Orthopaedic Trauma Surgery: Volume 1: Upper Extremity Fractures and Dislocations 9811602077, 9789811602078

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Peifu Tang Hua Chen Editors

Orthopaedic Trauma Surgery Volume 1: Upper Extremity Fractures and Dislocations

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Orthopaedic Trauma Surgery

Peifu Tang • Hua Chen Editors

Orthopaedic Trauma Surgery Volume 1: Upper Extremity Fractures and Dislocations

Editors Peifu Tang Department of Orthopaedics Chinese PLA General Hospital Beijing, China

Hua Chen Department of Orthopaedics Chinese PLA General Hospital Beijing, China

ISBN 978-981-16-0207-8    ISBN 978-981-16-0208-5 (eBook) https://doi.org/10.1007/978-981-16-0208-5 Jointly published with Military Science Publishing House The print edition is not for sale in China (Mainland). Customers from China (Mainland) please order the print book from: Military Science Publishing House. © Military Science Publishing House 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Foreword

In the last 50 years, the methodology of treating fractures has undergone a series of changes. The Association for the Study of Internal Fixation (AO), shortly after its establishment in 1980, proposed the treatment principle emphasizing mechanical stability and focusing on anatomical reduction, rigid internal fixation, surrounding soft tissue protection, and early functional exercise. Gradually, this concept evolved into one emphasizing a biological internal fixation that better protects the blood supply of bone and soft tissues at the fracture site. The change has prompted the invention of new types of implants, including locking compression plates and interlocking intramedullary nails, and the development of new technologies, including minimally invasive plate osteosynthesis. These advances, in combination with high-quality intraoperative imaging technologies, such as X-ray and CT, have raised fracture care to a new level. The Chinese PLA General Hospital is a top-tier comprehensive hospital. Its Department of Orthopaedics has been established in 1953. In 1977, the Orthopaedic Trauma Center was formed. It has obtained prominent medical and scientific achievements in the field of orthopaedic trauma treatment. Great thanks to the contributions of our respected seniors, such as Prof. Shibi Lu, Prof. Shengxiu Zhu, Prof. Boxun Zhang, and Prof. Yan Wang. Prof. Peifu Tang, as the editor-in-chief of this book, chairman of the department of orthopaedic surgery, director of the Orthopaedic Trauma Group of the Orthopaedics Division of the Chinese Medical Association, has been a good friend of mine for many years. Under his leadership, the Department of Orthopaedic Trauma of the Chinese PLA General Hospital has made brilliant achievements in clinical and scientific research. I am delighted to see that the books have summarized years of experience at the 301 Orthopaedic Hospital of the Chinese PLA General Hospital in fracture care in a book, which will surely benefit the development of orthopaedic trauma care in China. The following distinguishing features of this book stand out to me. First, this book is a valuable guide for clinicians. By introducing the conceptual evolution of internal fracture fixation approaches in recent years, the book increases the awareness and willingness of readers to utilize new technologies. Considering that orthopaedic trauma medicine covers a wide range of injuries with diverse mechanisms and complex conditions, the book emphasizes the importance of treatment timing and individualized optimal treatment strategies in clinical decision-making and presents practicable approaches for reference. Second, the book has a well-organized, easy-to-read structure with concise, bulleted text, full-colour illustrations, and intraoperative photographs. Each chapter follows a similar format, starting with applied anatomy and then combining it with the biomechanics and functional characteristics of the fractured body part to describe the anatomical structure and clinical issues such as injury mechanisms, treatments, and healing. This unique format is an attractive feature of the book. In addition, the book maintains a focus on clear, step-by-step depictions and descriptions of surgical procedures for each surgical technique, consistent with the working habits of clinicians. Another feature of the book is the combination of illustrations/photographs and text. On many occasions, intraoperative photographs, schematic diagram(s), and intraoperative X-ray or CT images are jointly used. The schematic diagrams help readers understand the mechanisms underlying the surgical approach and fracture reduction and v

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Foreword

­ xation, the intraoperative photographs supply readers with an intuitive visual impression of fi the intraoperative scene, and the intraoperative radiographs and CT images offer a reference for reduction and fixation. Third, this book provides tips and cautions based on the experience obtained over the years by the Department of Orthopaedic Trauma of the Chinese PLA General Hospital. In the sections introducing the surgical procedures in particular, the experience and lessons, which have not been easy to explain clearly in previous books, are unreservedly presented in detail through illustrations and text, which offers a surgeon’s-eye view of the relevant scenarios and helps readers grasp the “gold content” of the book. I have known Professor Peifu Tang for more than 15 years. He is a rising star in the young generation of orthopaedic traumatologists in China. With his intelligence and diligence, he has become a good model for the young generation of orthopaedic trauma surgeons. Hard work will certainly yield fruitful results. I sincerely applaud the publication of this book and hope that Prof. Peifu Tang will continue to publish more work in orthopaedic trauma. The Third Hospital of Hebei Medical University Shijiazhuang, Hebei, China

Ying-ze Zhang

Preface

In recent years, with the economic growth and subsequent rapid development of construction and transportation industry, the incidence of orthopaedic trauma has shown a prominent increasing trend. Moreover, with the advancement of medicine, the expectations of patients regarding treatment outcomes have also increased. Surgery is an important treatment method for orthopaedic trauma, which is attracting an increasing amount of attention. In response to these trends, the Department of Orthopaedics of the Chinese PLA General Hospital was established in 1953, upgraded to a Grade one Orthopaedic Trauma Center in 1977. The Department has been developed along the path initiated by a group of well-known researchers, including Prof. Jingyun Chen, Prof. Zhikang Wu, Academician Shibi Lu, Prof. Shengxiu Zhu, Prof. Boxun Zhang, Prof. Jifang Wang, and Prof. Yan Wang. They emphasize clinical and scientific research and has earned five first-class and two second-class awards of the National Science and Technology Progress Award. This book, Orthopaedic Trauma Surgery, is a summary of our valuable experience in fracture treatment gained over the previous 60 years. We systematically searched for relevant information in China and other countries and compiled case reports and imaging data from the Department of Orthopaedics of the PLA General Hospital accumulated over the years, writing this book, which has three volumes and 29 chapters that, respectively, introduce upper extremity fractures and dislocations, lower extremity fractures and dislocations, axial skeleton fractures, and nonunion. The book adopts the principle of guiding surgery by anatomy, fixation by biomechanics, and clinical procedures by functional recovery. In each chapter, the applied anatomy of the fracture site is first introduced. This section confers prominence to the relationship between the anatomical structure and surgery and emphasizes the structure that must be protected and repaired during surgery. In addition, the biomechanical characteristics of the fracture site are described, so that the appropriate fixation method can be selected according to the characteristics of the mechanical environment. In most chapters on periarticular fractures, the book also describes in detail how the joints fulfil their function, which is often the core of clinical decision-­making, with the hope that the reader can understand the how and the why. The book adopts the outline-style format instead of the traditional paragraph-by-paragraph discussion to supply readers with the extracted essence in a more succinct manner, which improves the logical flow and concision and thereby improves the readability of the book. In addition, using more than 3,000 illustrations and photos, many of which were obtained from our clinical practice, the book discusses injury mechanisms and the classification and assessment of extremity and axial skeleton fractures, with a focus on typical and new surgical methods developed in recent years. These illustrations and photos provide the reader with a good reference for learning surgical techniques and skills. Hopefully, this design will make the book useful for orthopaedic surgeons at all levels in China. Many professors and associate professors with rich clinical experience in the Department of Orthopaedic Trauma of the PLA General Hospital have contributed to this book. We would like to thank Dr. Zhe Zhao for his painstaking efforts in the preparation of this book. He has contributed a tremendous amount of work in the structural design, content compilation, case selection, and figure design. Thanks are extended to Dr. Hua Chen for his work in the structural vii

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Preface

design of this book, which laid the foundation for this book. We also thank Professor Boxun Zhang and Professor Yutian Liang for their meticulous review of the manuscript. During the preparation of this book, we have done our best to keep abreast of the latest surgical advances in fracture treatment and striven to deliver accurate and informative content. However, due to the rapid development of new concepts and instruments for the treatment of orthopaedic trauma, time and knowledge source limitations, inevitably there might be deficiencies in this book, and we welcome the reader to point them out and help us to improve the content of the book. Beijing, China

Peifu Tang

Contents

1 F  racture of the Scapula �������������������������������������������������������������������������������������������    1 Hua Chen, Zhe Zhao, and Lin Qi 2 F  racture of the Clavicle �������������������������������������������������������������������������������������������   25 Hua Chen, Zhe Zhao, and Zuhao Chang 3 P  roximal Humerus Fracture�����������������������������������������������������������������������������������   49 Hua Chen, Zhe Zhao, and Zhengguo Zhu 4 F  racture of the Humeral Shaft �������������������������������������������������������������������������������   95 Hua Chen, Zhe Zhao, and Gaoxiang Xu 5 F  racture of the Distal Humerus�������������������������������������������������������������������������������  127 Hua Chen, Zhe Zhao, and Bin Shi 6 F  racture of the Proximal Ulna���������������������������������������������������������������������������������  161 Hua Chen, Zhe Zhao, and Wei Zhang 7 F  racture of the Radial Head and Terrible Triad Injury of the Elbow�����������������  191 Hua Chen, Zhe Zhao, and Jiantao Li 8 F  ractures of the Ulnar and Radial Shaft ���������������������������������������������������������������  221 Hua Chen, Zhe Zhao, and Ming Li 9 F  racture of the Distal Radius�����������������������������������������������������������������������������������  251 Hua Chen, Zhe Zhao, and Jiaqi Li 10 F  ractures of the Scaphoid����������������������������������������������������������������������������������������  289 Yonghui Liang, Xuefeng Zhou, and Hao Guo

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Contributors

Zuhao Chang, MD  Chinese PLA General Hospital, Beijing, China Hua Chen  Chinese PLA General Hospital, Beijing, China Hao Guo, MD  Chinese PLA General Hospital, Beijing, China Yonghui Liang, MD  Aerospace Center Hospital, Beijing, China Jiantao Li, MD  Chinese PLA General Hospital, Beijing, China Jiaqi Li, MD  Chinese PLA General Hospital, Beijing, China Ming Li, MD  Chinese PLA General Hospital, Beijing, China Lin Qi, MD  Chinese PLA General Hospital, Beijing, China Bin Shi, MD  Chinese PLA General Hospital, Beijing, China Gaoxiang Xu, MD  Chinese PLA General Hospital, Beijing, China Wei Zhang, MD  Chinese PLA General Hospital, Beijing, China Zhe Zhao  Beijing Tsinghua Changgung Hospital, Beijing, China Xuefeng  Zhou, MD  Chinese PLA Strategic Support Force Characteristic Medical Center, Beijing, China Zhengguo Zhu, MD  Chinese PLA General Hospital, Beijing, China

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Fracture of the Scapula Hua Chen, Zhe Zhao, and Lin Qi

1.1 Basic Theory and Concepts 1.1.1 Overview • The incidence of scapular fracture is relatively low, accounting for 3–5% of shoulder injuries and 0.4–1% of all fractures. In descending order of incidence, scapular fractures include fractures of the scapular body, scapular neck, glenoid margin, glenoid, acromion, scapular spine, and coracoid process. Approximately 65% of scapular fractures are complicated type, that is, involving multiple anatomical sites of the scapula (Voleti et al. 2012; Rowe 1963; Koval and Zuckerman 2006). –– The scapula is adjacent to the thorax, and pulmonary contusion occurs in 11–54% of the patients, resulting in critical illness. Patients with severe pulmonary contusion should be treated with tracheal intubation as soon as possible to maintain positive pressure ventilation (Fischer et al. 1985; McGinnis and Denton 1989; Thompson et al. 1985). –– Pneumothorax complication occurs in 11–55% of scapular fractures and can occur at the time of injury or a few days after injury. In particular, tension pneumothorax can lead to death if not treated in a timely manner, and thus, early diagnosis and appropriate treatment should be provided. The occurrence of sudden wheezing a few days after injury warrants attention to pneumothorax (Armstrong and Vanderspuy 1984; McLennen and Ungersma 1982). –– Scapular fractures are often accompanied by injuries in the ipsilateral upper limb and trunk, such as rib fractures, clavicular fractures, sternal fractures, and fractures and dislocations around the shoulder (Fig. 1.1).

H. Chen (*) · L. Qi Chinese PLA General Hospital, Beijing, China Z. Zhao Beijing Tsinghua Changgung Hospital, Beijing, China

The diagnosis and treatment of complicated injuries warrant attention to prevent missed diagnosis. • Comolli’s sign is a rare compartment syndrome of the scapula. If severe swelling and severe pain at the scapula occur after scapular fracture, the occurrence of complications should be considered (Landi et al. 1992). –– Comolli’s sign is manifested as severe pain in the scapula area, with triangular or scapular swelling. –– Due to the lack of toughness on the surface fascia of the supraspinatus muscle and the infraspinatus muscle, the hematoma and the swelling soft tissue around the scapula may spread along the chest wall to the surroundings and even inward into the thorax. –– Once Comolli’s sign is clearly diagnosed, decompression by fascia incision should be performed as soon as possible. • Pseudo-rotator cuff tear is associated with clinical manifestations similar to those of rotator cuff injuries. –– Scapular fractures cause swelling in deep tissue. Due to bleeding and swelling of the muscle, followed by fibrosis, muscle contraction is limited, resulting in reduced shoulder function or even transient loss of arm lift function. The clinical manifestations of pseudo-­rotator cuff tear are similar to those of rotator cuff injuries, with spontaneous recovery usually within a few weeks. –– Compared to the rotator cuff, the degree of swelling in pseudo tear syndrome is often more severe. MRI examination can clearly reveal internal bleeding or rotator cuff injury. • The muscular bracing effect on the scapula fracture: –– The scapula is wrapped by many muscles with abundant blood supply, and thus the fracture healing rate is very high. –– The supraspinatus muscle and the infraspinatus muscle are attached to the rear surface of the scapula body, whereas the subscapular muscle is attached to the front, forming a muscular splint that helps maintain the position of the fracture fragment and plays a protective role (Fig. 1.2).

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_1

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2 Fig. 1.1  Scapular fractures with multiple rib fractures and pulmonary contusion. (a) A routine radiograph showing scapular fractures. (b) Computed tomography (CT) scan with three-dimensional reconstruction showing multiple rib fractures (another patient). (c) CT scan showing right pulmonary contusion, pneumothorax, and pleural effusion

H. Chen et al.

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Fig. 1.2  Lateral view of the scapula. The lateral view allows visualization of a large number of muscles attached to the scapula. The subscapular muscle is in the anterior aspect of the scapula. The supraspinatus and infraspinatus muscles are attached to the posterior aspect. These muscles can maintain the position of the fracture fragment

Coracoacromial arch Acromion

Coracoacromial ligament

Coracoid process

Supraspinatus Subacromialbursa Infraspinatus Glenoid cavity Glenoid labrum Joint capsule Teres minor

Infraspinatus

Subtendinous bursa of subscapularis Tendon of biceps brachii, long head Subscapularis Axillary recess

Subscapularis Scapula, lateral border

1  Fracture of the Scapula

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–– Due to the special muscular splint structure of the scapula and the high fracture healing rate, the majority of patients achieve satisfactory function through conservative treatment, and surgical indications should be strictly controlled.

1.1.2 Applied Anatomy 1. The glenohumeral joint is the main joint of the shoulder girdle complex, which is composed of the large humeral head and the shallow articular glenoid. The limited coverage of the articular glenoid on the humeral head underlies the inherent instability of the glenohumeral joint. From an evolutionary perspective, although this special joint structure reduces the stability of the joint, it increases the maximum degree of movement of the glenohumeral joint. 2. Stable structure of the shoulder joint and its injury: (a) The connection of the upper limb to the axial skeleton ensures the stability of the shoulder joint, and its physiological function is to implement the complex

a



b

function of the human upper limb, which is achieved through the structure of the shoulder girdle. The shoulder girdle is mainly composed of the scapula, the clavicle, the glenohumeral joint, the acromioclavicular joint, the sternoclavicular joint and the surrounding muscles, and the ligament structure. The connections between the scapula and the chest wall and between the clavicle and the sternum are the anatomical base, and the entire function is achieved by the anatomy of the superior shoulder suspensory complex (SSSC) (Lyons and Rockwood 1990). (b) The interaction of the scapula and the chest wall and the scapulothoracic dissociation: • The scapula and the chest wall are connected by three groups of muscles but no bone structure: the first group is the anterior serratus muscle; the second group is the rhomboideus and levator scapulae muscles; and the third group is the subclavius and pectoralis minor (Fig. 1.3). • These three groups of muscles do not perpendicularly connect the scapula and the lower chest wall.

c

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2

1

1 2 2

3

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Fig. 1.3 (a) The levator scapulae originates from the transverse process of the first to the fourth cervical vertebrae and is inserted into the superior angle of the scapula (1). The rhomboid minor muscle arises from the spinous process of the sixth to the seventh cervical vertebrae and is inserted into a small area of the medial border of the scapula above the level of the scapular spine (2). The rhomboid major muscle arises from the spinous processes of the first to the fourth thoracic vertebrae and is inserted into a small area of the medial border of the scap-

ula below the level of the scapular spine (3). (b) The subclavian muscle arises from the first rib and is inserted into the inferior surface of the clavicle (1). The pectoralis minor muscle arises from the third to the fifth rib and is inserted into the coracoid process (2). (c) The serratus anterior muscle originates from the first to the ninth ribs. Its upper part is inserted into the superior angle of the scapula (1), the middle part into the medial edge of the scapula (2), and the inferior part into the medial edge of the scapula and the subscapular angle (3)

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Instead, they stabilize the scapula on the surface of the chest wall similar to a cable-stayed bridge. This structure gives the scapula a certain ability of movement and also reduces the stability of the scapula. • Injury of scapulothoracic dissociation due to trauma is mostly caused by high-energy traction injury, with a high probability of complicated injuries in blood vessels and nerves that are often fatal. (c) The clavicle and the sternum are linked depending on the sternoclavicular joint and the muscles attached to the clavicle (see the section on clavicular fracture for details). (d) Anatomy of the superior shoulder suspensory complex (Goss 2004) (SSSC): • The SSSC consists of an annular structure with the upper and lower bony processes: –– The annular structure consists of the coracoid process, the coracoclavicular ligament, the distal clavicle, the acromioclavicular ligament, the acromion, and glenoid fossa. –– The upper bone process includes the middle 1/3 of the clavicle. –– The lower bone process includes the connection part of the outermost side of the scapular body and the innermost side of the scapular neck. • The SSSC is the link between the upper limbs and axial skeleton, which is an important structure to maintain the stability of the upper limbs and axial skeleton. • SSSC injury and floating shoulder injury. –– Due to the annular structure in the SSSC, the impact of a single tear or fracture on the stability of the SSSC is minor, and treatment efficacy is good. –– When more than two sites of the annular structure are injured, the stability of the annular structure will be damaged, and surgery is needed to repair the annular structure to avoid delayed healing of the fracture, weakened upper limb strength, and other long-term complications (Fig. 1.4). –– The traditional definition of floating shoulder injury is the loss of connection between the glenohumeral joint and axial skeleton due to fractures of the two bony struts of the SSSC; William et al. (Williams Jr et al. 2001) defined the floating shoulder as the loss of bone and ligament connection between the scapula and axial skeleton at the scapular neck with the glenoid cavity and glenohumeral joint.

