining injury pattern.

• PA view: The dislocated lunate appears to be wedge-shaped, with an elongated volar lip.

• Loss of normal carpal greater and lesser arcs and abnormal widening of the scapholunate interval are noted.

• Look for associated fractures, such as transscaphoid injuries.

• Lateral view: The spilled teacup sign occurs with volar tilt of the lunate.

• A clenched-fist PA view obtained after closed reduction of the midcarpal joint is useful for checking residual scapholunate or lunotriquetral dissociation as well as fractures.

• Classification: A sequence of progressive perilunate instability is seen as the injury spreads:

• From the scapholunate joint (radioscapholunate ligament) midcarpal joint (radioscaphocarpal ligament) lunotriquetral joint (distal limb of radiolunotriquetral ligament) dorsal radiolunotriquetral ligament volar dislocation of the lunate.

Stage I:	Disruption of the scapholunate joint: The radioscapholunate and interosseous scapholunate ligaments are disrupted.
Stage II:	Disruption of the midcarpal (capitolunate) joint: The radioscaphocapitate ligament is disrupted.
Stage III:	Disruption of the lunotriquetral joint: The distal limb of the radiolunotriquetral ligament is disrupted.
Stage IV:	Disruption of the radiolunate joint: The dorsal radiolunotriquetral ligament is disrupted, ultimately causing volar dislocation of the lunate.

• Treatment
• Closed reduction should be performed with adequate sedation.

• Technique of closed reduction
• Longitudinal traction is applied for 5 to 10 minutes.

• For dorsal perilunate injuries, volar pressure is applied to the carpus while counterpressure is applied to the lunate.

• Palmar flexion then reduces the capitate into the concavity of the lunate.

• Early surgical reconstruction is performed if swelling allows. Immediate surgery is needed if there are signs of mediaerve compromise.

• Closed reduction and pinning
• The lunate is reduced and pinned to the radius ieutral alignment.

• The triquetrum or scaphoid can then be pinned to the lunate.

• Transscaphoid perilunate dislocation
• This requires reduction and stabilization of the fractured scaphoid.

• Most of these injuries are best treated by open volar and dorsal reduction and repair of injured structures.

• Open repair may be supplemented by pin fixation.

• Delayed reconstruction is indicated if early intervention is not feasible.

• Complications
• Mediaeuropathy: This may result from carpal tunnel compression, necessitating surgical release.

• Posttraumatic arthritis: This may result from the initial injury or secondarily from small, retained osseous fragments.

• Chronic perilunate injury: This may result from untreated or inadequately treated dislocation or fracture-dislocation resulting in chronic pain, instability, and wrist deformity, often associated with tendon rupture or increasing nerve symptoms. Repair may be possible, but a salvage procedure, such as proximal row carpectomy or radiocarpal fusion, may be necessary.

CARPAL DISLOCATIONS

• Carpal dislocations represent a continuum of perilunate dislocations, with frank lunate dislocation representing the final stage. All such injuries reflect significant ligamentous injury.
• Associated fractures are common and may represent avulsion injuries (e.g., volar or dorsal intercalated segmental instability with associated radial rim fracture).

• Mechanism of injury: A fall onto an outstretched hand represents the most common cause, although direct force can cause traumatic carpal dislocations as well.

• Clinical evaluation: Patients typically present with painful, limited wrist range of motion. Mediaeuropathy may be present. Specific tests for carpal instability include the following:

• Midcarpal stress test: Dorsal-palmar stressing of the midcarpal joint results in a pathologic clunk representing subluxation of the lunate.

• Dynamic test for midcarpal instability: Wrist extension with radioulnar deviation produces a “catchup” clunk as the proximal row snaps from flexion to extension.

• Radiographic evaluation: Most dislocations may be diagnosed on PA and lateral views of the wrist.

• CT and MRI may aid in further injury definition.

• Treatment of carpal dislocations consists of closed reduction of the midcarpal joint, which is often accomplished with traction, combined with direct manual pressure over the capitate and lunate.

