Transcript PowerPoint 簡報 - National Cheng Kung University

Shoulder Trauma: Bone
Department of Orthopaedics, CKUH
Sen-Jen Lee
Reference: Orthopaedic Knowledge Update 6
Proximal Humeral Fractures
4% to 5% of all fractures
 85% of proximal humeral fractures are
minimally displaced
 Result from falls and involve osteoporotic
bone
 The humeral neck is the weakest region of
the proximal humerus
 Blood supply

 Anterior humeral circumflex artery
Proximal Humeral Fracture
Classification of Proximal Humeral
Fractures: 4-part System of Neer
Humeral head, greater tuberosity, lesser
tuberosity, and humeral shaft
 Determination of displacement >1 cm or
angulation > 45°
 Radiographic imaging, the trauma series:
scapular anteroposterior (AP), lateral, and
axillary radiographs

The Treatment of Proximal
Humeral Fractures
Based on: patient age, bone quality, medical
comorbidities, other concurrent injuries, and
fracture type
 Plate and screw fixation and ender nails with
figure-of-8 tension band were the strongest
constructs
 Tension band with nonabsorbable suture or
wire were the weakest fixation

The Treatment of Proximal
Humeral Fractures

For minimally or nondisplaced fractures
 Nonsurgical treatment
 Early passive motion within 14 days is
recommended for stable fractures.
 Active range of motion is started at 4 to 6 weeks
when healing is evident
 77% resulted in good or excellent results
Two-part Fractures of the
Surgical Neck

Mode of treatment depends on the stability of
the fracture.
 CR
 CR + percutaneous pins
 OR + IF
•

Ender nails with figure-of-8 tension banding or plate and
screw
Surgical reconstruction of nonunions of the
surgical neck remains challenging
Two-part Fractures of the
Greater tuberosity

Commonly occur
 In conjunction with a glenohumeral dislocation.
 Rule out an associated surgical neck fracture
before attempting reduction

ORIF
 Superior or posterior displacement > 5 to 10 mm
 Fixation of the tuberosity fragment with repair of
the rotator cuff tear
•
•
•
Intraosseous sutures incorporating the cuff insertion
Screw fixation
acromioplasty
Two-part Fractures of the Lesser
tuberosity

Rare and can be associated with posterior
shoulder dislocations.
Treatment of 3- and 4-part
Fractures of Proximal humerus
Controversial
 Anatomical reduction > residual displacement.
 Techniques:

 Ender nails with figure-of-8 tension band
 percutaneous reduction and screw fixation

Four-part fractures usually are treated with
humeral head replacement.
 ORIF: osteonecrosis --9% to 11%
 Humeral head replacement
 73% of patients had difficulty with some functional
task
Fractures of the Clavicle
4% to 15% of all fractures and 35% of
fractures about the shoulder
 85%: middle third of the clavicle
 Associated injuries occur in less than 3%
 Direct trauma > indirect mechanism( fall onto
the outstretched hand)

Fractures of the M/3 Clavicle
Sternocleidomastoid and trapezius muscles
the weight of the arm and pectoralis major
 Nonsurgical treatment

 Figure-of-8 bandage or sling for 6 weeks
 Shortening and a residual painless deformity

Indications for surgical treatment
 Open fractures
 Neurovascular injury/compromise
 Displaced fractures with impending skin compromise
Fractures of the L/3 Clavicle
Coracoclavicular (C-C) ligaments
 Type I: minimally displaced

 Interligamentous fractures between the conoid
and trapezoid
 Between the coracoclavicular and coracoacromial
ligaments.

Type II: displaced
 Lateral to the coracoclavicular ligaments with C-C
ligments rupture

Type III fractures involve the articular surface
of the lateral clavicle with no ligamentous
injury
Treatment of L/3 clavicular
fracture
Type I fractures are stable and treated in the
same manner as middle third fractures
 Treatment for the unstable type II fractures
remains controversial.

 ORIF for displacement

Type III fractures can be adequately managed
nonsurgically
 Distal clavicle resection is the procedure of choice if
symptomatic degenerative disease occurs.
Complications After clavicular
Fractures

The incidence of nonunion
 0.9% to 4.0%.
Acute laceration of the subclavian vessels or
brachial plexus injury.
 Malunion is common and rarely symptomatic
but can cause an unacceptable prominence.
Surgical intervention to improve cosmesis
may result in an ugly scar or a painful
nonunion.