H. Chen et al.

–– Therefore, the following three cases are considered generalized floating shoulder injury (Coleridge and Ricketts 2003; van Noort et al. 2001): Fracture through anatomical neck of the scapula Fracture through the surgical neck  +  ruptured coracoclavicular ligament  +  ruptured coracoacromial ligament  ±  ruptured acromioclavicular ligament Fracture through surgical neck of the scapula  +  clavicular fracture  +  ruptured coracoacromial ligament  +  ruptured acromioclavicular ligament 3. The areas that may be fixed in surgery for scapular fracture are the coracoid process, the glenoid neck, the base of scapular spine, and the lateral margin of scapula (Fig. 1.5). (a) Lateral margin of the scapula: • The arc extending from the subscapular angle outward and upward to the neck of the glenoid, which is the thickest margin of the scapula. • This site and the neck are the best place for fracture reduction and fixation with plate and screw. • Fixing material should not be placed in the scapula body, which is thin and translucent. (b) Coracoid process: • The coracoid process is the curved forwarding protrusion of the scapular neck and is an important anatomical landmark. • The coracoid process is the beginning of five anatomical structures, including the coracoradialis, coracobrachialis, entopectoralis, coracoacromial ligament, and coracoclavicular ligament. (c) Glenoid fossa: The glenoid is a pear-shaped fossa below the acromion with upper and lower diameters of 39 mm and an anteroposterior diameter of 29 mm (lower half). 4. Axillary nerve (a) The axillary nerve travels in front of the glenoid, bypasses from below the glenoid, and controls the deltoid after passing through the quadrilateral foramen (b) For glenoid fractures, operation for fixation of the scapular neck and scapula medial margin by the Judet approach should be performed in the gap between the infraspinatus and teres minor in the inner margin of the quadrilateral hole. If the triceps is crossed by mistake, the front axillary nerve may be damaged, leading to deltoid weakness.

1  Fracture of the Scapula

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a

b

Clavicle

Acromion

Glenoid fossa

Osteochondral ring

c intact

Triceps

Single injury Break

Torn ligament

d double disruptions of bone-ligament structures double injury Torn ligaments

e

Double break

Bone break/torn liganment

Bone break/ torn ligament

Double break

f

Fig. 1.4 (a) Anterior view of the left scapula. The superior shoulder suspensory complex (SSSC) includes an annular structure and two bony protrusions. The upper bony protrusion is the middle 1/3 of the clavicle. The lower bony protrusion is the junction between the lateral scapula and the medial scapular neck. (b) Lateral view of the left scapula. The annular structure of the SSSC is composed of the coracoid process, the coracoclavicular ligament, the distal clavicle, the acromioclavicular ligament, the acromion, and the glenoid fossa. (c) Annular structure injury is associated with a variety of mechanisms, including single- or two-site injury of the bone and ligament. Two-site injuries can be divided into two-site injuries of the ligament, two sites of fractures, and one-site injuries of the bone and the ligament. (d) Mechanisms

g

of two-site injury of the annular structure and the bony supportive structure: two fractures of the bony supportive structure and injury of a bony supportive structure with a ligament. (e) Scapular anatomical neck fracture results in a loss of the connection between the glenohumeral joint and the axial skeleton. (f) Scapular surgical neck fracture accompanied with coracoclavicular ligament and coracoid ligament rupture can also lead to a loss of the connection between the glenohumeral joint and the axial skeleton. (g) Scapular surgical neck fracture with clavicle fracture, acromioclavicular ligament, and coracoacromial ligament rupture can result in a loss of the connection between the glenohumeral joint and the axial skeleton

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Fig. 1.5  Designated regions for scapular fracture fixation: coracoid process (1), glenoid neck (2), base of scapular spine (3), and lateral edge of the scapula (4). Anterior view of the scapula (a) Posterior view of the scapula (b) Lateral view of the scapula (c) Fig. 1.6  The suprascapular nerve travels to the posterior aspect of the scapula via the suprascapular notch and then curves around the scapular spine inferior to supply the infraspinatus muscles. It is vulnerable to fractures and surgical operations. The axillary nerve passes through the quadrangular foramen into the posterior humerus; therefore, caution should be taken to avoid nerve injury when using the posterior approach. Damage to the axillary nerve can cause weakness in the deltoid muscle

clavicle

Suprascapular artery and nerve

supraspinatus scapular spine

Shouder joint capsule Teres minor

infraspinatus

teres minor deltoid

medial border

axillary nerve and posterior circumflex humeral artery

circumflex scapular artery

quadrilateral foramen profunda brachii artery and radial nerve

teres major

long head trilateral foramen

5. Suprascapular nerve: (a) The suprascapular nerve travels from the suprascapular notch to the suprascapular fossa to control the supraspinatus and passes the glenoid trace to control the infraspinatus (Fig. 1.6). (b) In the process of repairing the rear margin and lateral margin of the glenoid through the Judet approach, excessive inward separation to damage the nerve should be avoided and may result in the loss of

triceps brachii lateral head

i­ nnervation in the infraspinatus, causing weakness in the abduction movement of the arm. 6. The mechanism of shoulder abduction movement: The shoulder joint is the joint with the largest range of movement and has a complex anatomy. Shoulder movement is the joint movement of multiple joints. A full understanding of the complex biomechanics of the shoulder is necessary for effective treatment of shoulder diseases (Kapandji 2007).

1  Fracture of the Scapula

(a) The shoulder can be considered a complex lever mechanism in which movement not only relies on the glenohumeral joint but also involves the acromioclavicular joint, sternoclavicular articulation, and scapulothoracic joint. (b) In terms of abduction movement, the lever mechanism requires not only torque but also fulcrums to ensure that the positions of the related structures do not change in the movement of the shoulder joint. (c) The abduction movement of the shoulder joint can be divided into three stages The first stage is 0–60° abduction: At this stage, the abduction movement is basically accomplished by the movement of the glenohumeral joint, and the clavicle plays the role of the arm. Figure 1.7a, b: • Fulcrum: The humeral head and lower part of the glenoid in the shoulder joint form the fulcrum, and shrinkage of the rotator can stabilize the fulcrum. Both are indispensable. –– Glenoid: The glenoid is located in the lateral scapula and appears as a pear-like structure. The lower lip is more prominent and larger than the upper lip, playing the role of the fulcrum in the abduction movement of the shoulder. –– Rotator cuff: The humeral head is larger than the glenoid, and thus, the glenoid cannot wrap around the humeral head. Consequently, an additional stabilization device is needed to realize its fulcrum function. The rotator cuff includes the supraspinatus, infraspinatus, teres minor, and subscapularis muscle. The long head tendon of the brachial bicep wraps the glenohumeral joint to maintain the stability of the fulcrum through a “concave-compression” mechanism; that is, the medial component of the muscle contraction force pushes the humeral head toward the glenoid, playing a role in preventing dislocation (Fig. 1.7c). –– In fracture by the glenoid, the lower half of the glenoid is often an isolated bone, in association with humeral head subluxation. In this case, the fulcrum function is lost, and surgical treatment should be provided. –– In fracture of the scapular neck, once the displacement is more than 10  mm or the angle change is more than 45°, the movement of the rotator cuff will be abnormal, which will also affect the stability of the fulcrum. • Torque: The contraction of the deltoid can generate power, and the shoulder can complete the abduction movement with the fulcrum as the axis. The horizontal component of the contraction of

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the supraspinatus plays a supporting role in abduction movement of the shoulder. (d) The second stage is 60–120° abduction: Before the glenohumeral joint reaches 90°, movement of the scapula can be observed. In the synergistic movement, the angular ratio of the two joints is approximately 2:1, which is called the scapulohumeral rhythm. When the movement of the glenohumeral joint reaches 90°, the greater tubercle meets the upper edge of the glenoid, causing a buckle lock of the glenohumeral joint. Subsequent abduction movement is completed mainly by the auxiliary movements of the sternoclavicular joint, the acromioclavicular joint, and the scapulothoracic joint. Figure 1.7d, e, f. • Fulcrum: In this case, the scapula and the humerus can be considered as a single entity. –– In front of the body, this lever mechanism contains two fulcrums, the acromioclavicular joint and the sternoclavicular joint. At this stage, the clavicle plays the role of a support rod to prevent inward collapse of the shoulder joint. –– In the rear of the body, the scapulothoracic joint stabilizes the scapula during the contraction of the surrounding muscles. • Torque: The abduction movement of the shoulder is completed by the muscle power produced by the contraction of the trapezius and the serratus anterior muscle. • In the case of clavicular fracture, the fulcrum of abduction is not available, and appropriate treatment is needed. In the case of paralysis in the trapezius or serratus anterior muscle, the scapula cannot be attached to the chest wall, resulting in “wing-like scapula,” which can also cause abduction movement dysfunction. (e) The third stage is 120–180° abduction: The coordination movement of the glenohumeral joint, acromioclavicular joint, and sternoclavicular joint can provide an abduction angle of 150°, and the remaining 30° requires bending of the spine as compensation. In the actual movement, before upper arm abduction to 150°, movement of the spine can be observed. For simultaneous abduction of 180° of both sides, backward extension compensation of the spine is needed.

1.1.3 Mechanisms of Injury • Direct violence: High-energy injury is usually caused by direct hitting or falling with direct impact on the shoulder, resulting in fracture of the scapular body, acromion, and coracoid process (Wilber and Evans 1977; Zdravkovic and Damholt 1974).

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a

b glenohumeral joint 90° sternoclavicular joint

30° 30° humerus humerus

c

d

e

f

scapuloclavicular joints

sternoclavicular joint

clavicle

60°

sternoclavicular joint neutral position

90°

30°

Fig. 1.7 (a) The shoulder joint has 2 fulcrums: the sternoclavicular joint and the glenohumeral joint, resembling a boom arm of a crane, as shown in the diagram. The green lines represent the force from the deltoid muscles. In the first stage of shoulder abduction, the movement of the glenohumeral joint is responsible for initiating the abduction as the clavicle remains in place and functions as a boom arm. (b) In the second

stage of shoulder abduction, the sternoclavicular and scapuloclavicular joints complete the movement together, with each joint providing a 30° movement range. (c) The glenohumeral joint is the fulcrum of the first stage of abduction. (d–f) The glenohumeral, sternoclavicular, and scapuloclavicular joints are involved in shoulder abduction

1  Fracture of the Scapula

• Indirect violence: The axial component of the load on the abducting upper limb transfers along the upper limb, causing shoulder injury, such as the scapular neck, joint glenoid, intra-articular fracture, or avulsion fracture.

1.1.4 Classification of Fractures • Classification of scapular fractures: The morphology of the scapula is very irregular. The significance and treatment indications of the fracture differ in different parts. It is difficult to establish a comprehensive classification covering all fractures, and thus most scholars tend to use a classification that follows the anatomy (Zdravkovic– Damholt classification (Kuhn et  al. 1994), as shown in Table 1.1 and Fig. 1.8). • Classification of glenoid fractures (Ideberg classification): According to the direction of the fracture and the displacement, glenoid fractures are divided into five types, with the type VI supplemented by Goss (Goss 2004; Ideberg et al. 1995), as shown in Table 1.2 and Fig. 1.9. • Classification of acromion fractures (Kuhn classification): This classification indirectly determines the degree of displacement of the acromion fracture based on changes in the gap below the acromion. After fracture, the acromion shifts downward due to traction of the deltoid muscle, reflected by a smaller acromial gap in imaging study (Kuhn et al. 1994) (Table 1.3 and Fig. 1.10). • Classification of coracoid process fractures (Ogawa classification): This classification is based on fractures that occur at the proximal end of the coracoclavicular ligament, usually associated with acromioclavicular dislocation, clavicular fractures, and injury in other SSSC components (Ogawa and Naniwa 1997; Ogawa et  al. 1997) (Table 1.4 and Fig. 1.11). • Classification of scapular neck fractures: Scapular neck fractures are extra-articular fractures and are divided into two types (Goss 1995). –– Type I: Fracture with no displacement. –– Type II: Fracture with displacement >1  cm or angle >45°.

Table 1.1  Zdravkovic–Damholt classification

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1.1.5 Assessment of Scapular Fractures 1.1.5.1 Clinical Assessment 1. Typical manifestations: The hand on the healthy side supports the affected limb at the inner recipient position, the movement of the shoulder joint is limited, and pain is significantly aggravated during abduction movement.

5

7

6 4

3

2 1

Fig. 1.8  Zdravkovic–Damholt classification. (1) Scapular body. (2 and 3) Glenoid fossa. (4) Scapular neck. (5) Acromion.(6) Scapular spine. (7) Coracoid process. (Source: Kenneth A.  Egol, et  al. Handbook of fractures. th ed. Philadelphia: Lippincott Williams & Wilkins, 2009) Table 1.2  Ideberg classification

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type I

type II transverse

type II oblique

type III

type IA

type IB

type IV

type II

type V type VI comminuted

Fig. 1.9  Ideberg classification of glenoid fractures. Type I: avulsion fracture of the anterior glenoid rim. Type II: transverse or oblique fracture through the inferior glenoid fossa. Type III: oblique fracture through the superior glenoid fossa, accompanied by scapuloclavicular joint injury. Type IV: horizontal fracture of the medial scapula rim. Type V: type IV fracture accompanied by inferior glenoid fracture. Type VI: comminuted fracture of the glenoid fossa. (Source: BucholzRW, Heckman JD, Court-Brown C, et al. Rockwood and Green’s Fractures in Adults.Thed. Philadelphia: Lippincott Williams & Wilkins, 2006)

type III

type IV

Fig. 1.10  Classification of acromion fractures. Type I: fracture without acromion displacement or no change in the subacromial space. Type II: fractures are displaced and do not reduce the subacromial space. Type III: fractures with acromion displacement reduce the subacromial space, accompanied by acromioclavicular joint dislocation or involving the glenoid fossa Table 1.4  Ogawa classification

Table 1.3  Kuhn classification

2. Comprehensive assessment of airway, lung, vascular, and neurological functions. (a) Assessment of pulmonary function: very important. • Life-threatening lung contusion occurs in 11–54% of scapular fractures and requires tracheal ­intubation and positive ventilation at the end of expiration (Fischer et  al. 1985; McGinnis and Denton 1989).

• Pneumothorax can occur at the time of injury or a few days after injury. (b) Blood vessels: In case of upper limb circulation problems, ultrasound or angiography should be immediately performed, and consultation with vascular surgeons should be carried out. (c) Nerves: • Brachial plexus nerve injury occurs in 5–10% of scapular fractures (Ebraheim et al. 1988; Nunley and Bedini 1960; Tomaszek 1984).

1  Fracture of the Scapula

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attachment of the coracoclavicular ligaments

type I type II

Fig. 1.11  Classification of coracoid process fractures. Type I: fracture proximal to the coracoclavicular ligament. Type II: fracture distal to the coracoclavicular ligament

• For most patients, exercise assessment cannot be performed because of pain. Only assessment of whether the innervation area is normal is possible (Fig. 1.12). • Sensation in the axillary innervation area must be accurately recorded. 3. Scapulothoracic dissociation injury: When the connection between the scapula and the chest wall is broken, nerve damage occurs in 94% of cases, and 88% are associated with vascular injury. Because prognosis is extremely poor or even life-threatening, missed diagnosis should be carefully avoided (Damschen et  al. 1997; Lahoda et al. 1998). (a) Such injuries are often caused by violent pulling and retraction of the affected limb. (b) Even if the patient’s local skin is intact, when the shoulder is extremely swollen, with no pulsation in the upper limb and complete or partial nerve injury, careful diagnosis is required, and the lateral displacement in the ipsilateral scapula should be further assessed by X-ray. 4. Assessment of skin integrity: Fractures caused by a direct hit on the shoulder with sticks often show ecchymosis in the local skin.

supraclavicular nerve superior lateral brachial cutaneous (axillary nerve)

inferior lateral brachial cutaneous (axillary nerve)

lateral antebrachial cutaneous nerve (musculocutaneous nerve)

supraclavicular nerve superior lateral brachial cutaneous nerve (axillary nerve)

intercostal nerves, anterior cutaneous branch

posterior brachial cutaneous nerve (radial nerve)

medial branchial cutaneous nerve and intercostobrachial nerve medial brachial cutaneous nerve medial antebrachial cutaneous nerve medial antebrachial cutaneous nerve

radial nerve superficial branch

inferior lateral brachial cutaneous nerve (radial nerve) posterior antebrachial cutaneous nerve (radial nerve) lateral antebrachial cutaneous nerve (musculocutaneous nerve)

ulnar nerve palmar branch median nerve palmar branch common and proper palmar digital nerves (median nerve) common and proper palmar digital nerves (ulnar nerve)

ulnar nerve, dorsal branch dorsal digital nerves (ulnar nerve)

superficial branch of radial nerve

proper palmar digital nerve (median nerve)

Fig. 1.12  Schema of innervation of the brachial plexus and branches on the skin. As shown in this schema, the purple area lateral-posterior to the deltoid muscle is supplied by the axillary nerve

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5. After symptomatic treatment, if the patient suffers continuous unrelievable or gradually increasing pain, compartment syndrome of the scapular fascia should be highly suspected. Fig. 1.13 Imaging assessment of the shoulder joint. (a) Anteroposterior (AP) view of the shoulder joint. (b) AP view of the scapula. The angle between the X-ray beam and the body sagittal plane is 35o. This view allows observation of the lateral aspect of the glenohumeral joint. (c) Lateral view of the scapula (Y view). The humerus forms the base of the “Y”; the coracoid process and the scapular spine form the upper arms of the “Y”; the humeral head is superimposed at the center of the “Y”. (d) Axillary view. This view obtained in the position of mild abduction of the upper arm. A neutral position of the forearm allows observation of fractures in the margins of the acromion and glenoid fossa