• Irreducible dislocations or unstable injuries should be treated with open reduction and internal fixation utilizing a combined dorsal and volar approach. Dorsally, the osseous anatomy is restored and stabilized using Kirschner wire fixation. Volarly, the soft tissues are repaired.
• Complications
• Posttraumatic arthritis: This may result from unrecognized associated fractures or malreduction, with subsequent functional limitation and pain.

• Recurrent instability: This may result from inadequate repair of ligamentous structures on the volar aspect or insufficient fixation dorsally.

SCAPHOLUNATE DISSOCIATION

• This is the ligamentous analog of a scaphoid fracture; it represents the most common and significant ligamentous disruption of the wrist.

• The underlying pathologic process is a disruption of the radioscapholunate and the interosseous scapholunate ligaments.

• The mechanism of injury is loading of the extended carpus in ulnar deviation.

• Clinical findings include ecchymosis and tenderness on the volar wrist. The proximal pole of the scaphoid is prominent dorsally. Signs of scapholunate dissociation include a vigorous grasp that induces pain, decreasing repetitive grip strength, a positive Watson test (see earlier, under scaphoid fractures), and painful flexion-extension or ulnar-radial deviation of the wrist.

• Radiographic evaluation: PA, lateral, clenched fist PA, and radial and ulnar deviation views are obtained. Classic signs of scapholunate dissociation on the PA view include:

• The “Terry Thomas sign: widening of the scapholunate space (normal, <3 mm).

• The “cortical ring sign caused by the abnormally flexed scaphoid.

• A scapholunate angle of >70 degrees visualized on the lateral view.

• Treatment
• The scaphoid can often be reduced with an audible and palpable click, followed by immobilization for 8 weeks in a long arm thumb spica cast. Good results with anatomic reduction are reported.
• Arthroscopically assisted reduction with percutaneous pin fixation has been described with good results.

• An inability to obtain or maintain reduction is an indication for open reduction and internal fixation. This may be accomplished by a combined dorsal and volar approach with reduction and stabilization of the scapholunate joint dorsally using Kirschner wires and repair of the ligaments volarly.

• Complications
• Recurrent instability: Failure of closed or open reduction and internal fixation with ligament repair may necessitate ligament augmentation, intercarpal fusion, proximal row carpectomy, or wrist fusion. It may progress to a DISI pattern or a scaphoid-lunate advanced collapse of the wrist.

LUNOTRIQUETRAL DISSOCIATION

• These injuries involve disruption of the distal limb of the volar radiolunotriquetral ligament either as a stage III lesser arc injury of perilunate instability or as a result of a force causing excessive radial deviation and intercarpal pronation. The lunotriquetral interosseous and dorsal radiolunotriquetral ligaments are also injured.

• Clinical findings include swelling over the peritriquetral area and tenderness dorsally, typically one fingerbreadth distal to the ulnar head.

• Ballottement test (shear or shuck test): Dorsal-volar displacement of the triquetrum on the lunate results in increased excursion as compared with the normal, contralateral side, as well as painful crepitus.

• Radiographic evaluation: PA radiographs of the hand rarely reveal frank gapping of the lunotriquetral space, but a break in the normal smooth contour of the proximal carpal row can be appreciated.

• Radial deviation view: This may demonstrate the triquetrum to be dorsiflexed with the intact scapholunate complex palmar-flexed. A lateral projection may reveal a volar intercalated segmental instability pattern.

• Treatment
• Acute lunotriquetral dissociation with minimal deformity may be treated with a short arm cast or splint for 6 to 8 weeks.

• Closed reduction with pinning of the lunate to the triquetrum may be necessary to maintain reduction.

• Angular deformity or unacceptable reduction from nonoperative treatment may necessitate open reduction and internal fixation utilizing a combined dorsal and volar approach, with pinning of the triquetrum to the lunate and ligamentous repair.

• Complications
• Recurrent instability may necessitate ligament reconstruction with capsular augmentation. If recurrent instability persists, lunotriquetral fusion may be necessary, with possible concomitant ulnar shortening to tension the volar ulnocarpal ligaments.

ULNOCARPAL DISSOCIATION

• Avulsion or rupture of the TFCC from the ulnar styloid results in a loss of sling support for the ulnar wrist.

• The lunate and triquetrum away relative to the distal ulna and assume a semisupinated and palmar flexed attitude, with the distal ulna subluxed dorsally.