Fractures of the Scapula
0.5% to 1% of all fractures and 3% to 5% of
shoulder fracture
 High-energy trauma

 Associated injuries: severe and life-threatening
 Ipsilateral rib fracture with
•
•
•
•
•
Hemopneumothorax (27% to 54%)
Clavicular fracture (17% to 38%)
Closed head injury (11% to 57%)
Injury to the face and skull (10% to 24%)
Brachial plexus disruption (3% to 8%)
Fractures of the Scapula
True scapular AP and lateral views and an
axillary view (trauma series)
 West point axillary view
 Stryker notch view
 CT scan

Classification of Scapular
Fractures

Fractures of the body and spine (50%)
 Short-term immobilization in a sling and swathe
bandage

Scapular neck (25%)
 ORIF: if the glenoid fragment is displaced > 1 cm or
angulated > / = 40°

Acromion (7%)
 ORIF: encroach on the subacromial space and
interfere with rotator cuff function

coracoid process (3%) fractures.
Glenoid Fracture (Ideberge Classifi.)
Intra-articular glenoid Fractures

Type I fractures involve the glenoid rim.
 ORIF: 25% of the anterior glenoid or 33% of the
posterior glenoid with fracture displacement > 10
mm

Types II through VI
 ORIF:
•
•
•
Subluxation of the humeral head with a major fragment
> / = 5 mm intra-articular step-off
Severe separation between the glenoid fragments
Shoulder Girdle Unstable:
Complexity of Scapular Fractures

Superior shoulder suspensory complex
(SSSC):
 Glenoid process, coracoid process,
coracoclavicular ligaments, distal clavicle,
acromioclavicular joint, and acromial process
 ORIF is indicated for double disruption
 Often surgical stabilization at 1 site

“Floating shoulder”: M/3 clavicle and glenoid
neck
 Treated by surgical stabilization of the clavicle or
acromioclavicular joint
Shoulder Girdle Unstable:
Complexity of Scapular Fractures
Scapulothoracic Dissociation
A rare, often fatal, closed injury manifested by
lateral displacement of the scapula with
associated neurovascular injury and either
acromioclavicular or sternoclavicular separation
or clavicular fracture
 A severe direct force over the shoulder
accompanied by traction applied to the upper
extremity is the mechanism of injury
 As a "closed, traumatic forequarter
amputation."

Humeral Shaft Fractures
3% of all fractures
 Direct load :

 Short / long oblique fracture ± butterfly fragment

Indirect torque
 A spiral fracture

The neurovascular status of the limb must be
assessed
Nonsurgical Treatment of Humeral
Shaft Fractures

CR and immobilization with splint or hanging arm
cast followed by a functional brace at 1 to 2 weeks
 20° of anterior or posterior angulation,
 30° of varus or valgus angulation, and
 3 cm of shortening

Contraindications to use of the functional brace
 Massive soft-tissue or bone loss
 An unreliable or uncooperative patient
 An inability to obtain or maintain acceptable fracture
alignment

Range of motion (ROM) exercises
Surgical Treatment of Humeral
Shaft Fractures

Indications
Open fracture, except low-energy handgun wound
Associated vascular injury
Floating elbow
Segmental fracture
Pathologic fracture
Bilateral humeral fractures
Humeral fracture in polytrauma patient
Neurologic loss after lacerating injury
Neurologic loss during closed fracture alignment inability to
maintain acceptable alignment
 Displaced intra-articular fracture extension









Surgical Treatment of Humeral
Shaft Fractures

Surgical fixation using plates and screws
 Dynamic compression plate
 Reconstruction plates, T plates
 The surgeon should obtain 5 to 6 cortices of fixation both
proximal and distal to the fracture

Intramedullary fixation
 Flexible IM devices: ender pins, and rush rods
 Locked IM nails

Results and outcomes
 96% united with an average time to union of 9.5 weeks for
closed fractures and 13.6 weeks for open fractures
Results and Outcomes

CR & immobilization with functional brace: 96% united
 Varus deformity: average, 9°
 External rotation: lost between 5° and 45°

ORIF with plates and screws: 87% (102 p’ts)
 5 early failures of internal fixation, 2 nonunions, and 4
postoperative infections

ORIF with IM flexible rods or nails: 94% (58 p’ts)
 Antegrade nailing: excellent results
 Retrograde nailing: poor results

ORIF with an interlocked IM nail: 100% (51 p’ts)
 3 transient brachial plexus neurapraxias, 2 infections, 3 cases
of nail impingement, and 2 intraoperative fractures
Complications of Humeral Shaft
Fractures

Radial nerve injury: up to 18%
 Most commonly associated with M/3 fracture
 Neurapraxia or axonotmesis; 90% will resolve in 3 to 4
months
Vascular injury
 Nonunion: 7%
 Pathologic fractures

 Interlocked nail is the implant of choice for these
fractures