1.1.5.2 Imaging Assessment • AP (anteroposterior) view: –– Shoulder orthographic image: the commonly used body image in shoulder joint examination (Fig. 1.13a).

a

b

35°

c

d

1  Fracture of the Scapula

• •

•

•

13

–– Scapula orthodontic image: the projection at an angle of 35° with the sagittal plane (Fig. 1.13b). Scapular Y view: the 90° projection of the scapular AP view (Fig. 1.13c). Axillary view: the projection with mild abduction in the upper limb and neutral position of the forearm. The fracture in the acromion and glenoid margin can be observed (Fig. 1.13d). Stryker notch view: the anteroposterior view of the coracoid process. The image is captured with the elbow in flexion, vertically up, and the hand behind the head. The bulb is aligned with the coracoid process and is tilted to 10° to the head side for the projection to clearly observe the fracture in the coracoid process (Fig. 1.14). In the anteroposterior X-ray, differences in the distances of the bilateral scapula and the spinous process suggest

Fig. 1.14  Stryker notch view, i.e., anteroposterior view of the coracoid process. (a) This image is captured with the bilateral elbow in flexion, vertically up, and the hand behind the head. (b) The X-ray tube is tilted 10° to the head side for the projection to clearly observe the avulsion fracture at the tip of the coracoid process

Fig. 1.15  Right clavicle fracture with scapulothoracic dissociation. In this case, the patient lost sensation and motion of the right arm below the level of the shoulder joint. (a) Anteroposterior view X-ray radiography reveals a right clavicle fracture and significantly increased distance from the right scapula to the midline compared with the left side. (b) Magnetic resonance imaging (MRI) shows nerve root avulsion of the right brachial plexus

a

scapulothoracic dissociation. If complicated with vascular injury, arterial angiography of the upper limb should be performed to check other injuries such as the subclavian artery and axillary artery fracture, and MRI can be performed to check the brachial plexus injury in the advanced stage (Fig. 1.15). • CT scan with 3D reconstruction (McAdams et al. 2002) (Fig. 1.16): –– It is very helpful for the diagnosis of fractures in the glenoid or coracoid process and judgment of the reduction of the humeral head. –– CT can reveal complicated injury, especially intra-­ articular fracture of the glenoid; this type of fracture usually cannot be diagnosed by X-ray. • Chest orthostatic imaging must be performed to exclude pneumothorax.

b

10°

a

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b

Fig. 1.16  Special effects of a CT scan with 3D reconstruction. A CT scan with 3D reconstruction can clearly show a glenoid fracture, which cannot be found on an X-ray radiograph. (a) Anteroposterior view X-ray radiography of the scapula shows no signs of fractures. (b) A CT

scan reveals the glenoid fracture. (c) 3D reconstruction of the scapula (CT) shows the location, size, and degree of displacement of the fracture fragment

1.2 Surgical Treatment

• Glenoid fracture involving the glenohumeral joint as the intra-articular fracture. –– Articular surface step >4 mm –– Articular surface separation >10 mm –– The fracture fragment in the front is greater than the 1/4 of the glenoid, or the fracture fragment in the rear is greater than 1/3 of the glenoid –– Accompanied by displacement or subluxation of the humeral head • Scapular neck fracture –– When the shift is >10 mm and the angle is >45°, surgical treatment should be provided, with placement of a steel plate for reconstruction in the lateral edge of the scapula and/or under the mesoscapula to fix the fracture.

1.2.1 Surgical Indications and Purpose 1.2.1.1 Surgical Indications After conservative treatment and functional exercise, most scapular fractures can be cured with good function, and thus surgical indications should be strictly controlled. • Scapulothoracic dissociation injury: For fracture cases showing emergency surgical indications, emergency repair of blood vessels, exploration of the nerve injury, and surgical stabilization for the shoulder to allow the use of a strap should be performed (Protass et  al. 1975; Houghton 1980).

1  Fracture of the Scapula

–– The treatment of floating shoulder injury remains controversial. Due to the use of small sample sizes and other factors, the treatment strategies of conservative treatment (Edwards et al. 2000), fixation of clavicular fracture only (Hersovici Jr et al. 1992), or fixation of both the clavicle and scapular neck (Leung et al. 1993) have all achieved good results in different studies. Based on our experience, fixation of both the clavicle and scapular neck is recommended to restore the structure of the SSSC, allow early functional exercise, and facilitate limb function recovery. • Fractures of the bony process in the scapula: Conservative treatment is often applied for fractures of the bony process in the scapula. –– Fractures in the coracoid process: Conservative treatment is often applied unless the fracture hinders the reduction of the humeral head or clinical symptoms occur due to stimulation of the surrounding tissue (Protass et al. 1975; Montgomery and Loyd 1977). –– Fractures in the acromion: According to the Kuhn classification, conservative treatment can be applied to type I and type II. For type III, the narrowed gap under the acromion may cause acromial impingement, and surgical treatment is needed (Houghton 1980; De Villiers et al. 2005).

1.2.1.2 Purpose of Surgery • Intra-articular fractures: –– To restore the smooth articular surface of the glenoid –– To restore the biomechanical stability of the shoulder joint –– To restore the stability of the superior ligament in the upper part of the shoulder • Extra-articular fractures: –– To restore the morphology of the scapular neck and the mesoscapula lateral margin to maintain the stability of the scapular body –– To recover the natural morphology of the scapular body as much as possible

1.2.2 Surgical Techniques • Deltopectoral approach: Suitable for fractures in the coracoid process at the front margin of the glenoid and involving the upper glenoid and for type III glenoid fracture (Gross 1993). • Judet approach: Suitable for fracture in the rear margin of the glenoid, the glenoid neck, and other parts of the glenoid (Judet 1964). • Anterior-posterior approach: Suitable for fracture in the front margin of the glenoid associated with fractures in the scapular neck and scapular body.

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1.2.2.1 Open Reduction and Fixation for Fractures of the Front Margin of the Glenoid and Coracoid Process Through the Deltopectoral Intercostal Approach 1. Position and preoperative preparation (a) General anesthesia: The patient is placed in the beach-chair position, with a pillow under the affected shoulder to push the shoulder forward; intraoperative C-arm fluoroscopy assisted operation is performed. 2. Operative incision according to the projection on the body surface (a) On the body surface, the positions of the distal clavicle, acromion, and coracoid process are labeled. The deltoid and the pectoralis major groove are palpated to draw the marking line for the skin incision, and the incision is made along this line, with the center in the glenohumeral joint (Fig. 1.17). 3. Surgical procedures (a) Surgical approach (Fig. 1.18): • The skin and the subcutaneous tissue are cut, with separation to the deltopectoral interval. • After finding the head vein in the intermuscular septum, the medial chest fascia is cut to retract the head vein and the deltoid muscle outward, which are protected by the musculocutaneous flap. • The deltoid muscle and the pectoralis major muscle septum are further separated to the clavipectoral fascia, which covers the coracobrachialis and the subscapular tendon. • The fascia is cut to place the retractor up and down, the humerus is rotated outward to generate subscapular muscle tension, and the subscapular muscle attachment point is identified (lesser tuberosity of humerus). • The subscapular muscle tendon is truncated at 1 cm outside the ending of the subscapularis, the subscapularis is marked using silk, and the end after cutting is pulled inward. The travel of the axillary nerve under the subscapularis muscle tendon is noted to ensure that the axillary nerve is away from the lower edge of the subscapularis muscle during outward rotation of the humerus (extreme backward rotation of the upper arm). • The anterior humeral vessel and axillary nerve should be carefully protected (the anterior humeral vessel is located in the lower margin of the subscapular muscle, and the axillary nerve is below the blood vessel). The coracoid process is an important anatomical marker. It acts as a lighthouse, in which the area in the outer side of the coracoid process is a safe area and the area inside is a dangerous area that includes the brachial

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a

c

b

Fig. 1.17 (a, b) The patient is placed in the Fowler’s position. C-arm fluoroscopy was performed during surgery. (c) The projections of the distal clavicle, acromion, and coracoid process on the body surface are marked. The deltopectoral groove approach was used for the procedure



plexus, axillary arteries, and other important structures. Operation inside the coracoid process will easily damage these important structures. • A longitudinal incision of the joint capsule in the lateral lips outside the glenoid is conducted using a silk marker to expose the anterior glenoid fracture. (b) Reduction and fixation of fractures: • Reduction and fixation of fracture in the anterior and inferior margins of the glenoid (Fig. 1.19): –– After rinsing the joint cavity, reduction of the fracture fragment is performed from the outside of the joint under direct vision, and the anatomical reduction of the bone is observed. –– Kirschner wire is applied for temporary fixation. Depending on the size of the fracture fragments and the degree of crushing, the fragments are fixed in the front margin of the glenoid with a small supporting plate (screw diameter of 2.0–3.5 mm) or hollow screw (3.0 mm). –– For comminuted fractures, if the fracture fragments are difficult to reset, iliac autologous



transplantation can be performed based on the size of the missing bone after cleaning the joint cavity, with fixation using the same screws or micro-plate. • Reduction and fixation of the coracoid process (Fig. 1.20): –– For Ogawa II fractures of the coracoid process, the treatment depends on the size of the fracture fragment. If the fracture fragment is sufficiently large to apply screw internal fixation, the bone can be fixed with a 3.5-mm lag screw; for comminuted fractures, the bone fragments attached to the joint tendon should be removed, and the joint tendon end should be sutured and fixed to the remaining coracoid. –– For Ogawa I factures of the coracoid process, lag screw internal fixation near the fracture fragment can be performed. (c) Closure of the incision: • The joint capsule is closed, and the subscapularis muscle is sutured using No.2 knitting line. The subcutaneous tissue is sutured using 2-0 suture

1  Fracture of the Scapula

a

17

b

coracoid process

cephalic vein subscapular tendon tricep fascia axillary nerve

pectoralis major fascia

teres major muscle latissimus dorsi external rotation

c

e

d

f

deltoid

Fig. 1.18 (a) Soft tissue was dissected to expose the cephalic vein. The clavipectoral fascia is incised medially parallel to the cephalic vein. The cephalic vein and the deltoid muscle are retracted laterally and protected under the musculocutaneous flap. (b) When the upper arm is in a neutral position, the axillary nerve is located beneath the tendon of the subscapularis muscle. Therefore, it easily causes damage to the axillary nerve to incise the subscapularis muscle at a site 1 cm away from insertion of the tendon of the subscapularis muscle. Extremely lateral rotation of the upper arm can reduce the risk of axillary nerve injury. (c) The tendon of the subscapular muscle is transected at a site 1 cm from its insertion and

separated toward the midline by sharp dissection; the cutting ends should be marked by sutures for preparation of accurate tendon anastomosis during closure. (d) Caution should be taken to protect the nerves and blood vessels. The coracoid process is an important anatomical landmark (like a lighthouse); surgeries are safer in the region lateral to the coracoid process but risk damaging important structures (i.e., brachial plexus and axillary artery and vein) in the region medial to the coracoid process. (e) A longitudinal incision was made in the joint capsule to expose the articular surface of the glenoid fossa. (f) The joint capsule and the insertion of the subscapular muscle should be sutured in layers during closure

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a

b

coracoid process subscapular tendon joint capsule deltoid

glenoid fossa glenoid labrum

joint capsule

posterior capsule teres major muscle

pectoralis major muslce humeral head

c d

dorsal

e

Fig. 1.19 (a) Reduction of a glenoid fracture. (b) A lag screw can be used to fix a large fragment of a glenoid fracture. (c) A comminuted fracture of the glenoid fossa is difficult to be reduced and fixed; therefore, an appropriately sized autologous iliac bone graft can be used to

repair the glenoid fossa. (d, e) Open reduction and internal fixation of an anteroinferior glenoid fracture (radiographs before and after surgery)

1  Fracture of the Scapula

19

a 4.



b

c

Fig. 1.20 (a) Ogawa type II coracoid process fractures can be fixed with a 3.5 mm lag screw via the fragment if the fragment is sufficiently large. (b) In terms of comminuted fractures, the fragments attached to the joint tendon are removed, and the stump of the joint tendon is sutured and fixed to the remaining coracoid process. (c) Ogawa type I coracoid process fractures are fixed with a lag screw via the fragment



line, and the skin is intradermally sutured using a single strand of absorbable suture line. Postoperative treatment (a) Week 1 postoperative: Passive movement in the full range of shoulder movement can begin. (b) Week 4 postoperative: The goal is to regain and maintain the level of activity before the injury; daily activities are encouraged, but the patient is not allowed to lift, push, pull, or take heavy objects. (c) If the subscapularis muscle is truncated and reconstructed, outward rotation movement exceeding the neutral position and inward rotation of the shoulder against resistance are avoided for 6 weeks to facilitate healing of the subscapular muscle. (d) To prevent muscle atrophy and promote subsidence of limb swelling, functional exercises for the ipsilateral elbow, wrist, and hand are encouraged, including carrying 1–2  kg of weight by the elbow with support.

1.2.2.2 Open Reduction and Internal Fixation of Fractures in the Glenoid Rear Margin and the Lateral Margin of the Scapula by the Simplified Judet Approach 1. Position and preoperative preparation (a) General anesthesia. (b) The patient is in the lateral position and tilted slightly forward on the pad, with a pillow under the armpit to prevent pressure sores; the upper limb is placed on the tray in 90° flexion with slight abduction (Fig. 1.21). (c) With intraoperative C-arm assisted fluoroscopy, the orthotopic and axillary positions of the scapula are intraoperatively adjusted (Fig. 1.22). 2. Operative incision according to the projection on the body surface (Obremskey and Lyman 2004) (a) The simplified Judet approach can be used to reveal the rear lip of the glenoid, the scapular neck, and the outer margin of the scapula: the outline of the scapula is marked by palpating the surface of the scapula, and a straight incision is created along the full length of the scapula below the length, parallel to the mesoscapula (Fig. 1.23). (b) If greater exposure of the mesoscapula and even the scapular medial margin is required, the Judet approach should be used. 3. Surgical procedures (a) Surgical approach (Fig. 1.24): • The skin and the subcutaneous tissue are cut, with fascial dissection with sharp separation. • In the lower margin of the mesoscapula, the deltoid muscle is truncated. Some muscle tissue attached to the mesoscapula should be retained to

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a

b

Fig. 1.21  Photograph showing that a patient is placed in the left lateral recumbent position and titled slightly forward with surgical pads under the axilla to prevent decubitus ulcers. The upper limb is placed on a tray

a

with 90° flexion and slight abduction (a). The C-arm of the fluoroscopic machine is located at the patient’s head side (b)

b

Fig. 1.22  During surgery, the X-ray tube of the C-arm machine can be changed to perform fluoroscopy of anteroposterior (a) and axillary views (b) of the scapula

facilitate postoperative repair. When flipping and pulling the deltoid muscle, the circumflex humeral artery attached on its medial side should be carefully protected. • After pulling the deltoid muscle out, the intermuscular septum of the infraspinatus and teres minor is exposed, and blunt separation along the intermuscular septum of the infraspinatus and teres minor is performed. The infraspinatus and teres minor are, respectively, pulled up and down to expose the shoulder capsule beneath. • Downward dissection under the periosteum is conducted along the scapular neck to fu lly expose the glenoid, scapular neck, lateral margin of the scapula, and most of the scapula body.

• During the dissection of the outer edge of the scapular neck, the operation should be performed in the correct intermuscular septum. Entry of the wrong intermuscular septum may damage the axillary nerve and the posterior circumflex humeral artery traveling in the quadrilateral foramen. • For fractures requiring treatment in the scapular base or containing large fractures within the ­comminuted joint, truncation can be performed at 1 cm from the ending of the greater tubercle, with sharp dissection of the infraspinatus tendon from the articular surface, to fully expose the shoulder and the scapular base. • When turning the infraspinatus muscle to the inside, the suprascapular nerve traveling backward from the suprascapular notch and control-

1  Fracture of the Scapula Fig. 1.23  Modified Judet approach. (a) Diagram showing the proposed straight incision, which is made slightly below and parallel to the scapula spine (the length of the incision equals the length of the scapula spine). (b) Photograph of the actual incision during surgery. (c) Diagram showing the Judet approach: the incision starting below the acromion is based on the border of the scapular spine and angled sharply at the superomedial angle of the scapula and follows the medial border inferiorly to the inferior angle

21

a

b

ling the infraspinatus should be carefully protected. (b) Reduction and fixation of fractures (Fig. 1.25): • For avulsion fracture in the rear of the glenoid and type II fracture, reduction and fixation can be performed using two hollow screws or a 3.5-mm steel reconstruction plate. • For the fractures of type III or higher and fractures in the scapular neck, fixation with a 3.5-mm reconstruction plate should be performed after reduction. • For patients with floating shoulder injury, fixation of the clavicle and/or the scapular neck should be conducted based on the evaluation results. 4. Closure of the incision: (a) The truncated infraspinatus tendon is sutured using No.2 knitting line. Brace protection is provided for the first 6 postoperative weeks, and outward rotation of the shoulder against resistance is avoided. 5. Postoperative treatment: (a) Week 1 postoperative: Passive activities in the full range of shoulder movement can begin.

scapular spine

Acromion

c

(b) Week 4 postoperative: The goal is to regain and maintain the level of movement present before injury; daily activities are encouraged, but the patient is not allowed to lift, push, pull, and take heavy objects. (c) If the infraspinatus, teres minor and deltoid muscle are dissociated from the ending point, protection with a triangular bandage should continue for 6 weeks; the patient can begin to bear load after 6 weeks, starting with 1–2  kg, which is gradually increased to the extent bearable by the patient. (d) To prevent muscle atrophy and promote subsidence of limb swelling, functional exercises for the ipsilateral elbow, wrist, and hand are encouraged, including carrying 1–2 kg of weight by the elbow with support.