• Clinical evaluation reveals dorsal prominence of the distal ulna and volar displacement of the ulnar carpus.

• Radiographic evaluation: The PA view may reveal avulsion of the ulnar styloid. Dorsal displacement of the distal ulna on true lateral views suggests disruption of the TFCC in the absence of an ulnar styloid avulsion fracture.

• MRI may demonstrate a tear of the TFCC and may additionally provide evidence of chondral lesions and effusion.

• Treatment: Operative repair of the TFCC may be achieved via a dorsal approach between the fifth and sixth extensor compartments.

• Open reduction and internal fixation of large displaced ulnar styloid fragments are necessary.

• Complications
• Recurrent instability: This may occur with or without previous operative intervention and may result in pain and functional debilitation that may be progressive.

• Ulnar neuropathy: Transient sensory symptoms may result from irritation of the ulnar nerve in Guyon canal or its dorsal sensory branch. Permanent damage is rare, but persistence of symptoms beyond 12 weeks may necessitate exploration.

Hand

EPIDEMIOLOGY

• Metacarpal and phalangeal fractures are common, comprising 10% of all fractures; >50% of these are work related.

• The 1998 United States National Hospital Ambulatory Medical Care Survey found phalangeal (23%) and metacarpal (18%) fractures to be the second and third most common hand and forearm fractures following radius fractures. They constitute anywhere from 1.5% to 28% of all emergency department visits, depending on survey methods.

• Location: Border digits are most commonly involved with approximate incidence as follows:

• Distal phalanx (45%)
• Metacarpal (30%)
• Proximal phalanx (15%)
• Middle phalanx (10%)
• Male-to-female ratios run from 1.8:1 to 5.4:1, with higher ratios seen in the age groups associated with the greatest incidence (sports injuries in the early third decade and workplace injuries in the fifth decade).

ANATOMY

Metacarpals

• They are bowed, concave on palmar surface.

• They form the longitudinal and transverse arches of the hand.

• The index and long finger carpometacarpal articulation is rigid.

• The ring and small finger carpometacarpal articulation is flexible.

• Three palmar and four dorsal interosseous muscles arise from metacarpal shafts and flex the metacarpophalangeal (MCP) joints.

• These muscles create deforming forces in the case of metacarpal fractures, typically flexing the fracture (apex dorsal angulation).

Phalanges

• Proximal phalanx fractures usually angulate into extension (apex volar).

• The proximal fragment is flexed by the interossei.

• The distal fragment is extended by the central slip.

• Middle phalanx fractures are unpredictable.

• Distal phalanx fractures usually result from crush injuries and are comminuted tuft fractures.

MECHANISM OF INJURY

• A high degree of variation in mechanism of injury accounts for the broad spectrum of patterns seen in skeletal trauma sustained by the hand.

• Axial load or jamming injuries are frequently sustained during ball sports or sudden reaches made during everyday activities such as to catch a falling object. Patterns frequently resulting from this mechanism are shearing articular fractures or metaphyseal compression fractures.

• Axial loading along the upper extremity must also make one suspicious of associated injuries to the carpus, forearm, elbow, and shoulder girdle.

• Diaphyseal fractures and joint dislocations usually require a bending component in the mechanism of injury, which can occur during ball handling sports or when the hand is trapped by an object and is unable to move with the rest of the arm.

• Individual digits can easily be caught in clothing, furniture, or workplace equipment to sustain torsional mechanisms of injury, resulting in spiral fractures or more complex dislocation patterns.

• Industrial settings or other environments with heavy objects and high forces lead to crushing mechanisms that combine bending, shearing, and torsion to produce unique patterns of skeletal injury and associated soft tissue damage.

CLINICAL EVALUATION

• History: a careful history is essential as it may influence treatment. This should include the patient’s:
• Age
• Hand dominance
• Occupation
• Systemic illnesses
• Mechanism of injury: crush, direct trauma, twist, tear, laceration, etc.

• Time of injury (for open fractures)

• Exposure to contamination: barnyard, brackish water, animal/human bite

• Treatment provided: cleansing, antiseptic, bandage, tourniquet

• Financial issues: workers compensation
• Physical examination includes:
• Digital viability (capillary refill should be <2 seconds).