1.2.3 Experience and Lessons • Auxiliary methods for functional exercise of the shoulder: During the first 48–72  h after surgery, a nerve-blocking analgesia pump can be applied in the intermuscular area of the scalenus for painless activity; pulling and pushing

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H. Chen et al. teres minor

a

b

infraspinatus fascia deltoid

c

posterior capsule

infraspinatus

d

posterior capsule infraspinatus

teres minor

articular surface

deltoid

teres minor deltoid

glenoid labrum scapula

e

medial border of scapula spine infraspinatus

supraspinatus infraspinatus articular surface

f

teres minor deltoid

posterior labrum joint capsule

Fig. 1.24 (a, b) Along the inferior border of the scapula spine, the origin of the deltoid muscle is incised to expose the space between the infraspinatus and teres minor. (c) Upward retraction of infraspinatus muscles and downward retraction of the teres minor allow exposure of the posterior joint capsule and the scapular neck. Caution should be taken not to damage the suprascapular nerve, which supplies the infraspinatus muscles, the subcutaneous branch (medial to the suprascapular

nerve) of the circumflex scapular artery, and the posterior humeral circumflex artery (lateral to the suprascapular nerve). (d) Opening of the joint capsule allows exposure of the glenoid fossa and the humeral head. (e) If an enlarged operative field is needed, the insertions of the infraspinatus muscles can be cutoff 1 cm from the greater tubercle, and the infraspinatus muscles can be separated from the articular capsule surface by sharp dissection. (f) Intraoperative photograph

1  Fracture of the Scapula

23

a

b

Kirschner drill wire

screws

tap

c

d

e

Fig. 1.25 (a) A Kirschner wire (K-wire) is temporarily used to fix the reduced fragment, and a hollow screw is placed over the K-wire to fixate the inferior fragment. (b) A 3.5 mm reconstruction plate is used to treat type III fractures. (c) Intraoperative photograph showing a locking plate placed in the lateral edge of the scapula for treatment of scapular

f

fractures. (d) Intraoperative fluoroscopy: anteroposterior and axillary views. (e, f) Scapular neck fracture accompanied by ipsilateral clavicle fractures and surgical fixation of the scapular neck and the clavicle (radiographs before and after surgery)

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rod movement with the contralateral upper limb in the supine position is recommended. • If the shoulder is stiff with poor activity at 6 weeks postoperatively, passive movements of the shoulder under brachial plexus anesthesia or arthroscopic surgery to release the adhesions are recommended. • Reconstruction of the lateral margin of the scapula is conducive to the precise reduction of the complex of the glenoid and the neck. –– A 2.7-mm dynamic compression plate (DCP) or steel reconstruction plate can meet the mechanical requirements for scapular fracture fixation. A steel plate is easy to shape and fix with close attachment in the fracture site. –– When a 3.5-mm or 2.7-mm steel plate is used to fix the fracture along the lateral margin of the scapula, the position of the reduction forceps will be in conflict with the position of the steel plate. A 2.0-mm blade plate can be used for temporary fixation until removal of the reduction forceps to complete the ultimate fixation. –– A small bone plate can be used for temporary fixation and can also be retained for auxiliary fixation. • A long screw placed in the coracoid process can enhance the stability of the fixation. –– The perspective of the scapula in the “Y” position determines the direction of the screw for the coracoid process. –– The position of the scapula is determined by the position of the screw for the coracoid process.

References Armstrong CP, Vanderspuy J.  The fractured scapula: importance in management based on series of 62 patients. Injury. 1984;15:324–9. Coleridge S, Ricketts D. The floating shoulder: a multicentre study. J Bone Joint Surg Br. 2003;85:308–9. Damschen DD, Cogbill TH, Siegel MJ. Scapulo-thoracic dissociation caused by blunt trauma. J Trauma. 1997;42:537–40. De Villiers RV, Pritchard M, de Beer J, et al. Scapular stress fracture in a professional cricketer and a review of the literature. S Afr Med J. 2005;95:312–7. Ebraheim NA, An HS, Jackson WT, et al. Scapulothoracic dissociation. J Bone Joint Surg Am. 1988;70:428–32. Edwards SG, Wittle AP, Woodll GW. Nonoperative treatment of ipsilateral fracture of the scapular and clavicle. J Bone Joint Surg Am. 2000;82B:774–80. Fischer RP, Flynn TC, Miller PW, et al. Scapular fractures and associated major ipsilateral upper-torso injuries. Curr Concepts Trauma Care. 1985;1:14–6. Goss TP. Scapular fractures and dislocations. J Am Acad Orthop Surg. 1995;3:22–33. Goss TP.  Fractures of the scapula: diagnosis and treatment. In: Rockwood CA, Matsen FA, Wirth MA, et al., editors. The shoulder. Philadelphia: Saunders-Elsevier; 2004. p. 413–54. Gross TP. Fractures of the glenoid cavity; operative principles and techniques. Techniques in orthopaedics, 1993, 8(3): 199–204.

H. Chen et al. Hersovici D Jr, Fiennes AG, Allgöwer M, Rüedi TP. The floating shoulder: ipsilateral clavicular and scapular neck fractures. J Bone Joint Surg Br. 1992;74B:362–4. Houghton GR. Avulsion of the cranial margin of the scapula: a report of two cases. Injury. 1980;11:45–6. Ideberg R, Grevsten S, Carsson S. Epidemiology of scapular fractures. Incidence and classification of 338 fractures. Acta Orthop Scand. 1995;66:395–7. Judet R.  Surgical treatment of scapular fractures. Acta Orthop Belg. 1964;30:673–8. Kapandji IA. The physiology of the joints, volume 1: upper limb. 6th ed. London: Churchill Livingstone; 2007. p. 978. –0443103506. Koval KJ, Zuckerman JD. Handbook of fractures, 3rd ed. Philadelphia: Lippincott, 2006: 139. Kuhn JE, Blasier RB, Carpenter JE. Fractures of the acromion process: a proposed classification system. J Orthop Trauma. 1994;8:6–13. Lahoda LU, Kreklau B, Gekle C, et al. Skapulo-thorakale dissoziation. Ein missed injury? Unfallchirurg. 1998;101:791–5. Landi A, Schoenhuber R, Funicello R, et al. Compartment syndrome of the scapula. Definition on clinical, neurophysiological and magnetic resonance data. Ann Chir Main Memb Super. 1992;11(5):383–8. Leung KS, et  al. Open reduction and internal fixation of ipsilateral fracture of the scapular neck and clavicle. J Bone Joint Surg Am. 1993;75A:1014–8. Lyons FA, Rockwood CA. Migration of pins used in operations on the shoulder. J Bone Joint Surg Am. 1990;72:1262–7. McAdams TR, Blevins FT, Martin TP, et  al. The role of plain films and computered tomography in the evaluation of scapular neck fractures. J Orthop Trauma. 2002;16:7. McGinnis M, Denton JR. Fractures of the scapula: a retrospective study of 40 fractured scapulae. J Trauma. 1989;29:1488–93. McLennen JG, Ungersma J.  Pneumothorax complicating fractures of the scapula. J Bone Joint Surg Am. 1982;64-A:598–9. Montgomery SP, Loyd RD. Avulsion fracture of the coracoid epiphysis with acromioclavicular separation. Report of 2 cases in adolescents and review of the literature. J Bone Joint Surg Am. 1977;59:963–5. Nunley RL, Bedini SJ. Paralysis of the shoulder subsequent to comminuted fracture of the scapula: rationale and treatment methods. Phys Ter Rev. 1960;40:442–7. Obremskey W, Lyman JR. A modified Judet approach to the scapula. J Orthop Trauma. 2004;18:696–9. Ogawa K, Naniwa T. Fractures of the acromion and the lateralscapular spine. J Shoulder Elb Surg. 1997;6:544–8. Ogawa K, Yoshida A, Takahashi M, et al. Fractures of the coracoid process. J Bone Joint Surg Br. 1997;79-B:17–9. Protass JJ, Stampflfli FB, Osmer JC.  Coracoid process fracture diagnosis in acromioclavicular separation. Radiology. 1975;116:61–4. Rowe CR.  Fractures of the scapula. Surg Clin North Am. 1963;43:1565–71. Thompson DA, Flynn TC, Miller PW, et al. The significance of scapular fractures. J Trauma. 1985;25:974–7. Tomaszek DE. Combined subclavian artery and brachial plexus injuries from blunt upper-extremity trauma. J Trauma. 1984;24:161–53. van Noort A, te Slaa RL, Marti RK, van der Werken C. The floating shoulder. A multicenter study. J Bone Joint Surg (Br). 2001;83:795–8. Voleti PB, Namdari S, Mehta S. Fractures of the scapula. Adv Orthop. 2012;2012:903850. Wilber MC, Evans EB.  Fractures of the scapula. An analysis of forty cases and a review of the literature. J Bone J Surg Am. 1977;59(3):358–62. Williams GR Jr, Naranja J, Klimkiewicz J, et al. The floating shoulder: a biomechanical basis for classification and management. J Bone Joint Surg Am. 2001;83A:1182–7. Zdravkovic D, Damholt VV. Comminuted and severely displaced fractures of the scapula. Acta Orthop Scand. 1974;45:60.

2

Fracture of the Clavicle Hua Chen, Zhe Zhao, and Zuhao Chang

2.1 Basic Theory and Concepts

2.1.2 Applied Anatomy

2.1.1 Overview

• Anatomy and biomechanics of the clavicle: –– Viewed from above, the clavicle is S-shaped, with a backward distal end and forward proximal end; the inner end is larger than the outer end. –– The middle 1/3 segment is located in the transition area of the clavicle arc, and the section shape resembles a thin tube. The middle 1/3 segment is a site of concentrated axial load and is the predominant site of fracture (Bucholz 2012). –– The clavicle is an important structure connecting the shoulder strap and the axial skeleton. The clavicle plays the role of a boom when the upper arm is sagging and a supporting role when the upper arm is abducting (details are shown in the section on the functional anatomy of scapular fractures). Thus, recovery of the boom and support functions of the clavicle are the goals of treatment. • The muscles attached on the clavicle surface and the mechanism of displacement in injury: –– Above the clavicle, the sternocleidomastoid muscle is attached on the medial side, and the trapezius muscle is attached on the lateral side. –– Below the clavicle, the pectoralis major is attached on the medial side, the subclavian muscle is attached on the middle, and the deltoid muscle is attached on the lateral side (Fig. 2.1). –– Fracture may cause an imbalance in proximal muscle strength, resulting in fracture displacement, which is usually manifested as upward and inward displacement of the fracture proximal.

• Fracture of the clavicle is one of the most common fractures, accounting for 2.6–12% of all fractures (Koval and Zuckerman 2006; Bucholz 2010a; Postacchini et al. 2002) and 44–66% of shoulder fractures (Koval 2006; Rowe 1968). • Fractures in the middle segment of the clavicle account for 80% of all clavicular fractures (Craig 1990; Craig 1996; Craig 1998; Crenshaw, 199a; Moseley 1968; Robinson 1998; Stanley et al. 1988), whereas fractures in the inner 1/3 and outer 1/3 segments account for 5% (Seo et al. 1999; Throckmorton and Kuhn 2007) and 15% (Goldberg et al. 1997; Robinson and Cairns 2004; Rockwood 1982a; Rokito et al. 2003; Webber and Haines 2000) of clavicular fractures, respectively. • Approximately 9% of clavicular fractures are associated with fractures in other areas (Koval and Zuckerman 2006). • The inner 1/3 of the clavicle plays a protective role for the vital organs, including the brachial plexus, subclavian vein, axillary vein, and lung tip, and fractures in this area can be associated with severe complications, such as brachial plexus injury. • Scholars are increasingly recommending surgical treatment for clavicular fractures (Canadian Orthopaedic Trauma Society 2007; Lazarides and Zafiropoulos 2006).

H. Chen (*) · Z. Chang Chinese PLA General Hospital, Beijing, China Z. Zhao Beijing Tsinghua Changgung Hospital, Beijing, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_2

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26

a

H. Chen et al. trapezius sternocleidomastoid pectoralis major acromion

b trapezius muscle superior surface

muscle origin muscle insertion

cephalic vein

posterior

deltoid

ligament attachment point sternocleidomastoid muscle

anterior deltoid muscle inferior suface anterior

pectoralis major muscle

posterior trapezoid ligament subclavius muscle (part of coracoclavicular ligament) conoid ligament (part of coracoclavicular ligament)

costoclavicular ligament

sternohyoid muscle

Fig. 2.1 (a) Muscles attached on the clavicle surface. (b) Attachment points of muscles and ligaments on the top and bottom surfaces of the clavicle

• Ligament anatomy of the clavicle: The ligaments of the clavicle can be divided into two groups. The medial group includes the articular capsule ligament (anterior sternoclavicular ligament, posterior sternoclavicular ligament), interclavicular ligament, and costoclavicular ligament. The lateral group includes the coracoclavicular ligament and acromioclavicular ligament (Fig.  2.2). The most important are the posterior sternoclavicular ligament and the coracoclavicular ligament (Palastanga and Soames 2012). –– Posterior sternoclavicular ligament: The posterior sternoclavicular ligament is located in the posterior part of the capsular articulatio sternoclavicularis. It is very hard and is an important structure for preventing forward and backward displacement of the clavicle; Important structures such as the brachial plexus and subclavian vein are in the rear, and thus during surgery to stabilize the sternoclavicular joint, the penetration of the posterior sternoclavicular ligament and damage to the above structures should be carefully avoided (Rockwood 2008a). –– Coracoclavicular ligament: The coracoclavicular ligament consists of the medial cone-shaped ligament and the lateral orthorhombic ligament, which is essential for the stability of the acromioclavicular joint. It provides stability in the vertical direction for the acromioclavicular joint, which has far greater strength than the acromioclavicular ligament (Fukuda et al. 1986; Rockwood and Green 2006; Urist 1963).

If the coracoclavicular ligament ruptures in the fracture and poor prognosis is suggested, surgical repair or reconstruction of the coracoclavicular ligament is recommended. • Collateral relationship between the clavicle and surrounding organs: The tips of the lungs are in the medial clavicle and higher than the level of the clavicular head, and thus, they should be protected in front-to-rear drilling for screw placement. Excessively deep penetration may pierce the pleural cavity and damage the lung, causing pneumothorax. The medial 1/3 of the clavicle has a protective effect on the subclavian artery, vein, and brachial plexus behind and below it. During drilling, the periosteal elevator should be placed under the clavicle to prevent the drill from penetrating too deep and damaging these important structures (Fig. 2.3). • Clavicle and sternoclavicular joint movement: –– The sternoclavicular joint is a saddle-shaped joint with two movement redundancies. The movement of the clavicle is an important part of the movement of the shoulder strap. –– The clavicle can move up and down by 35° and front and back by 35°. In addition, as a third type of movement, the clavicle can rotate along the long axis by 30° (Fig. 2.4). Therefore, during the surgical repair of clavicular fractures, in addition to axial stability, special attention to the stability of rotation is needed. At both ends of the fracture, three screws are needed to control the rotation to avoid failure of the internal fixation (Neumann 2010).

2  Fracture of the Clavicle

27

Fig. 2.2 (a) The intrinsic ligamentous connections of the clavicle, including the sternoclavicular ligament, costoclavicular ligament, and interclavicular ligament. (b) The extrinsic ligamentous connections of the clavicle, including the coracoclavicular ligament and acromioclavicular ligament

a

articular disc of sternoclavicular joint anterior sternoclavicular costoclavicular ligament ligament intercalvicular Clavicle 1st rib ligament

costal cartilages radiate manubrium sternocostal ligament

b

coracoclavicular ligament acromial end

acromioclavicular ligament acromion coracoacromial coracoacro-mial arch ligament coracoid process humeral head

trapezoid ligament

superior angle superior transverse scapular ligament suprascapular notch

intertubercular groove

scapula, costal surface medial border

glenoid cavity

trachea cupula pleurae apex pulmonis

1st rib

clavicle

less tuberosity

Humerus

a

conoid ligament

sternal end

greater tuberosity

Fig. 2.3 (a) The tips of the lungs are higher than the level of the clavicle in the medial 1/3 of the clavicle, and thus, special attention should be paid to avoid damaging the lungs and causing a pneumothorax during screw placement into the bore hole. (b) The subclavian artery and vein are behind and below the medial 1/3 of the clavicle, and thus, special attention should also be paid to avoid damaging these structures during drilling

sternocostal (synovial) joint

aortic arch clavicle

b

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H. Chen et al.

a elevation

retraction posterior rotation

protraction

b depression

Fig. 2.4  The clavicle moves up by 30° when the upper arm is lifted above the head. The clavicle moves forward and backward by 35° on the horizontal plane during extension and flexion of the shoulder joint, respectively. The clavicle can rotate along the long axis by 30° when the upper arm is lifted above the head

2.1.3 Mechanisms of Injury

Fig. 2.5  Common mechanisms of clavicular injury. (a) Direct falling of the shoulder onto the ground. (b) Falling with the upper limb in the elbow-straight position and pushing the ground using the palm results in a clavicular fracture due to the passage of stress along the upper limb

• Direct violence: The clavicle is located in the subcutaneous layer and lacks protection from soft tissue. Most fracbility of the fracture, and thus group II in the Allman tures are caused by direct violence; 87% of fractures are classification of outer 1/3 fractures is divided into three caused by the force of direct falling of the shoulder onto types: type I comprises fractures in the proximal or distal the ground, and 7% are caused by direct hitting (Koval ends of the coracoclavicular ligament that show no disand Zuckerman 2006). placement and integrity of the coracoclavicular ligament; • Indirect violence: Only 6% of the fractures are due to falltype II comprises fractures with rupture in the proximal ing with the upper limb in a straight position and pushing conoid ligament and integrity in the distal trapezoid ligathe ground using the palm, which results in fracture due to ment; type III comprises fractures in the acromioclavicupassage of stress along the upper limb (Koval and lar joint (Neer II 1984, 1968). Zuckerman 2006) (Fig. 2.5). • Rockwood further divided Neer type II into two subtypes. • Other causes of fractures: These cases are rare, such as Type IIa includes fractures located in the medial coracofracture secondary to epilepsy with muscle spasms, non-­ clavicular ligament with integrity in the conoid ligament traumatic pathological fracture, and stress fatigue fracture and trapezoid ligament, whereas type IIb includes frac(Koval and Zuckerman 2006). tures located between the conoid ligament and the trapezoid ligament that show rupture in the conoid ligament and integrity in the trapezoid ligament (Rockwood 1982b). 2.1.4 Classification of Clavicular Fractures • Craig integrated the above typing methods and added some unusual types of fractures to develop a more detailed and • Allman divided clavicular fractures into three groups comprehensive classification method (Craig 1990, 1996): according to location: group I includes medial 1/3 frac–– Group I: Middle clavicular fracture (80%). This type tures, group II includes outer 1/3 fractures, and group III of fracture can occur in children and adults. The distal includes inner 1/3 fractures. However, this classification and proximal fractures are relatively fixed by the does not consider the displacement and degree of crushattached ligaments and muscles. ing in the fracture and thus has little significance for –– Group II: Distal clavicular fracture (15%). According determining treatment and prognosis (Allman 1967). to the location of the fracture relative to the coracocla• Neer believed that, in distal clavicular fractures, the coravicular ligament, this group can be divided into three coclavicular ligament plays an important role in the statypes (Fig. 2.6):

2  Fracture of the Clavicle Fig. 2.6  Group II fractures (distal 1/3 of the clavicle) in Craig’s classification. (a) Type I (fractures without displacement): the fractures occur between the conoid ligament and the trapezoid ligament or between the coracoclavicular ligament and the acromioclavicular ligament, without any ligament tear. Type II (fractures with displacement): the fractures occur in the medial side of the coracoclavicular ligament. (b) Type IIa: the conoid ligament and trapezoid ligament are intact. (c) Type IIb: the conoid ligament is ruptured, and the trapezoid ligament is intact. (d) Type III includes the fractures on the articular facet of the acromioclavicular joint without displacement and ligament injury

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a

c

Type I: Fractures without displacement. The fractures occur between the conoid ligament and the trapezoid ligament or between the coracoclavicular ligament and the acromioclavicular ligament, with no ligament tear Type II: Fractures with displacement. The fractures occur in the medial coracoclavicular ligament, with a high incidence of nonunion Type IIa: The conoid ligament and trapezoid ligament are intact Type IIb: The conoid ligament is ruptured, and the trapezoid ligament is intact Type III: Fractures on the articular surface of the acromioclavicular joint, with no ligament injury. These fractures are easily confused with degree 1 dislocation of the acromioclavicular joint Type IV: Periosteal sleeve fractures (in children) Type V: Comminuted fractures, in which the ligament attachment point is neither proximal nor distal but is in the crushed bone –– Group III: Proximal clavicular fracture (5%). If the sternoclavicular ligament is intact, the fracture is usually not associated with displacement and often shows epiphyseal injury in children and adolescents. This group can be divided into:

b

d

Type I: no displacement Type II: displacement with ligament rupture Type III: intra-articular fractures Type IV: epiphyseal separation (in children and minors) Type V: comminuted fracture

2.1.5 Assessment of Clavicular Fractures 2.1.5.1 Clinical Assessment • Typical manifestations: Head bias to the affected side and adduction of the affected, with the contralateral hand holding the affected forearm. • Shortness of breath and weakened respiratory sounds should be assessed. Weakened respiratory sounds often suggest lung injury and complication of pneumothorax, which require immediate treatment. • The integrity of the skin (except for open fractures) should be evaluated. If the proximal protrusion of the fracture pushes the local skin out, there is a potential open risk, and surgical treatment is recommended. • The length of the ipsilateral clavicle should be measured from the sternoclavicular joint to the acromioclavicular joint, and the result should be compared with that of the contralateral healthy side.

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• Nerve and vascular function should be examined: if any complicated nerve or vascular injury is found, timely surgery is necessary.

2.1.5.2 Imaging Assessment • X-ray of the anterior and posterior clavicle: routine examination to diagnose clavicular fracture and reveal the degree of fracture displacement. • X-ray for the oblique clavicle: If it is difficult to determine the degree and direction of the displacement from fluoroscopy, another fluoroscopy can be applied. In general, the projection tilting 20–60° to the head is selected. In this case, the impact of thorax on the display of the clavicle is minimal (Fig.  2.7) (Craig 1998; Crenshaw 1992). • Other special projection angles: –– Top oblique position: projection with the affected shoulder tilted by 45° and the bulb tilted 20° for the diagnosis of mild fractures, such as neonatal fractures and greenstick fractures in children (Weinberg et al. 1991). a

b

c

Fig. 2.7 (a) Anteroposterior radiographic view of the clavicle: visualization of the medial clavicle is unclear due to the thorax. (b) To obtain an oblique radiographic view of the clavicle, the incident beam should be projected at an angle of 20–60° with respect to the head. (c) Oblique radiographic view of the clavicle: the impact of the thorax on the visualization of the clavicle is minimized, creating another angle for observation

H. Chen et al.

–– Abduction position of the spine lordosis: projection with shoulder abduction >135° and bulb tilted 25° to reveal the clavicle and reduction of the fracture below the steel plate (in abduction of the shoulder, the clavicle has an upward rotation in the vertical axis) (Riemer et al. 1991). –– Projection at stress position: to evaluate the integrity of the coracoclavicular ligament and fracture displacement from the projection in the anteroposterior position and the forward and backward oblique 45° position while the affected limb holds 10 pounds of weight (Bucholz 2010b). • CT scan: to identify whether sternoclavicular joint dislocation, epiphyseal injury, and distal clavicular fracture are involved in the articular surface.

2.2 Surgical Treatment 2.2.1 Surgical Indications and Purpose 2.2.1.1 Surgical Indications • Proximal clavicular fracture: –– Most proximal clavicular fractures show no significant displacement or have only a small displacement, and thus non-surgical treatment is preferred. –– When the fracture fragment shows a significant backward displacement, especially when the bone is protruding into the neck and mediastinum, there is a risk of compression of the cervical nerve and vessels by the fracture fragment, and thus, open reduction and internal fixation should be performed (Rockwood 2008a). • Middle clavicular fracture: –– Most middle clavicular fractures can be treated with forearm mitella or an 8-shaped bandage (Rockwood 2008a). –– The indications for surgical treatment (Bucholz 2012) include the following: Open fracture Fracture complicated with subclavian nerve and vascular injury Fracture with obvious displacement and raised skin, which may develop into an open fracture Ipsilateral clavicle and scapular fracture (floating shoulder) or facture complicated with the damage in other parts of the SSSC Fracture with displacement exceeding the clavicle diameter or shortened space greater than 2 cm Fracture combined with scapulothoracic dissociation –– Contraindications for surgical treatment: Fracture with soft tissue injury at the surgical site or nearby

2  Fracture of the Clavicle

Fracture associated with systemic infection Pathological fractures with obstruction for adequate internal fixation or fracture in severe osteoporosis • Distal clavicular fracture: (Rockwood 2008a) –– Conservative treatment can be provided for distal clavicular fracture with no displacement. –– Surgical treatment is preferred for distal clavicle type II fracture.

2.2.1.2 The Purpose of Surgery • To restore the stability of the structures including the sternoclavicular joint, acromioclavicular joint, and coracoclavicular ligament. • To restore the normal morphology of the clavicle and its boom function. • To recover shoulder function as early as possible.

2.2.2 Surgical Techniques • Proximal clavicular fracture: –– If symptoms of compression are persistent, partial resection of the medial clavicle and reconstruction of the sternoclavicular joint are recommended. –– Because of the important structure in the rear of the sternoclavicular joint, a thoracic surgeon must participate in the operation (Rockwood 2008a). • Middle clavicular fracture: –– Internal fixation using a steel plate and screw can be applied to provide pressure on the fracture end and effectively control the rotation with the widest applicable range. –– Intramedullary fixation is suitable for fractures that are not very comminuted or only in a wedge-shaped bone fragment. Because the clavicle is S-shaped, it is difficult to obtain adequate resistance to rotation by intramedullary fixation, and there is the possibility of inward displacement or even injury in the mediastinum organs, reducing its application (Rockwood 2008a). –– For comminuted fractures, shortened reduction is not recommended, and a local bone graft may be considered to promote healing and retain the length of the clavicle. • Distal clavicular fracture: –– A distal clavicle plate can provide stable fixation after the anatomical reduction of the fracture through fixation of the acromioclavicular joint, and early postoperative functional exercise is conducive to shoulder function recovery. –– In recent years, attention has turned to reconstruction of the coracoclavicular ligament. Reconstruction methods include stitch rivet and PDS II suture.

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2.2.2.1 Partial Resection of the Medial Clavicle and Reconstruction of the Sternoclavicular Joint • Position and preoperative preparation: –– In supine position, the treatment towel is placed as a small column in the scapular area (the entire chest is exposed to enable expansion of the surgical incision if surgical complications occur). • Operative incision according to the projection on the body surface: –– The important structures, such as the clavicle, the sternoclavicular joint, the manubrium of sternum, and the sternocleidomastoid muscle, are labeled with a marker. An incision is made along the Langer’s line of the necklace of the clavicular head and the manubrium of the sternum (Fig. 2.8). • Surgical procedures: –– The skin and the subcutaneous tissue are cut, with subcutaneous dissociation on the platysma surface. The platysma is cut along the skin incision to expose the sternoclavicular joint capsule and the starting point of the sternocleidomastoid muscle (the joint capsule is marked with silk, and the sternum of the sternocleidomastoid muscle should not be cut off). –– After partial resection of the clavicular head, the sternoclavicular joint is reconstructed (non-traumatic dysfunction) (Fig. 2.9). –– The joint capsule is carefully pushed and lifted from the clavicular head with an electric scalpel; the outward dissociation should not be too far, and damage to the posterior sternoclavicular ligament should be avoided. –– The joint capsule is carefully cut along the edge of the articular cartilage in the clavicular head to remove the articular disc.

Fig. 2.8  Preoperative incision marks by surface projection

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Fig. 2.9  Resection of the articular disc of the sternoclavicular joint and proximal clavicle. (a) Resection of the articular disc. (b) Partial resection of the clavicular head. (c) The removed clavicular head

–– The joint capsule is opened using an automatic retractor to place a blunt periosteal elevator close to the articular surface. Approximately 0.5–1 cm of the clavicular head is sawed using a small bone saw, or a small part of the clavicular head is removed, and then the remaining bone is ground using a grinder to avoid excessive removal of bone and damage to the posterior sternoclavicular ligament, which will lead to damage to the mediastinum by joint capsule injury after clavicular proximal perforation. –– The clavicle head is pried up using a bone knife. The posterior lateral capsule is carefully dissected and separated in the rear of the clavicle, with the sternoclavicular ligament carefully protected. It is very important to maintain the integrity of the joint capsule. After the joint capsule is completely stripped from the clavicle, the joint capsule ending point in the clavicle should be reconstructed using a stitch rivet; if the sternoclavicular ligament is completely ruptured, the articular disc and the ligament should be sutured and fixed through the bone marrow cavity of the clavicle. –– A small incision is created at the wrist stripes, the palmaris longus tendon is transcutaneously collected using a tendon stripper, and stitching is sutured at the end of the tendon for fixation. –– The tendon palmaris longus is rolled up on a small cylinder and then sutured to maintain a shape similar to an “articular disc.” –– The prepared “articular disc” is inserted in the space created by resection of the clavicular head (a filler is

inserted between the clavicle resection surface and the manubrium of the sternum to replace the function of the articular cartilage disc). –– The palmaris longus tendon passing the clavicle and the first rib is sutured in an “8” shape to fix and strengthen the unstable sternoclavicular joint (Fig. 2.10). –– The joint capsule is closed with intermittent “8”-shaped, non-absorbable suture, with in situ suture fixation of the sternal head of the sternocleidomastoid. –– The incision is closed layer by layer. • Postoperative treatment: –– Protection with a hanging triangular bandage should last for 6 weeks without movement of the upper limbs to permit joint capsule healing and prevent the occurrence of instability. –– Beginning 6  weeks after surgery, the range of upper limb movement is gradually increased. –– At 12  weeks after surgery, strength exercises of the upper limbs can be started. –– At 16 weeks after surgery, voluntary movement can be performed. • Experience and lessons: –– The instability of the sternoclavicular joint may cause severe discomfort in the rear of the sternum that is progressively aggravated. If the sternoclavicular ligament is torn, the articular disc and ligament can be sewn into the medullary cavity of the clavicle, or the sternoclavicular joint can be reinforced by fixing the tendon around the first rib.

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b

c

Fig. 2.10  Reconstruction of the sternoclavicular joint. (a) Drilling on the proximal clavicle and the manubrium. (b) The palmaris longus tendon or hamstring tendon is sutured in an “8”-shaped pattern to fix and

strengthen the unstable sternoclavicular joint. (c) Photograph taken during surgery

–– Reconstruction of the unstable sternoclavicular joint: Many methods are reported in the literature; we recommend the “8”-shaped suture fixation. After exposing the structure above the jugular notch of the sternum and in the rear of the manubrium of sternum, the retractor should be placed in the rear of the manubrium of sternum for protection. Two holes can be drilled in the rear of the manubrium of sternum so that the suture can pass through, and 2 more holes can be drilled from front and back in the proximal clavicle. The semitendinosus tendon can pass through the holes in an “8”-shaped suture, followed by suture and fixation of the sternoclavicular joint. The palmaris longus should turn around the first ribs to strengthen and fix sternoclavicular joint (the

posterior structure of the first rib should be evaluated to avoid damage to the thoracic artery). The exposure of the posterior sternal notch should be assisted by a thoracic surgeon. –– For proximal clavicular fracture, the proximal end can be removed, and the articular disc and joint capsule can be pushed and fixed into the clavicle cavity to stabilize the sternoclavicular joint.

2.2.2.2 Steel Plate Above the Clavicle and Screw Fixation for Middle Clavicular Fractures • Position and preoperative preparation: –– The beach chair (semi-sitting) position is used, with a pillow behind the shoulder and the affected limb placed beside the body. –– Operative incision according to the projection on the body surface.

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• A longitudinal incision is created along the clavicle surface parallel to the clavicle diaphysis long axis and slightly lower than the clavicle (Fig. 2.11). • Surgical procedures: –– The skin and the subcutaneous tissue are cut, with mild subcutaneous dissociation on the platysma surface. The supraclavicular nerve should be carefully protected. The platysma is cut along the skin incision to expose the clavicular fracture for reduction (Fig. 2.12). –– Reduction for the fracture, with fixation using a steel plate and screws. Placement of the steel plate: A 3.5-mm LC-DCP steel plate or anatomical plate is placed on the upper surface of the clavicle (Fig. 2.13).

a

Fixing the screws: At least three screws are needed on each of the fracture ends to provide adequate resistance to rotation. Clavicular fractures are usually oblique fractures, and thus interlocking lag screws between the fracture fragments can enhance the stability of the fixed structure. Bone graft: If the blood supply of the fracture fragments is well protected, bone graft is not necessary; if the periosteum in the contralateral cortex at the steel plate surface is extensively stripped or shows showing a gap, a graft with a small amount of autogenous iliac cancellous bone should be considered. –– After rinsing with a large amount of saline, the incision is closed layer by layer (the platysma is closed to

b

Fig. 2.11 (a) The patient is positioned in a semirecumbent position with a pillow behind the shoulder and the affected limb placed in front of the body. (b) The preoperative incision marks by surface projection,

including an incision mark created on the skin surface along and parallel to the clavicle on the affected side

supraclavicular sensory nerves

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b

Fig. 2.12  Exposure of the clavicular fracture and reduction of the clavicle with a reduction clamp. (a) Local anatomy. (b) Photograph taken during surgery

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Fig. 2.13  A patient with a middle 1/3 clavicular fracture received open reduction and internal fixation with a stainless-steel reconstruction plate placed on the upper surface of the clavicle. (a) Preoperative X-ray image. (b) Postoperative X-ray image

prevent skin scarring and adhesion), with an indwelling negative pressure drainage tube. –– If skin conditions allow, subcutaneous non-invasive suture can be performed. • Postoperative treatment: –– Immediately after surgery, the patient can be encouraged to perform pendulum or small windmill movements with the hand on the side of the body. –– Shoulder abduction and weight-bearing exercise of the upper limb should not be performed until the fracture has healed. –– Shoulder stiffness rarely occurs but can be quickly restored after shoulder exercise, and shoulder exercise is recommended after healing of the fracture. • Experience and lessons: –– Incision exposure: The clavicular nerve traveling on the surface of the platysma should be protected during fracture exposure as much as possible to avoid postoperative numbness in the innervation area of the supraclavicular nerve in the surgical area. A small automatic retractor or temporary external fixator can be used to help maintain the force lines and temporary fixation. Stripping of the muscle attachment points and periosteum should be avoided (especially the muscles on the surface of the isolated fracture fragment) to preserve the blood supply of the fracture fragments. –– Fracture reduction and fixation: The operation should be performed carefully and not roughly, and temporary external fixation can be used to aid the reduction.

Note: When viewed from the top, the clavicle is S-shaped. When a DCP steel plate is used for fixation, the steel plate must be shaped. This process should be completed in a single attempt as much as possible to avoid repeated bending, which may cause fatigue of the plate. The selection of an appropriate anatomical plate at this time can reduce the difficulty of shaping. If the steel plate cannot be properly attached, less than 3 screws may be available for effective fixation, which will weaken the anti-rotation effect of the fixed steel plate and cause pullout of the screws. In this case, a locking plate can provide better resistance to pull out, with certain advantages (Fig. 2.14). If the fixed plate is too short or the force distribution of the screws in the two ends is uneven, failure of the internal fixation may occur (Fig. 2.15). The lateral bone fragment should be fixed with locking screws to prevent pullout of the screws. Fixation of the steel plate in the anterior clavicle can reduce the degree of steel plate protrusion. However, the mechanical characteristics of the clavicle determine the tension side of the supraclavicular plane. Based on the principle of tension of a steel plate, placement of the screws of the steel plate above the clavicle is more consistent with its mechanical characteristics. –– Clavicular locking plate (Fig. 2.16): In recent years, many manufacturers have introduced anatomical locking plates suitable for the clavicle, which have reduced the difficulty of intraoperative shaping and provided angle stability more suitable for patients with osteoporosis.

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a

b

c

d

e

f

Fig. 2.14  Example of an internal fixation failure causing fixer and fracture displacements. (a) An X-ray image showing a middle clavicular fracture before internal fixation. (b) An X-ray image taken immediately after internal fixation. (c) An X-ray image showing bone displacement 2 months after fixation. (d) An X-ray image illustrating

bone fracture healing 1  year after using a triangular bandage to re-­ secure the fixation. (e) A CT scan reconstruction image showing bone fracture healing and complete shaping 2  years after surgery. (f) An X-ray image after surgical removal of the internal fixator

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In the distal plate, a design with multiple locking screws can be applied to a distal clavicular fracture. Ryan Will et al. have shown that locking plate fixation for a clavicular fracture has better anti-rotation stress performance than a non-locking plate (Will et al. 2011). The distal locking plate employs a thin design that is compatible with percutaneous placement technology to reduce incision exposure. In accordance with the principle of a locking steel plate with angle stability, single-layer cortical screw fixation can effectively avoid the injury to blood vessels, nerves and lung caused by penetration of the cortex below by the drill or screw. However, an in vitro study by K. J. Little et al. (2012) showed that the strength of single-layer cortical screw fixation for the locking plate is significantly lower than those of double-layer cortical screw fixation for the

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locking plate and double-layer cortical screw fixation for the non-locking plate. Clavicle locking plates are still relatively new, and reports with a large number of cases are lacking in the literature.