• Neurologic status (documented by two-point discrimination [normal is 6 mm] and individual muscle testing).

• Rotational and angulatory deformity.
• Range of motion (documented by goniometer).

• Malrotation at one bone segment is best represented by the alignment of the next more distal segment. This alignment is best demonstrated when the intervening joint is flexed to 90 degrees. Comparing nail plate alignment is an inadequate method of evaluating rotation.

RADIOGRAPHIC EVALUATION

• Posteroanterior, lateral, and oblique radiographs of the affected digit or hand should be obtained. Injured digits should be viewed individually, when possible, to minimize overlap of other digits over the area of interest.

CLASSIFICATION

Descriptive

• Open versus closed injury (see later)

• Bone involved
• Location within bone
• Fracture pattern: comminuted, transverse, spiral, vertical split

• Presence or absence of displacement
• Presence or absence of deformity (rotation and/or angulation)

• Extraarticular versus intraarticular fracture
• Stable versus unstable

Open Fractures

Swanson, Szabo, and Anderson

Type I:	Clean wound without significant contamination or delay in treatment and no systemic illness
Type II:	One or more of the following:

• Contamination with gross dirt/debris, human or animal bite, warm lake/river injury, barnyard injury

• Delay in treatment >24 hours
• Significant systemic illness, such as diabetes, hypertension, rheumatoid arthritis, hepatitis, or asthma

Rate of infection:

Type I injuries (1.4%) Type II injuries (14%)

• Neither primary internal fixatioor immediate wound closure is associated with increased risk of infection in type I injuries. Primary internal fixation is not associated with increased risk of infection in type II injuries.

• Primary wound closure is appropriate for type I injuries, with delayed closure appropriate for type II injuries.

OTA Classification of Metacarpal Fractures

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

OTA Classification of Phalangeal Fractures

See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.

TREATMENT: GENERAL PRINCIPLES

• Fight-bites injuries: Any short, curved laceration overlying a joint in the hand, particularly the metacarpal-phalangeal joint, must be suspected of having been caused by a tooth. These injuries must be assumed to be contaminated with oral flora and should be addressed with broad-spectrum antibiotics (need anaerobic coverage).

• Animal bites: Antibiotic coverage is needed for Pasterella and Eikenella.

• There are essentially five major treatment alternatives:

• Immediate motion.
• Temporary splinting.
• Closed reduction and internal fixation (CRIF).

• Open reduction and internal fixation (ORIF).

• Immediate reconstruction.
• The general advantages of entirely nonoperative treatment are lower cost and avoidance of the risks and complications associated with surgery and anesthesia. The disadvantage is that stability is less assured than with some form of operative fixation.

• CRIF is expected to prevent overt deformity but not to achieve an anatomically perfect reduction. Pin tract infection is the prime complication that should be mentioned to patients in association with CRIF.

• Open treatments are considered to add the morbidity of surgical tissue trauma, titrated against the presumed advantages of the most anatomic and stable reduction.

• Critical elements in selecting betweeonoperative and operative treatment are the assessments of rotational malalignment and stability.

• If carefully sought, rotational discrepancy is relatively easy to determine.

• Defining stability is somewhat more difficult. Some authors have used what seems to be the very reasonable criterion of maintenance of fracture reduction when the adjacent joints are taken through at least 30% of their normal motion.

• Contraction of soft tissues begins approximately 72 hours following injury. Motion should be instituted by this time for all joints stable enough to tolerate rehabilitation.

• General indications for surgery include:

• Open fractures.
• Unstable fractures.
• Irreducible fractures.
• Multiple fractures.
• Fractures with bone loss.
• Fractures with tendon lacerations.
• Treatment of stable fractures:
• Buddy taping or splinting is performed, with repeat radiographs in 1 week.

• Initially unstable fractures that are reduced and then converted to a stable position: External immobilization (cast, cast with outrigger splint, gutter splint, or anterior-posterior splints) or percutaneous pinning prevents displacement and permits earlier mobilization.