2.2.2.3 Anterior Clavicle Fixation with a Steel Plate and Screws for Middle Clavicular Fractures • The technique is essentially the same as that for steel plate fixation for middle clavicular fracture. The only difference is that the attachment of the pectoralis major and deltoid is partially disassociated from the outer part of the periosteum of the anterior clavicle. • The front view of the clavicle shows a more regular shape than the top view. The steel plate only needs to be bent in one dimension, and thus the steel plate shaping is relatively simple.

a

b

c

d

Fig. 2.15 (a) Clavicle diaphyseal fracture with sphenoid bone mass. (b) X-ray after clavicle fixation. (c) Eight months after operation, the plate was broken, nonunion, and the fracture site was painful during shoulder joint movement. (d) Surgical removal and internal fixation of the broken end of the fracture. (e) Broken plates, wires, and screws

removed during the operation. (f) Abnormal activity of the broken end of the fracture was observed when the internal fixation was removed. (g) After bone grafting and locking plate fixation at the broken end of iliac crest. (h) X-ray film after revision of nonunion

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f

g

h

Fig. 2.15 (continued)

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Fig. 2.16  Clavicular locking plates. (a) Anterior-superior stainless-­ ing plate: it can be fixed with multiple locking screws on its lateral side steel locking plate: it employs a thin-end design that is compatible with and thus can be applied to a distal clavicular fracture percutaneous placement technology. (b) Superior stainless-steel lock-

• Placement of the steel plate in front of the clavicle can reduce the protrusion of the internal fixation. The directions for drilling and the screw are backward, not lower than the clavicle, and thus the safe area for the protection

of blood vessels and nerves is greatly increased. However, operation in the interior should be performed carefully to avoid reaching too deep and causing damage to the tip of the lungs (Fig. 2.17).

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a

b

Fig. 2.17  Internal fixation of the anterior clavicle with a stainless-steel plate and screws for a middle clavicular fracture. (a) Photograph taken during surgery. (b) Postoperative X-ray image

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b

Fig. 2.18  Preparation of the medullary cavity of the proximal clavicle for a middle clavicular fracture. (a) Schematic diagram. (b) Intraoperative fluoroscopy image

2.2.2.4 Intramedullary Nail Fixation for Middle Clavicular Fractures • Position and preoperative preparation: –– The patient is set in the beach chair position, with a pillow behind the shoulder. The clavicle, fracture site, and surrounding anatomical structure are marked. • Operative incision according to the projection on the body surface: –– The fracture site is marked with C-arm fluoroscopy. A 2–3-cm incision is created along the Langer line of the neck skin folds at the fracture site. • Surgical procedures: (Rockwood 2008b) –– Surgical approach: The skin and subcutaneous tissue are cut to reach the platysma (if the subcutaneous fat is very thin, a

full thickness of the flap can be prepared), followed by subcutaneous disassociation on the surface of the platysma. Blunt dissection is performed along the traveling direction of the platysma fibers (the supraclavicular nerve should be identified, retracted, and protected; the middle branch should be located around the middle of the clavicle). With the exposure of the clavicular fracture ends, the hematoma and embedded muscle tissue in the fracture ends are removed (for wedge-shaped bone fragments, the soft tissue attached to the bone should be retained). –– Preparation of the medullary cavity in the proximal clavicular fracture: (Fig. 2.18)

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The diameter of the medullary cavity: While holding the proximal end of the clavicular fracture with a bone holder or towel clips, the diameter is measured with a suitable drilling bit, and then a C-arm is used to verify that the drilling bit fills the medullary cavity and to mark the direction of the medullary cavity. Expansion of the medullary cavity: The drilling bit and T handle are connected to expand the clavicular medullary cavity; penetration of the anterior cortex of the clavicle should be avoided. Tapping: After connecting the tapper and T handle, tapping of the medullary cavity is performed to approach the front lateral cortex. –– Preparation of the medullary cavity in the distal clavicular fracture: (Fig. 2.19) With outward rotation of the upper arm, the clavicular fracture distal is raised. The same drill bit is used to connect the T handle and expand the medullary cavity in the distal clavicular fracture. The posterior lateral cortex is penetrated with C-arm guidance to ensure that the drill bit pierces from the posterior medial of the acromioclavicular capsule to the lower part of the posterior lateral clavicle. The tapper and T handle are connected for tapping. –– Reduction, fixation, and compression of the fractures: The nut of the intramedullary nail is removed to connect the T handle to the medial end of the intramedullary nail without thread. While holding the lateral part of the clavicular fracture, the clavicular intramedullary nail is penetrated

Fig. 2.19  Preparation of the medullary cavity of the distal clavicle for a middle clavicular fracture

into the lateral medullary cavity, piercing from the hole previously drilled. After palpating the subcutaneous intramedullary nail, a small incision is created for the blunt separation of the subcutaneous tissue using a pair of hemostatic forceps to expose the intramedullary nail. With protection provided by a pair of hemostatic forceps or a small retractor, the intramedullary nail is pushed through the incision and then rotated with a wrench until the medial thread securely grips the lateral cortex. The T handle is then connected to the outer head of the ­intramedullary nail to continue rotating the intramedullary nail into the medullary cavity. The upper arm is lifted to reset the fracture ends, and the intramedullary nail is rotated into the proximal end of the clavicular fracture. A C-arm can be used to confirm that the intramedullary nail passes through the medial fracture line and to ensure that all medial threads pass through the fracture line (Fig. 2.20). Two nuts are cold welded on the outer side of the intramedullary nail; one nut is threaded first, followed by a smaller nut. The inner nut is gripped with a wrench, and the outer nut is then rotated using another wrench to lock the two nuts together. With guidance from the C-arm, the outer nut wrench is used to rotate the intramedullary nail into the proximal end of the clavicular fracture until the intramedullary nail reaches the anterior cortex. A wrench is used to unlock the two nuts in reverse clockwise. The inner nut is then screwed in to apply compression onto the position of the clavicular fracture. The two nuts are then locked again. The inner nut wrench is used to pull out the intramedullary nail system from the soft tissue and expose the nut by approximately 1 cm to facilitate cutting of the intramedullary nail at the same level as the nut. Finally, the outer nut wrench is used to push the intramedullary nail system back into the medial clavicular fracture with the same compression on the fracture site. –– Treatment of wedge-shaped bone fragments and wound closure: For anterior wedge bone fragments, No. 0 or No. 1 absorbable suture is used for cerclage (to move the suture, a periosteal stripper is placed below the clavicle, and the suture passes through the periosteum of the wedge-shaped bone fragment around the bone and the clavicle).

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b

c

Fig. 2.20  Placement of an intramedullary nail after reduction, fixation, and compression of the fracture. (a, b) Schematic diagram. (c) Postoperative X-ray image

An intermittent 8-shaped suture (No. 0 absorbable line) is used to suture the periosteum at the fracture site. An intermittent 8-shaped suture with 2-0 absorbable suture is used to suture the fascia of the platysma. The subcutaneous tissue and skin of the two incisions are closed. • Postoperative treatment: –– Protection with a hanging triangular bandage should last for 4  weeks. The triangular bandage should be removed at least five times every day to allow initiative movements within the elbow movement range and shoulder-associated initiative flexion by 90°. –– After 4 weeks, the triangular bandage can be removed, and exercise of the active function of the shoulder in full range can be started. –– If the patient’s shoulder function is not limited, and fracture healing is confirmed by the clinical and radio-

logical examinations, the shoulder joint resistance exercise can be started and gradually increased after 6 weeks. –– Once the clavicular fracture heals, the internal intramedullary nails can be removed 10–12  weeks postoperatively. • Removal of the clavicular intramedullary nail: (Rockwood 2008c) –– After the fracture heals, i.e., at 10–12 weeks postoperatively, the intramedullary nail can be removed. –– In the lateral position, local block anesthesia is provided for the patient. –– The previous lateral incision is cut, and the subcutaneous tissue is separated using a hemostatic clamp to expose the inner nut. –– The intramedullary nail is pulled out with the inner nut wrench. –– The nut is removed, and the T handle and screw are connected to pull out the intramedullary nail.

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• Experience and lessons: –– Locking technique for the lateral nut of the intramedullary nail: The medial head should be blunt to technically avoid penetrating the anterior cortex of the clavicle. Under fluoroscopy, the drill bit should pierce from the posterior lateral to the lower part of the clavicle to avoid excessive protrusion of the lateral intramedullary nail, which may lead to skin wear. If the tapping in the proximal and distal of the clavicular fracture is too tight, a drill bit with a large diameter should be used to avoid breaking the medullary cavity of the clavicle.

2.2.2.5 Open Reduction with Clavicular Hook and Steel Plate Fixation for Distal Clavicular Fractures • Position and preoperative preparation: –– The patient is in beach chair (semi-sitting) position, with a pillow behind the shoulder and the affected limb placed beside the body. • Operative incision according to the projection on the body surface: (Fig. 2.21) –– An arc-shaped incision is created along the clavicle and acromioclavicular joint surface, with the middle arc facing the coracoid process (the coracoclavicular ligament is easy to expose and repair); infiltration with diluted adrenaline can reduce bleeding of the skin edge. • Surgical procedures (Bucholz 2010a): –– The skin, subcutaneous tissue, and platysma are cut to dissect under the platysma. Stripping on the muscle attachment point and periosteum should be avoided while exposing the coracoclavicular ligament and acromioclavicular joint.

Fig. 2.21  The preoperative incision marks by surface projection

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–– Repair of the coracoclavicular ligament and acromioclavicular joint: The rivet is screwed into the base of the coracoid process. The ruptured coracoclavicular ligament is sutured, with no knot. The acromioclavicular joint is reset and temporarily fixed with Kirschner wire. The appropriate hook plate is selected: if the hook is too deep, the fixation for the acromioclavicular joint will not be strong; if the hook is too shallow, the pressure of the hook on the shoulder will be too great, and the hook will fall into the shoulder and cause pain. The clavicular hook is placed below the acromion immediately next to the clavicle. The gap below the acromion is wide in the front and narrow in the back, and thus the more backward the location of the clavicular hook placement, the deeper the depth of the hook. First, the size of the hook plate should be determined using the test mold, starting from 12 mm, with the hook end placed under the acromion, and then the clavicular part of the steel plate is attached to the upper surface of the clavicle. If the steel plate is difficult to attach, a deeper test mold is needed. When the hook plate is placed on the clavicle, the hook end should be in contact under the acromion. During shoulder movement, especially shoulder abduction and outward rotation, the shoulder should be monitored with fluoroscopy to avoid collision of the hook end and the humeral head (Fig. 2.22). At least three screws are used to fix the fracture proximal (Fig. 2.23). A knot is made in the suture to repair the ruptured coracoclavicular ligament. If the acromioclavicular ligament is ruptured, PDS II suture can be used to reinforce the suture. –– Rinsing with saline is followed by complete hemostasis and incision closure layer by layer. • Postoperative treatment: –– Protection with a hanging triangular bandage should last for 6  weeks. The triangular bandage should be removed for at least five times every day. The patient can be encouraged to perform pendulum exercises or small windmill movements. –– After 6 weeks, the triangular bandage can be removed, and exercise of the active function of the shoulder in full range can be started. • Experience and lessons: –– The indications for a clavicular hook plate should be strictly controlled. For a distal clavicular fracture

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b

Fig. 2.22  Placement of the clavicular hook plate: The hook end is pushed along the posterior clavicle until it is under the acromion. (a) Schematic diagram illustrating the position of the hook plate. (b) Intraoperative fluoroscopy image for observation of the hook plate

a

b

Fig. 2.23  Fixation of the hook plate on the clavicle. (a) Photograph taken during surgery. (b) Radiograph after surgery using rivets to repair the ruptured coracoclavicular ligament

(Neer II type), because the distal residual bone is small and the bone is cancellous, ordinary plate screws result in poor fixation force or even fixation failure, whereas the clavicular hook steel plate can provide a stable fixation. –– The clavicular hook plate restricts the movement of the acromioclavicular joint, resulting in greater stress at the turning point of the steel plate hook, which can lead to complications such as breakage (Fig.  2.24). Thus, early removal is recommended. In addition, the

hook plate proximal and the clavicle also form a concentrated stress, causing complications such as secondary clavicular fracture (Fig. 2.25). –– Complications of the hook plate include acromial bone absorption (Fig.  2.26) and acromial collision. Taneja reported that 7 of 37 patients with clavicular hook plate fixation showed symptoms of acromial collision (Taneja 2009). The timing of hook steel plate removal is more stringent than that of ordinary steel plate (Rockwood 2008b):

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Fig. 2.24  A patient with clavicular and scapular fractures. (a) Hook plate fixation of the clavicle and open reduction and internal fixation of the scapula. (b) The clavicular hook plate was broken after surgery

a

b

c

d

Fig. 2.25 (a, b) Fixation with the clavicular hook plate for simple acromioclavicular dislocation. (c) A traumatic fracture occurring at the stress concentration site of the medial hook plate 4 years after surgery.

a

(d) Open reduction and internal fixation using a superior clavicular reconstruction plate

b

Fig. 2.26 (a) The bright acromial bone area between the hooks indicate bone absorption after fixation using a clavicular hook plate. (b) The acromial bone absorption remains visible after removal of the plate

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For simple acromioclavicular dislocation (no distal clavicular fracture), the hook steel plate can be removed 8 weeks after surgery. For acromioclavicular dislocation combined with clavicular fracture, the hook steel plate can be removed after healing of the fracture (approximately 12 weeks). For young patients, the hook steel plate can be removed late or even left in place; however, for elderly patients, removal of the hook steel plate as early as possible once the fracture or coracoclavicular ligament is healed is recommended. –– The coracoclavicular ligament is the most important vertical stable structures of the clavicle (Palastanga and Soames 2012). If coracoclavicular ligament rupture is not repaired during surgery, it will be difficult to provide sufficient vertical stability after removing the hook plate. This may lead to re-fracture or acromioclavicular dislocation. Thus, intraoperative repair with a rivet during surgery should be performed as much as possible.

2.2.3 Common Surgical Complications and Prevention Strategies • Nonunion: –– McKee et al. reported that the incidence of nonunion was as high as 21% in non-surgical treatment (McKee 2010), compared with 2.4% in patients undergoing surgery [51, 52]. –– In patients undergoing surgical treatment, nonunion is often related to blood supply damage caused by unstable internal fixation and soft tissue damage. For simple fractures, fixation with lag screws and compression on the fracture ends should be applied as much as possible. –– The central part of the clavicle is mainly nourished by the periosteal blood vessels, and the blood supply is from the thoracoacromial artery branch, which enters from the pectoralis major and deltoid attachment. In surgery, periosteal stripping should be minimized to reduce blood supply damage. A bone graft can be applied if necessary to restore the blood supply and promote bone healing (Archdeacon 2012a, b). –– An appropriate material should be selected for internal fixation of the clavicle. The strength of a 1/3 or 1/2 tube-type steel plate is insufficient to support the movement of the upper arm. A 3.5-mm reconstructed steel plate is easier to pre-bend but is less strong. The strength of a 3.5-mm LC-DCP is sufficient, but this plate is difficult to pre-bend. The anatomical locking plate does not require pre-bending, and strength is sufficient, particularly patients with distal clavicular frac-

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ture and osteoporosis, but is expensive; in addition, there is no large-scale study reporting superior effectiveness compared to an ordinary steel plate. The hook plate shows many complications, and indications for application should be strictly limited to patients with distal clavicular fracture and coracoclavicular ligament injury. The clavicle intramedullary nail has an advantage with respect to postoperative appearance, but the risk of displacement is a disadvantage. –– For nonunion after conservative treatment, surgical treatment should be provided. The medullary cavity is drilled through for fixation using a steel plate and screws after cancellous bone graft. If there are obvious bone defects, cortical iliac bone graft can be performed to restore the length. –– For nonunion in the distal clavicle, depending on the situation, an anatomical locking steel plate or hook plate can be used for repair. A joint screw can be used to temporarily fix the acromioclavicular joint, with timely removal after fracture healing. –– Old distal clavicular fracture or distal clavicular nonunion is difficult to suture and repair if the coracoclavicular ligament injury is complicated and the coracoclavicular ligament shows contracture. For these cases, our hospital employs transposition of the coracoacromial ligament to repair the coracoclavicular ligament (Fig. 2.27) with good treatment efficacy. This method ensures the vertical stability of the clavicle after removal of the clavicular hook plate. • Malunion: The clavicle is an important component of the shoulder joint complex, and its malunion after fracture healing will lead to restricted joint movement of the shoulder. Matrumura showed that clavicle shortening of greater than 10% will affect the movement of the scapula, resulting in clinical symptoms (Matsumura et al. 2010). To avoid malunion of the clavicle, attention should be paid to the quality of intraoperative reduction, including reduction with deformity of length, angle, and rotation. In addition, postoperative follow-up should be performed regularly to avoid loss of fixation caused by internal fixation failure. • Injury of blood vessels and nerves: Drilling may cause injury in the subclavian artery and vein. Although the incidence is low, such injury is dangerous. Consequently, a set of sharp drill bits should be used for drilling in the operating room, and retractors should be used below the fracture for protection. The drill should be carefully ­controlled and should be stopped immediately stop once penetration is noted. Kloen et al. reported a method for placing a steel plate under the clavicle. Although the plate is not placed on the tension side of the clavicle, it can reduce the damage rate of blood vessels, nerves, and lungs (Kloen et al. 2009).

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a

b

Fig. 2.27  Transposition of the coracoacromial ligament to repair the coracoclavicular ligament for an old distal clavicular fracture accompanied by rupture and contracture of the coracoclavicular ligament. (a) After cleanup of the scar tissue surrounding the fractured bone, the coracoacromial ligament is cut at its end point on the acromion, and a hole is drilled in the distal clavicular fracture fragment, followed by

placement of a rivet into the coracoid process for subsequent use. (b) The coracoacromial ligament is inserted into the bore hole on the distal clavicular fracture fragment, and then the proximal clavicle is fixed with the rivet, followed by clavicular fixation with a combination of a hook plate and lag screws

• Implant-related complications (Archdeacon 2012a, b): –– Protruding screw of the steel plate: Because the skin above the clavicle is thin and sensitive, it may cause discomfort. If the fracture had healed based on the assessment after the occurrence of this complication, the screw of the plate can be removed; if it is removed too early, it may cause re-fracture. –– Displacement of the internal fixation: Especially when an intramedullary nail and other smooth internal fixation are applied, regular postoperative review of the internal fixation position should be conducted to avoid damage to dangerous areas such as the mediastinum. –– Hook plate-related complications: Because the hook end is placed under the acromion, the hook plate can cause complications such as shoulder stiffness. Therefore, the internal fixation should be removed as soon as possible depending on fracture healing, as described previously. • Nerve damage and scarring: Damage of the supraclavicular nerve during the surgical approach may cause postoperative pain keloid, anterior chest wall numbness, sensory abnormalities, and other complications. Without affecting exposure and reduction, the supraclavicular nerve should be preserved as far as possible (Archdeacon 2012a, b).

Archdeacon MT.  Prevention and management of common fracture complications. Slack Inc; 2012b. p. 81. Bucholz RW.  Rockwood and Green’s fractures in adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010a. p. 1107. Bucholz RW.  Rockwood and Green’s fractures in adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010b. p. 1128. Bucholz RW.  Rockwood and Green’s fractures in adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. p. 1107. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89:1–10. Craig EV.  Fractures of the clavicle. In: Rockwood CA, Matsen FA, editors. The shoulder. Philadelphia: WB Saunders; 1990. p. 367–412. Craig EV.  Fractures of the clavicle. In: Rockwood CA, Green DP, Bucholz RW, et al., editors. Rockwood and Green’s fractures in adults. Philadelphia: Lippincott-Raven; 1996. p. 1109–61. Craig EV.  Fractures of the clavicle. In: Rockwood CA, Matsen FA, editors. The shoulder. 3rd ed. Philadelphia: WB Saunders; 1998. p. 428–82. Crenshaw AH. Fractures of the shoulder girdle, arm and forearm. In: Willis CC, editor. Campbell’s operative orthopaedics. 8th ed. St. Louis: Mosby-Year Book; 1992. p. 989–95. Fukuda K, Craig EV, An KN, et al. Biomechanical study of the ligamentous system of the acromiocla-vicular joint. J Bone Joint Surg Am. 1986;68(3):434–40. Goldberg JA, Bruce WJ, Sonnabend DH, et al. Type 2 fractures of the distal clavicle: a new surgical technique. J Shoulder Elb Surg. 1997;6:380–2. Kloen P, et al. Anteroinferior plating of midshaft clavicle nonunions and fractures. Oper Orthop Traumatol. 2009;21:170–9. Koval KJ.  Handbook of fractures. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006. Koval KJ, Zuckerman JD. Handbook of fractures. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 122. Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the middle third of the clavicle: the relevance of shortening and clinical outcome. J Shoulder Elb Surg. 2006;15:191–4. Little KJ. Biomechanical analysis of locked and non-locked plate fixation of the clavicle. Injury. 2012;43:921–5.

References Allman FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967;49:774–84. Archdeacon MT.  Prevention and management of common fracture complications. Slack Inc; 2012a. p. 78.

2  Fracture of the Clavicle Matsumura N, et al. Effect of shortening deformity of the clavicle on scapular kinematics: a cadaveric study. Am J Sports Med. 2010;38:1000–6. McKee MD.  Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am. 2010;41: 225–31. Moseley HF.  The clavicle: its anatomy and function. Clin Orthop. 1968;58:17–27. Neer CS II.  Fractures of the distal third of the clavicle. Clin Orthop Relat Res. 1968;58:43–50. Neer CS II.  Fractures of the clavicle. In: Rockwood CA, Green DP, editors. Fractures in adults. Philadelphia: JB Lippincott; 1984. p. 707–13. Neumann DA. Kinesiology of the musculoskeletal system. 2nd ed. St. Louis: Mosby Elsevier; 2010. p. 129–30. Palastanga NP, Soames RW. Anatomy and human movement. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. p. 108. Postacchini F, Gumina S, De Santis P, et al. Epidemiology of clavicle fractures. J Shoulder Elb Surg. 2002;11(5):452–6. Riemer BL, et al. The abduction lordotic view of the clavicle: a new technique for radiographic visualization. J Orthop Trauma. 1991;5:392–4. Robinson CM. Fractures of the clavicle in the adult. J Bone Joint Surg (Br). 1998;80B:476–84. Robinson CM, Cairns DA.  Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am. 2004;86A:778–82. Rockwood CA. Fractures of the outer clavicle in children and adults. J Bone Joint Surg (Br). 1982a;64B:642. Rockwood CA. Treatment of the outer clavicle in children and adults. Orthop Trans. 1982b;6:472.

47 Rockwood CA. The shoulder. 4th ed. Philadelphia: Saunders Elsevier; 2008a. p. 422. Rockwood CA. The shoulder. 4th ed. Saunders Elsevier; 2008b. p. 429. Rockwood CA. The shoulder. 4th ed. Saunders Elsevier; 2008c. p. 443. Rockwood CA, Green DP.  Fractures in adults. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. Rokito AS, Eisenberg DP, Gallagher MA, et al. A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Joint Dis. 2003;61:32–9. Rowe CR. An atlas of anatomy and treatment of mid-clavicular fractures. Clin Orthop. 1968;58:29–42. Seo GS, Aoki J, Karakida O, et al. Case report: nonunion of a medical clavicular fracture following radical neck dissection: MRI diagnosis. Orthopedics. 1999;22:985–6. Stanley D, Trowbridge EA, Norris SH.  The mechanism of clavicular fracture. A clinical and biochemical analysis. J Bone Joint Surg (Br). 1988;70B:461–4. Taneja T. Clavicular hook plate: not an ideal implate. J Bone Joint Surg Br. 2009;91B(SUPP I):11. Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elb Surg. 2007;16:49–54. Urist MR. Complete dislocation of the acromioclavicular joint. J Bone Joint Surg Am. 1963;45:1750–3. Webber MC, Haines JF.  The treatment of lateral clavicle fractures. Injury. 2000;31:175–9. Weinberg B, Seife B, Alonso P. The apical oblique view of the clavicle: its usefulness in neonatal and childhood trauma. Skeletal Radiol. 1991;20:201–3. Will R. Locking plates have increased torsional stiffness compared to standard plates in a segmental defect model of clavicle fracture. Arch Orthop Trauma Surg. 2011;131:841–7.

3

Proximal Humerus Fracture Hua Chen, Zhe Zhao, and Zhengguo Zhu

3.1 Basic Theory and Concepts 3.1.1 Overview • Fracture of the proximal humerus is fracture of the humerus including its surgical neck and the parts above. • Proximal humerus fractures are more common, accounting for 5% of all fractures of the body and 45% of humeral fractures (Koval and Zuckerman 2006a). • The incidence is two times higher in females than in males. • These fractures are most common in elderly patients with osteoporosis, followed by young people with high-energy damage, often complicated with injury to the head, neck, chest, and spine (Koval and Zuckerman 2006b).

3.1.2 Applied Anatomy • The applied anatomy of the proximal humerus: Codman divided the proximal humerus into four parts, including the humeral head, greater tuberosity, lesser tuberosity, and humeral stem (Fig. 3.1). Other important anatomical structures are the dissecting neck, intertubercular groove, and surgical neck of the humerus (Codman 1934). –– The humeral head is connected to the anatomical neck of the humerus, in approximately 1/3 of the surface of the sphere, and the surface is covered with cartilage. The top view of the humeral head is inclined at an angle of 30° relative to the transverse axis of the humeral condyle (Boileau and Walch 1997). –– The anatomical neck of humerus is closely connected to the edge of the humeral head and is the site of attachment

H. Chen (*) · Z. Zhu Chinese PLA General Hospital, Beijing, China e-mail: [email protected] Z. Zhao Beijing Tsinghua Changgung Hospital, Beijing, China

of the articular capsule of the shoulder. When fracture and displacement of the anatomical neck occur, the blood supply of the humeral head is severely damaged, with poor prognosis. The humeral neck axis and the humeral stem axis form an angle of 135°, which is known as the humeral neck stem angle (Iannotti et al. 1992). –– The lesser tuberosity is located in front of the anatomical neck and is the site of attachment of the subscapular muscle. –– The greater tuberosity is located in the lateral proximal humerus and is the site of attachment of the supraspinatus, infraspinatus, and teres minor. It is lower than the highest point of the humeral head by 6–8 mm (Visosky et al. 2003). With abduction of the shoulder by 90–120°, it can reach the acromion, causing buckle lock of the glenohumeral joint. Therefore, in the reduction of large nodular fractures, the position should be lower than the highest point of the humeral head; also, while placing the lateral humerus plate, the upper margin of the plate should be below the greater tuberosity by 5–8 mm, otherwise acromial collision will occur and cause pain. –– The intertubercular groove is located between the greater and lesser tuberosity and is an important anatomical marker to determine the rotation and displacement in the reduction process of proximal humeral fracture. It is also an important positional reference for placing the steel plate in the lateral of the proximal humerus. The medial margin of the steel plate should be located 2–4 mm on the outer side of the intertubercular groove (Saha 1971; Cyprien et al. 1983). –– The surgical neck of humerus is located below the greater and lesser tuberosity and is a common site of fracture. After fracture of the surgical neck of the humerus, blood supply on both ends of the fracture is abundant, with a high fracture healing rate. • Blood supply in the humeral head and judgment of damage to blood supply after displacement of fracture: –– The blood perfusion of the humeral head is mainly from the arcuate artery (Fig.  3.2): The ascending

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_3

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a

b

c

135°

30°

Fig. 3.1 (a) Front and rear views of the proximal humerus. The humeral neck axis and the humeral shaft axis form an angle of 135°, which is known as the humeral neck-shaft angle. (b) Top view of the proximal humerus: The humeral head is retroverted at an angle of 30°

Fig. 3.2  The blood supply to the humeral head is mainly from the arcuate artery. The ascending branch of the anterior circumflex humeral artery, which is responsible for the major blood supply of the humeral head, travels along the intertubercular groove and enters the bone at the vertex level of the greater tuberosity. The remaining blood supply is derived from the blood vessels entering the metaphysis at the attachment points on the greater and lesser tuberosities and the posterior medial branch of the posterior circumflex humeral artery

relative to the epicondylar axis of the humerus. (c) Codman divided the proximal humerus into four parts, including the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft

suprascapular artery and nerves axillary nerve and posterior humeral artery

ascending branch of anterior circumflex humeral artery

thoracoacromial artery axillary artery lateral thoracic artery

anterior cirumflex humeral artery musculocutaneous nerve

subscapular artery median nerve branchial artery ulnar nerve medial cutaneous nerve

3  Proximal Humerus Fracture

branch of the anterior circumflex humeral artery after the separation travels with the long head of the biceps brachii along the intertubercular groove, enters the bone at the vertex level of the greater tuberosity, and bends inside the humeral head to the rear, which is known as the arcuate artery. This artery is responsible for the major blood supply of the humeral head (Gerber et al. 1990). –– The rest of the blood supply is derived from the blood vessels entering the metaphysis at the attachment point of the greater and lesser tuberosity and the posterior medial branch of the posterior circumflex humeral artery. –– Studies have shown that (Hertel et al. 2004) the type of fracture, the medial metaphyseal retention in the humeral head bone, and the integrity of the medial soft tissue can aid the assessment of the possibility of ischemic necrosis in the humeral head after the displacement of the fracture: Fracture of the anatomical neck is very rare. If such fracture occurs, the arcuate artery is likely to be severely damaged, which is associated with poor prognosis. Long medial metaphyseal retention on the humeral head bone (>8 mm) suggests that the blood supply in the humeral head is good. For posterior medial fracture, if the medial protruding part of the soft tissue remains intact, the humeral head blood supply is likely to be maintained, which is conducive to reduction (Fig. 3.3). • The trabecular bone structure of the humeral head and fixation with a plate and screw (Fig. 3.4): –– The trabecular bone structure in the center of the humeral head and the humeral neck gradually becomes loose with age (Yamada et al. 2007). –– The bone density is highest in the subchondral bone of the humeral head cartilage. In internal fixation for proximal humeral fracture, the tip of the screw should stop at 5–10 mm of the subchondral bone to ensure the fixation strength and prevent cutting of the screw into the glenohumeral joint (Tingart et al. 2003). –– The humeral calcar is the thickening of the bone plate at the medial proximal humerus and is an important support structure of the proximal humerus. In the reduction process, the restoration of the medial support has important significance for the prevention of collapse of the humeral head after fixation. The anatomical locking plate of the proximal humerus is designed with two humerus screws to resist the varus of the humeral head, which greatly improves the medial support and angular stability. The screw should be placed in the fixing process if possible (Osterhoff et al. 2012; Brianza et al. 2012).

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a

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Fig. 3.3 (a) In the two cases shown in the left and right images, longer medial metaphyseal retention (>8  mm) on the bone fragment of the humeral head (left) suggests a better blood supply in the humeral head. (b) For a posterior medial fracture, if the medial protruding part of the soft tissue remains intact (left), the humeral head blood supply is more likely to be maintained, which is conducive to reduction. Serious displacement of the medial part and severe damage of the soft tissue are associated with a poor prognosis (right)

–– The strength of the bone at the greater and lesser tuberosity is limited. In the reduction process, the excessive use of pointed reduction forceps should be avoided to prevent aggravation of the breakage of the bone. A towel clamp can be used for tendon handling, traction, reduction, and fixation of the greater and lesser tuberosity. Ordinary suture needles can easily pass through the cancellous bone of the greater and lesser tuberosity, and a variety of stitching technologies can be applied to repair the greater and lesser tuberosity. • The muscle attachment at the proximal humerus (Fig. 3.5) and the displacement direction during fracture (Fig. 3.6): –– The proximal humerus is covered with a large number of muscles, and distraction by the muscles and tendon can cause displacement of the fracture fragment. –– When fracture of the proximal humerus occurs in four parts, the supraspinatus, infraspinatus, and teres minor can pull the greater tuberosity with upward and backward displacement; the subscapularis and teres major can pull the lesser tuberosity with inward displacement; and the pectoralis major, brachial biceps, and

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Fig. 3.4 (a) CT scan of the humeral head. The greater tuberosity has a remarkably porous structure with sparse trabeculae. The high-density subchondral bone of the humeral head can serve as a good screw placement site for internal fixation. (From Meyer DC, Fucentese SF, Koller B, Gerber C. Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elbow Surg 2004. 13(3)). (b) The anatomical locking plate of the proximal humerus is designed with 2 humerus calcar screws to resist the tendency toward varus deformity of the humeral head, which greatly improves the medial support and angular stability. The screws should be positioned for fixation if possible. (c) Ordinary suture needles can easily pass through the cancellous bone of the greater and lesser tuberosities, allowing a variety of stitching technologies to be used for fixation of the greater and lesser tuberosities

a

deltoid can pull the humeral shaft with upward and inward displacement (Matsen et al. 2004). –– When the fracture of the proximal humerus occurs in three parts (Neer 1970b): If the greater tuberosity is connected to the humeral head, the supraspinatus and infraspinatus can pull upward and backward, leading to outward rotation of the articular bone fragment such that the articular surface of the humeral head rotates forward, with inward displacement of the lesser tuberosity and medial and proximal displacement of the humeral shaft. If the lesser tuberosity is connected to the humeral head, the subscapularis and teres major can pull inward, resulting in inward rotation of the fracture fragment in the joint such that the articular surface of the humeral head rotates backward, with upward and backward displacement in the fracture fragment of the greater tuberosity and medial and proximal displacement in the humeral shaft.

b

calcar screw

c

• Rotator cuff: The rotator cuff was described in the chapter on scapular fractures (see the sections on the applied anatomy of scapular fractures and the abduction movement of the shoulder joint). –– The rotator cuff is a dense tendon cap wrapping the humeral head on the upper, anterior and posterior surfaces that consists of the supraspinatus, infraspinatus, and teres minor attached to the greater tuberosity and the subscapular muscle and long head of biceps brachii attached to the lesser tuberosity. –– The function of the rotator cuff (Fig.  3.7) mainly involves two aspects: The muscle group forming the rotator cuff provides the torque for shoulder joint activities: the supraspinatus is one of the two main driving muscles for shoulder joint abduction, and the subscapular muscle and infraspinatus are the main driving muscles for the internal and external rotation of the shoulder joint.

3  Proximal Humerus Fracture

a greater tuberosity lesser tuberosity

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coracoid process acromion incisura supraspinatus scapulae superior angle

b superior angle

superior border

coracoid process acromion scapular spine

supraspinatus greater tuberosity

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medial border

inferior angle

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d deltoid, clavicle part

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acromion

deltoid, acromial part clavicle pectoralis major, sternum and ribs sternum

scapula, costal surface

pectoralis major, abdominal part deltoid tuberosity

humerus

humeral shaft

Fig. 3.5 (a) The subscapularis. (b) The supraspinatus, infraspinatus, and teres minor. (c) The pectoralis major and coracobrachialis. (d) The deltoid muscle

The rotator cuff is an important stabilization structure of the shoulder joint: the co-contraction of the supraspinatus, infraspinatus, and subscapular muscle can provide tension to press the humeral head on the glenoid, thus playing the role of the fulcrum in a lever in shoulder movement involving the glenohumeral joint (Matsen and Lippitt 2004). Treatment of proximal humeral fractures focuses on resetting and fixing the small and greater tuberosity, repairing the ending point of rotator cuff, achieving biological healing of the greater and lesser tuberosity with the humeral shaft, and restoring shoulder movement function.

• Long head of the biceps brachii (Fig. 3.8): –– The long head of the biceps brachii starts from the supraglenoid tubercle of the scapula, passes along the intertubercular groove, and continues to the biceps. –– The long head of the biceps brachii is an important marker in the reduction and reconstruction of the lesser and greater tuberosity. –– In the reduction of proximal humeral fracture, it may insert between the bone fragments, thus obstructing the reduction or causing nonunion. –– In the process of shoulder replacement, the tension can be used as a reference for the insertion depth of a humeral proximal prosthesis into the humeral shaft.

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b anatomical neck 1+3

long head of biceps brachii

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subscapularis

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deltoid

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Fig. 3.6 (a)Four-part fracture of the proximal humerus. The pulling force from the muscles can cause an upward and backward displacement of the greater tuberosity, an inward displacement of the lesser tuberosity, and an upward and inward displacement of the distal humeral shaft. (b) Three-part fracture of the proximal humerus; if the greater tuberosity (3) is connected to the humeral head fragment (1),

then the articular facet of the humeral head rotates forward with displacement of the humeral shaft (4). (c) Three-part fracture of the proximal humerus: if the lesser tuberosity (2) is connected to the humeral head fragment, then the articular facet of the humeral head rotates backward

3.1.3 Mechanisms of Injury

3.1.4 Classification of Fractures

• Indirect violence: Proximal humeral fractures are mostly the result of contact between straight upper limbs and the ground when falling; the impact is therefore conducted along the upper limb, causing fracture. This type of injury is more common in elderly patients with osteoporosis. • Direct violence: A small number of proximal humerus fractures are due to car accidents and other high-energy damage, which are more common in young people, or the shoulder striking the ground while falling, which is more common in elderly patients with osteoporosis. • Rare situation: Pathological fractures can be caused by electrical shock or epilepsy.