• Treatment of unstable fractures:
• Unstable fractures that are irreducible by closed means or exhibit continued instability despite closed treatment require closed reduction or ORIF, including Kirschner wire fixation, interosseous wiring, tension band technique, interfragmentary screws alone, or plates and screws.

• Fractures with segmental bone loss
• These continue to be problematic. The primary treatment should be directed to the soft tissues, maintaining length with Kirschner wires or external fixation.

MANAGEMENT OF SPECIFIC FRACTURE PATTERNS

 

Metacarpals

Metacarpal Head

• Fractures include:
• Epiphyseal fractures.
• Collateral ligament avulsion fractures.
• Oblique, vertical, and horizontal head fractures.

• Comminuted fractures.
• Boxer’s fractures with joint extension.

• Fractures associated with bone loss.

• Most require anatomic reduction (if possible) to reestablish joint congruity and to minimize posttraumatic arthrosis.

• Stable reductions of fractures may be splinted in the protected positions consisting of metacarpal-phalangeal flexion >70 degrees to minimize joint stiffness (Fig. 51).

• Percutaneous pinning may be necessary to maintain reduction; severe comminution may necessitate the use of minicondylar plate fixation or external fixation with distraction.

• Early range of motion is essential.

Metacarpal Neck

• Fractures result from direct trauma with volar comminution and dorsal apex angulation. Most of these fractures can often be reduced closed, but maintenance of reduction may be difficult (Fig. 52).

Figure 51. Left: The collateral ligaments of the metacarpophalangeal joints are relaxed in extension, permitting lateral motion, but they become taut when the joint is fully flexed. This occurs because of the unique shape of the metacarpal head, which acts as a cam. Right: The distance from the pivot point of the metacarpal to the phalanx in extension is less than the distance in flexion, so the collateral ligament is tight when the joint is flexed. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:659.)

Figure 52. Reduction of metacarpal fractures can be accomplished by using the digit to control the distal fragment, but the proximal interphalangeal joint should be extended rather than flexed. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• The degree of acceptable deformity varies according to the metacarpal injured:

• Less than 10-degree angulation for the second and third metacarpals.

• Less than 30- to 40-degree angulation for the fourth and fifth metacarpals.

• Unstable fractures require operative intervention with either percutaneous pins (may be intramedullary or transverse into the adjacent metacarpal) or plate fixation.

Metacarpal Shaft

• Nondisplaced or minimally displaced fractures can be reduced and splinted in the protected position.

• Operative indications include rotational deformity, dorsal angulation >10 degrees for second and third metacarpals, and >40 degrees for fourth and fifth metacarpals.

• Ten degrees of malrotation (which risks as much as 2 cm of overlap at the digital tip) should represent the upper tolerable limit.

• Operative fixation may be achieved with either closed reduction and percutaneous pinning (intramedullary or transverse into the adjacent metacarpal) or open reduction and plate fixation.

Metacarpal Base

FINGERS

• Fractures of the base of the second, third, and fourth fingers are generally minimally displaced and are associated with ligament avulsion. Treatment is by splinting and early motion in most cases.

• The reverse Bennett fracture is a fracture-dislocation of the base of the fifth metacarpal/hamate.

• The metacarpal is displaced proximally by the pull of the extensor carpi ulnaris.

• The degree of displacement is best ascertained via radiograph with the hand pronated 30 degrees from a fully supinated (anteroposterior) position.

• This fracture often requires surgical intervention with ORIF.

THUMB

• Extraarticular fractures: These are usually transverse or oblique. Most can be held by closed reduction and casting, but some unstable fractures require closed reduction and percutaneous pinning. The basal joint of the thumb is quite forgiving, and an anatomic reduction of an angulated shaft fracture is not essential.

• Intraarticular fractures (Figs. 53 and 54):

Figure 53. The most recognized patterns of thumb metacarpal base intraarticular fractures are (A) the partial articular Bennett fracture and (B) the complete articular Rolando fracture. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Figure 54. Displacement of Bennett fractures is driven primarily by the abductor pollicis longus and the adductor pollicis resulting in flexion, supination, and proximal migration. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Treatment: Both type I and II fractures of the base of the first metacarpal may be treated with closed reduction and percutaneous pins, or ORIF.

Proximal and Middle Phalanges

Intraarticular Fractures

• Condylar fractures: single, bicondylar, osteochondral
• They require anatomic reduction; ORIF should be performed for >l mm displacement.

• Comminuted intraarticular phalangeal fractures should be treated with reconstruction of the articular surface, if possible. Severely comminuted fractures that are deemed nonreconstructible may be treated closed with early protected mobilization.

Fracture-Dislocations

• Volar lip fracture of middle phalangeal base (dorsal fracture-dislocation)

• Treatment is controversial and depends on percentage of articular surface fractured:

• Hyperextension injuries without a history of dislocation with <30% to 35% articular involvement: Buddy tape to the adjacent digit.

• More than 30% to 35% articular involvement: Some recommend ORIF with reconstruction of the articular surface or a volar plate arthroplasty if the fracture is comminuted; others recommend nonoperative treatment with a dorsal extension block splint if the joint is not subluxed.

• Dorsal lip fracture of middle phalangeal base (volar fracture-dislocation)

• Usually this is the result of a central slip avulsion.

• Fractures with <1 mm of displacement: may be treated closed with splinting, as in a boutonniere injury.

• Fractures with >l mm of displacement or volar subluxation of the proximal interphalangeal (PIP) joint: Operative stabilization of the fracture is indicated.

Extraarticular Fractures

• Fractures at the base of the middle phalanx tend to angulate apex dorsal, whereas fractures at the neck angulate the apex volarly owing to the pull of the sublimis tendon (Fig. 55).

Closed reduction should be attempted initially with finger-trap traction followed by splinting.

Figure 55. Top: A lateral view, showing the prolonged insertion of the superficialis tendon into the middle phalanx. Center: A fracture through the neck of the middle phalanx is likely to have a volar angulation because the proximal fragment is flexed by the strong pull of the superficialis. Bottom: A fracture through the base of the middle phalanx is more likely to have a dorsal angulation because of the extension force of the central slip on the proximal fragment and a flexion force on the distal fragment by the superficialis. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:627.)

Figure 56. Fracture patterns seen in the distal phalanx include (A) longitudinal shaft, (B) transverse shaft, (C) tuft, (D) dorsal base avulsion, (E) dorsal base shear, (F) volar base, and (G) complete articular. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Fractures in which a stable closed reduction cannot be achieved or maintained should be addressed with closed reduction and percutaneous pinning or ORIF with minifragment implants.

Distal Phalanx (Fig. 56)

Intraarticular Fractures

• Dorsal lip

• A mallet finger may result from a fracture of the dorsal lip with disruption of the extensor tendon. Alternatively, a mallet finger may result from a purely tendinous disruption and may therefore not be radiographically apparent.

• Treatment remains somewhat controversial.
• Some recommend nonoperative treatment for all mallet fingers with full-time extension splinting for 6 to 8 weeks, including those with a significant articular fracture and joint subluxation.

• Others recommend CRIF for displaced dorsal base fractures comprising >25% of the articular surface. Various closed pinning techniques are possible, but the mainstay is extension block pinning.

• Volar Lip
• This is associated with flexor digitorum profundus rupture (jersey finger: seen in football and rugby players, most commonly involving the ring finger).

• Treatment is primary repair, especially with large, displaced bony fragments.

Extraarticular Fractures

• These are transverse, longitudinal, and comminuted (nail matrix injury is very common).

• Treatment consists of closed reduction and splinting.

• The splint should leave the PIP joint free but usually needs to cross the distal interphalangeal (DIP) joint to provide adequate stability. Aluminum and foam splints or plaster of Paris are common materials chosen.

• CRIF is indicated for shaft fractures with wide displacement because of the risk for nonunion.

Nailbed Injuries (Fig. 57)

• These are frequently overlooked or neglected in the presence of an obvious fracture, but failure to address such injuries may result in growth disturbances of the nail.

Figure 57. An intimate relationship exists between the three layers of the dorsal cortex of the distal phalanx, the nail matrix (both germinal and sterile), and the nail plate. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Subungual hematomas should be evacuated with cautery or a hot paper clip.

• If the nailplate has been avulsed at its base, it should be removed, cleansed with povidone-iodine, and retained for use as a biologic dressing.

• Nailbed disruptions should be carefully sutured with 7-0 chromic catgut under magnification.

• Polypropylene artificial nail dressings may be used if the original nailplate is not usable as a biologic dressing.

Carpometacarpal (CMC) Joint Dislocations and Fracture-Dislocations

• Dislocations at the finger CMC joints are usually high-energy injuries with involvement of associated structures, including neurovascular injury.

• Particular care must be given to the examination of ulnar nerve function, especially motor, owing to its close proximity to the fifth CMC joint.

• Overlap on the lateral x-ray obscures accurate depiction of the injury pattern, and most authors recommend at least one variant of an oblique view.

• When fracture-dislocations include the dorsal cortex of the hamate, computed tomography may be necessary to evaluate the pathoanatomy fully.

• Most thumb CMC joint injuries are fracture-dislocations rather than pure dislocations. Terms associated with these fracture-dislocations are Bennett (partial articular), and Rolando (complete articular) fractures.

• Dorsal finger CMC fracture-dislocations cannot usually be held effectively with external means alone. For those injuries that can be accurately reduced, CRIF is the treatment of choice.

Metacarpophalangeal (MCP) Joint Dislocations (Fig. 58)

• Dorsal dislocations are the most common.

• Simple dislocations are reducible and present with a hyperextension posture.

• They are really subluxations, because some contact usually remains between the base of proximal phalanx and the metacarpal head.

• Reduction can be achieved with simple flexion of the joint; excessive longitudinal traction on the finger should be avoided. Wrist flexion to relax the flexor tendons may assist reduction.

• The other variety of MCP joint dislocation is a complex dislocation, which is by definition irreducible, most often the result of volar plate interposition.

• Complex dislocations occur most frequently in the index finger.

• A pathognomonic x-ray sign of complex dislocation is the appearance of a sesamoid in the joint space.

• Most dorsal dislocations are stable following reduction and do not need surgical repair of the ligaments or volar plate.

• Volar dislocations are rare but are particularly unstable.

• Volar dislocations are at risk for late instability and should have repair of the ligaments.

• Open dislocations may be either reducible or irreducible.

Thumb Metacarpophalangeal (MCP) Joint Dislocations

Figure 58. Simple metacarpophalangeal joint dislocations are spontaneously reducible and usually present in an extended posture with the articular surface of P1 sitting on the dorsum of the metacarpal head. Complex dislocations have bayonet apposition with volar plate interposition that prevents reduction. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• The thumb MCP joint, in addition to its primary plane of flexion and extension, allows abduction-adduction and a slight amount of rotation (pronation with flexion).

• With a one-sided collateral ligament injury, the phalanx tends to subluxate volarly in a rotatory fashion, pivoting around the opposite intact collateral ligament.

• The ulnar collateral ligament may have a two-level injury consisting of a fracture of the ulnar base of proximal phalanx with the ligament also ruptured off the fracture fragment.

• Of particular importance is the proximal edge of the adductor aponeurosis that forms the anatomic basis of the Stener lesion. The torn ulna collateral ligament stump comes to lie dorsal to the aponeurosis and is thus prevented from healing to its anatomic insertion on the volar, ulnar base of the proximal phalanx (Fig. 59).

• The true incidence of the Stener lesion remains unknown, because of widely disparate reports.

• Nonoperative management is the mainstay of treatment for thumb MCP joint injuries.

• Surgical management of thumb MCP joint injuries is largely limited to ulna collateral ligament disruptions with a Stener lesion and volar or irreducible MCP dislocations.

 

Proximal Interphalangeal (PIP) Joint Dislocations

Figure 59. The Stener lesion: The adductor aponeurosis proximal edge functions as a shelf that blocks the distal phalangeal insertion of the ruptured ulnar collateral ligament of the thumb metacarpophalangeal joint from returning to its natural location for healing after it comes to lie on top of the aponeurosis. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

• Dislocations of the PIP joint have a high rate of missed diagnoses that are passed off as sprains.

• Although large numbers of incomplete injuries occur (especially in ball-handling sports), complete disruptions of the collateral ligaments and the volar plate are also frequent (50% occur in the long finger followed in frequency by the ring finger).

• Congruence on the lateral radiograph is the key to detecting residual subluxation.

• Residual instability is quite rare in pure dislocations, as opposed to fracture-dislocations, in which it is the primary concern.

• Recognized patterns of dislocation other than complete collateral ligament injury are dorsal dislocation, pure volar dislocation, and rotatory volar dislocation.

• Dorsal dislocations involve volar plate injury (usually distally, with or without a small flake of bone).

• For pure volar dislocations, the pathologic findings are consistently damage to the volar plate, one collateral ligament, and the central slip.

• Volar dislocation occurs as the head of proximal phalanx passes between the central slip and the lateral bands, which can form a noose effect and prevent reduction.

• In pure dislocations, stiffness is the primary concern. Stiffness can occur following any injury pattern and responds best at the late stage to complete collateral ligament excision.

• Chronic missed dislocations require open reduction with a predictable amount of subsequent stiffness.

• Treatment
• Once reduced, rotatory volar dislocations, isolated collateral ligament ruptures, and dorsal dislocations congruent in full extension on the lateral radiograph can all begin immediate active range of motion with adjacent digit strapping.

• Dorsal dislocations that are subluxated on the extension lateral radiograph require a few weeks of extension block splinting.

• Volar dislocations with central slip disruptions require 4 to 6 weeks of PIP extension splinting, followed by nighttime static extension splinting for 2 additional weeks. The DIP joint should be unsplinted and actively flexed throughout the entire recovery period.

• Open dorsal dislocations usually have a transverse rent in the skin at the flexion crease. Debridement of this wound should precede reduction of the dislocation.

Distal Interphalangeal (DIP) and Thumb Interphalangeal (IP) Joint Dislocations

• Dislocations at the DIP/IP joint are ofteot diagnosed initially and present late.

• Injuries are considered chronic after 3 weeks.

• Pure dislocations without tendon rupture are rare, usually result from ball-catching sports, are primarily dorsal in direction, and may occur in association with PIP joint dislocations.

• Transverse open wounds in the volar skin crease are frequent.

• Injury to a single collateral ligament or to the volar plate alone at the DIP joint is rare.

Nonoperative Treatment

• Reduced dislocations that are stable may begin immediate active range of motion.

• The rare unstable dorsal dislocation should be immobilized in 20 degrees of flexion for up to 3 weeks before instituting active range of motion.

• The duration of the immobilization should be in direct proportion to the surgeon’s assessment of joint stability following reduction.

• Complete collateral ligament injuries should be protected from lateral stress for at least 4 weeks.

• Should pin stabilization prove necessary because of recurrent instability, a single longitudinal Kirschner wire is usually sufficient.

Operative Treatment

• Delayed presentation (>3 weeks) of a subluxed joint may require open reduction to resect scar tissue and to allow tension-free reduction.

• Open dislocations require thorough debridement to prevent infection.

• The need for fixation with a Kirschner wire should be based on the assessment of stability, and it is not necessarily required for all open dislocations.

• The duration of pinning should not be >4 weeks, and the wire may be left through the skin for easy removal.

COMPLICATIONS

• Malunion: Angulation can disturb intrinsic balance and also can result in prominence of metacarpal heads in the palm with pain on gripping. Rotational or angulatory deformities, especially of the second and third metacarpals, may result in functional and cosmetic disturbances, emphasizing the need to maintain as near anatomic relationships as possible.

• Nonunion: This is uncommon, but it may occur with extensive soft tissue injury and bone loss, as well as with open fractures with gross contamination and infection. It may necessitate debridement, bone grafting, or flap coverage.
• Infection: Grossly contaminated wounds require meticulous debridement and appropriate antibiotics depending on the injury setting (e.g., barnyard contamination, brackish water, bite wounds), local wound care with debridement as necessary, and possible delayed closure.

• Metacarpal-phalangeal joint extension contracture: This may result if splinting is not in the protected position (i.e., MCP joints at >70 degree) owing to soft tissue contracture.

• Loss of motion: This is secondary to tendon adherence, especially at the level of the PIP joint.

• Posttraumatic osteoarthritis: This may result from a failure to restore articular congruity.