• As the classification of proximal humeral fractures, the Neer classification is currently widely recognized and the most widely used in clinical practice. • The Neer classification (Fig.  3.9) follows the four-part theory of the proximal humerus of Codman, and proximal humeral fractures are divided into six types according to the displacement of the fractures (Neer 1970a). • This classification notes the destruction of the soft tissue attachment by the fracture displacement and emphasizes the increased probability of necrosis of the humeral head after the loss of soft tissue attachment. • In the Neer classification, the degree of displacement of the fracture is determined using the humeral head as a

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b deltoid

a sffective acting point of force

supraspinatus

acting

f force

line o

c

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infraspinatus

Fig. 3.7 (a, b) The muscle groups forming the rotator cuff participate in internal and external rotations and abduction of the shoulder joint. (c) The rotator cuff can provide tension to press the humeral head on the

scapular glenoid and maintain the stable position of the humeral head inside the scapular glenoid fossa, thus playing the role of the fulcrum in a lever during shoulder movement

reference. Referring to the humeral head, an angle of the fracture fragment ≥45° or distance between the fracture fragment >1 cm is considered a displacement; if the shift does not meet the standard, regardless of the number of fracture fragments, the fracture will be regarded as no displacement. This definition is too precise and dogmatic and was based on the requirement of the editor of JBJS before the publication of this classification by Neer. • Special types of fractures in the Neer classification: –– Anatomic neck fracture of the humerus: This type of fracture is a 2-part fracture in the Neer classification but is very rare and differs from the other type of 2-part fracture. The blood supply of the humeral head in such fractures is seriously damaged. Some scholars believe

that the probability of secondary humeral head necrosis is high for treatment by internal fixation is high, and thus replacement treatment of the humeral head is recommended (Court-Brown et al. 2001; Neer 1970b). –– The outreach insertion type of four-part fractures (Fig. 3.10) is characterized by an angle of the humeral head ≥45° angular and displacement in the greater and lesser tuberosity. Despite severe crushing of the fracture fragments, with a large displacement, the integrity of the soft tissue hinge of the medial proximal humerus is good, and the retention of the blood supply of the humeral head is maximized. The prognosis of this type of fracture is better than that of classic four-part fracture.

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a

Subglenoid tubercle

Coracoid process

scapula, anterior surface

b

greater tuberosity lesser tuberosity inertubercular groove

long head of biceps brachii

short head of biceps brachii

Fig. 3.8 (a) The long head of the biceps brachii runs along the intertubercular groove and can be used as a reference marker in reduction and fixation of the greater and lesser tuberosities. (b) The long head of the biceps brachii may be embedded in the gap between the bone fragments

of the fractured greater tuberosity, obstructing the reduction or even causing nonunion of the lesser and greater tuberosities if it is not reduced

3.1.5 Assessment of Proximal Humeral Fractures

–– After injury, arterial angiography or vascular ultrasound should be performed immediately, followed by active treatment. • Nerves: –– The probability of damage is highest for the axillary nerve. The physical examination should include an assessment of neurological function. If the injury is complicated, conservative treatment is recommended, with minor impact on fracture treatment. –– At 3–4  weeks after injury, EMG examination can be performed to understand the scope of the nerve injury.

3.1.5.1 Clinical Assessment • Typical manifestations: The hand on the healthy side helps hold the affected limb close to the chest wall, with swelling and pain, and limb activity is limited. • Blood vessels: –– For complicated anterior dislocation of the humeral head or significant inward shift of the humeral shaft, axillary vascular function should be examined.

3  Proximal Humerus Fracture Fig. 3.9  The Neer classification: One-part fractures include proximal humerus fractures without displaced fragments regardless of the number of fracture lines; two-part fractures include surgical neck fractures, avulsion fractures of the greater and lesser tuberosities, and anatomic neck fractures of the humerus; three-part fractures are divided into two types based on whether the greater tuberosity or the lesser tuberosity is connected to the humeral head fragment; and four-part fractures refer to fractures with displacements of the humeral head, the humeral shaft, and the greater and lesser tuberosities

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A B

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Fig. 3.10  Everted and compressed four-part fractures: The fractured bone is displaced, the soft tissue hinge of the medial proximal humerus remains intact, and the blood supply to the humeral head is partially retained The humeral head slips into the synthetic cavity

–– If no sign of nerve recovery is observed at 3 months after the injury, nerve exploration surgery should be performed.

3.1.5.2 Imaging Assessment • Assessment of the proximal humerus by X-ray (Fig. 3.11): –– The anteroposterior position: In the anteroposterior position, the glenoid partially overlaps the humeral head. When the angle of projection is 45° to the sagittal line of the body, that is, when the photoreceptor plane is parallel to the plane of the scapula, the true anteroposterior position of the shoulder joint is revealed, and the glenoid and humeral head do not overlap. –– Axillary position: In the axillary position, the relationship between the glenoid and the humeral head is clearly exposed, showing the fracture of the humeral head. ① In the conventional axillary projection mode, with the upper arm outstretched by 70–90°, the X-ray is projected from the bottom of the armpit, and the photo-

graphic plane is parallel to and above the shoulder plane (Lawrence 1918, 1915). ② Velpeau axillary position: For patients who cannot outstretch, the X-ray is projected downward from the top, with the body tilted back by 20–30° and the upper arm pressing the chest, and the photographic plane is placed on the console close to the rear of the body (Bloom and Obata 1967). –– Lateral position: For the lateral position of the glenohumeral joint, the X-ray bulb is located at the rear of the body, with the projection direction parallel to the scapula, the photographic plane perpendicular to the projection direction, and the shoulder blade in the Y-shape (Rontgen 1896). • CT scanning and reconstruction (Fig. 3.12) can facilitate the judgment of whether fracture of the joint has occurred, the degree of displacement in the fracture, and the identification of compression fracture and fracture at the edge of the glenoid. • MRI is not used for fracture diagnosis but can be used to determine the integrity of the rotator cuff.

Fig. 3.11  Radiographic evaluation of the proximal humerus. (a) In standard anteroposterior and lateral X-rays, the glenoid partially overlaps the humeral head. The true anteroposterior view of the shoulder joint is obtained only when the beam projection forms an angle of 45° to the sagittal line of the body. (b) X-rays at a body anteroposterior

position and humeral anteroposterior position. (c) A standard axillary projection. (d) A Velpeau axillary projection with the affected limb fixed. (e) Axillary lateral X-ray of the humerus. (f, g) Schematic diagrams of a lateral projection of the humerus (the shoulder blade shows a “Y” shape). (h) Lateral X-ray image of the humerus

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routine anteroposterior shoulder

posterior glenoid rim

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45°

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Fig. 3.12  CT scan and reconstruction images clearly showing the degrees of comminution and displacement of the fractured bone. (a) Coronal view. (b) Sagittal view. (c) Reconstructed 3D image

3.2 Surgical Treatment 3.2.1 Surgical Indications • Non-surgical treatment: Of proximal humeral fractures, 80–85% exhibit no displacement or mild displacement, and satisfactory results can be obtained through non-­ surgical treatment. Non-surgical treatment should also be employed for frail patients suffering from a variety of diseases or who cannot tolerate anesthesia or surgery (Iannotti et al. 2003). • Surgical treatment: –– Closed reduction and percutaneous pinning fixation (Chen et al. 1998; Ebraheim et al. 1996; Kocialkowski and Wallace 1990; Soete et  al. 1999; Williams and Wong 2000): This type of treatment can be applied for fracture of the surgical neck with good bone quality, some 3-part fractures and the outreach insertion type of four-part fractures. Metaphyseal comminution is a relative contraindication. –– Open reduction and internal fixation (Nho et al. 2007; Haidukewych 2004): It is very important to determine whether the bone meets the requirements for internal fixation during the preoperative evaluation. This treatment can be applied in patients with 2-part or 3-part fractures and in young patients (age ≤ 45 years) with four-part fractures. Limited internal fixation can be used for simple fractures of the greater tuberosity and lesser

tuberosity or non-comminuted fractures of the humeral surgical neck, as well as some 3-part fractures and the outreach insertion type of fourpart fractures. –– Intramedullary nail fixation (Roberts et  al. 2006; Rajasekhar et al. 2001; Agel et al. 2004): Intramedullary nail fixation can be used for surgical neck fracture with displacement and for 3-part fractures involving the greater tuberosity. –– Humeral head replacement (Neer 1970a; Zuckerman et al. 1997): Absolute indications include comminuted fractures of the humeral head, old compressive fractures with compression in more than 40% of the articular surface of the humeral head, and severe absorption of the humeral head due to delayed operation showing affected function of the shoulder joint. Relative indications include fractures complicated with dislocation of the humeral head, split fracture of the humeral head (Fig.  3.13), and severe osteoporosis. For young patients (30°, and angular deformity >20° –– Open fracture –– Bilateral humeral shaft fractures or multiple injuries, floating elbow

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–– Humeral shaft fracture complicated with arterial or nerve injury –– Humeral shaft nonunion –– Pathological fracture

4.2.1.2 The Purpose of Surgery • To correct the humeral shaft rotation, shortening, and angular deformities. • To restore the blood supply and nerve continuity.

4.2.2 Surgical Techniques 1. Surgical approach selection: (a) For proximal 2/3 fractures, the anterolateral humerus approach is preferred (Goss 1950; DePalma 1970; Gregory 2001; Hollinshead 1958; Hoppenfeld and De Boer 1984; Schemitsch and Bhandari 2001b). (b) For middle and distal 1/3 fractures, the lateral humerus approach is preferred (Mills et al. 1996). (c) For distal 1/3 fractures, the posterior humerus approach is preferred (Kettlekamp and Alexander 1967; Pollock et al. 1981). (d) Simple fracture of the humeral shaft can be treated with anterograde or retrograde intramedullary nail fixation (Canale 2012b). (e) Spiral fracture with a large segment involving more than 1/3 of the shaft circumference will lead to a lack of stability after intramedullary nail fixation, and thus these patients should undergo open reduction and internal fixation (Bucholz 2010b). 2. Plate screw fixation technology for fractures (Colton and Fernandez 2000a): The reduction and fixation of most fractures in this book involves steel plate screw fixation technology, and thus a variety of steel plate screw fixation technologies are systematically introduced for the first long bone shaft fracture. (a) Compression steel plate: for simple fractures, such as short oblique and transverse fractures (Pollock et al. 1981) (Fig. 4.4). • A pre-bent steel plate is placed between the posterior steel plate of the fracture site and the shaft, and a gap of 1 mm should be maintained. • The fracture is reset, and the steel plate is temporarily fixed on the shaft using a bone holding device; the first screw is inserted through the sliding hole, and then the second screw is inserted through the compression hole at the opposite side of the fracture end to achieve the compression on the fracture end. • In the fracture end, a lag screw is screwed vertical to the fracture plane to achieve the second compression on the fracture end.

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• The remaining screws are screwed into the steel plate. (b) Lag screw and protection plate: for long oblique, spiral, and wedge-shaped fractures (Colton and Fernandez 2000b) (Fig. 4.5). • Fixation of wedge fragments. –– Compression fixation for the wedge fragment and main bone is first performed to convert the type B fracture into a type A fracture. • Compression steel plate for the fixation of type A fractures. –– A lag screw is screwed into the fracture end vertical to the fracture plane to achieve the second compression on the fracture end of the wedge fragment and the main bone. –– The remaining screws are then screwed on the steel plate. (c) Bridging plate: for comminuted fractures (Colton and Fernandez 2000c; Morrey 2013c) (Fig. 4.6). • Without exposing the fracture ends, the shaft is exposed in the distal part of the fracture site, and the steel plate is percutaneously inserted and fixed to complete the fracture fixation under fluoroscopy. • Two screws are used to fix the proximal end of the fracture to ensure the alignment of the steel plate and bone for position and fracture line matching. • The distal fracture is temporarily fixed with a bone holder to ensure the alignment of the fracture end for position and fracture line matching under fluoroscopy; two screws are used to fix the distal fracture. • The alignment of the fracture end for position and fracture line matching is confirmed under fluoroscopy, and the remaining screws are placed if the reduction of the fracture is satisfactory.

4.2.2.1 Proximal 2/3 Fractures of the Humeral Shaft (Anterolateral Approach) Position and Preoperative Preparation • The patient is in the supine position, with a pillow under the scapula. The affected limb is free, allowing exposure of the neck (subclavian blood vessels), and the forearm is placed on a small table next to the operating table. Intraoperative C-arm auxiliary fluoroscopy is used. Operative Incision According to the Projection on the Body Surface • The coracoid process, deltopectoral interval, intertubercular groove, and lateral condyle are labeled on the body

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Fig. 4.4  Compression stainless-steel plate technique. (a) The stainless-steel plate is re-shaped to allow a close contact with the fixation site. (b) The pre-bent stainless-steel plate is placed at the fracture site, ensuring a 1-mm-wide gap between the plate and the shaft. (c) If the plate is not pre-bent to fit the fractured bone, the two fracture ends at the fixation site will be separated at the side opposite to the plate, increasing the fatigue stress on the plate, which will cause instability of the fixation and eventual fixation failure. (d) The fracture is reset, and the stainless-steel plate is temporarily fixed on the shaft using a bone holding device; the first screw is inserted 8 mm away from the fracture end

through the neutral position of the guide device. (e) After the first screw is positioned, the contact between the plate and bone is checked. (f) The second screw is inserted at the opposite side of the fracture end through the eccentric position. (g) The screws at both sides are tied to achieve compression on the fracture ends. (h) The remaining screws are screwed into the stainless-steel plate through the neutral position. (i) For a long fracture with a short-oblique shape, a proximal cortex broaching - lag screw fixation technique can be applied, with the third screw across the fracture line. (j) The order of screw placement

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Fig. 4.4 (continued)

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Fig. 4.5  The lag screw and protection plate technique. (a) Fracture reduction, temporary fixation with a pointed reduction clamp, and stainless-steel plate re-shaping. (b) A lag screw is screwed into the center of and vertical to the fracture plane; if the fracture line is too long, another lag screw can be used to enhance the fixation stability. (c) Guided by a 3.5 mm guiding sleeve, a 3.5 mm diameter drill is used to drill through the proximal cortex. (d) A 2.5  mm diameter sleeve is

inserted, through which a 2.5 mm diameter drill is used to drill through the cortex on the opposite side. (e) The plate is placed, and then all the screws are inserted to fix the plate in the neutral position. (f) A Type B fracture with butterfly-shaped bone fragments: The Type B fracture is first converted to a Type A fracture, and then the fracture is fixed following the procedures shown in the figure

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Fig. 4.6  The bridging plate technique: Without exposing the fracture ends, the bone shaft segments proximal and distal to the fracture site are exposed, and a stainless-steel plate is percutaneously inserted and fixed to complete the fracture fixation under fluoroscopy. (a) After the fracture is reduced by hand, a long bone distractor is used for temporary fixation, and then the tissue proximal and distal to the fracture site is cut to expose the bone shaft. (b) Two screws are fixed in the proximal fracture fragment to ensure good alignment of the fracture end for position

and fracture line matching. (c) The distal fracture fragment is temporarily fixed with a bone holder to ensure alignment of the fracture ends for position and fracture line matching under fluoroscopy; and then the distal fracture fragment is fixed with two screws. (d) The alignment of the fracture ends for position and fracture line matching is confirmed under fluoroscopy, and the remaining screws are placed if the reduction of the fracture is satisfactory

surface. The projections of the coracoid process and deltopectoral interval and the intertubercular groove and outer epicondyle on the body surface are connected (Fig.  4.7), and the appropriate incision site is selected according to the position of the fracture.

• Distal port: –– Separation along the interval between the biceps brachii and brachial muscle is performed to reveal the brachialis muscle. –– The brachialis muscle is longitudinally split along the lateral middle line of the brachial muscle to directly reach the humeral surface and expose the middle of the humerus. –– The lateral part of the brachial muscle is controlled by the radial nerve, and the medial part is controlled by the musculocutaneous nerve. Thus, the longitudinal split of the brachialis muscle minimizes damage to the motor function of the brachial muscle. –– The radial nerve controlling the lateral brachial muscle should be carefully protected. • With flexion in the elbow, sharp dissection of the deltoid ending point and medial brachialis ending point are performed to allow the fracture to be reset and placement of the steel plate on the anterolateral humerus (Fig. 4.8).

Surgical Approach • The skin and the subcutaneous tissue are cut, with separation of the skin and the fascia to expose the deltopectoral interval and the biceps triceps interval. • Proximal port: –– Entering along the deltopectoral interval, the middle of the biceps is pulled inward, and the deltoid and cephalic vein are pulled outward to avoid damaging the proximal cephalic vein and the transverse anterior circumflex humeral artery. –– Sharp outward dissection of the deltoid muscle ending point is performed in the tuberosity site of the deltoid to expose the proximal humerus.

4  Fracture of the Humeral Shaft Fig. 4.7 (a) The patient is placed in a supine position, with the affected limb placed on a radiolucent holder. (b) The coracoid process, deltopectoral interval, and lateral epicondyle of the humerus are labeled on the body surface; the line connecting the three labeled points indicates the preoperative incision marked by the surface projection

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coracoid process

coracoid process lateral antebrachial cutaneous n.

biceps

Fracture Reduction and Fixation • Based on the AO classification, the appropriate steel plate screw technique is selected according to the above steel plate screw technology: (www.AOfoundation.org). • For type A2 and type A3 humeral shaft fractures, compression plate technology can be used. For type A2 ­fracture, lag screws on or outside the steel plate can be used to increase stability. • For type A1, B1, and B2 humeral shaft fractures, lag screw and protection plate technology can be applied. Type B1 and B2 fractures are first converted into a type A fracture using a lag screw, followed by further fixation. Notably, even for long oblique fractures, it is not possible to use multiple lag screws without using protective plates for fixation.

• Type B3 and C fractures can be fixed using bridging plate technology (Fig. 4.9).

4.2.2.2 Distal 1/3 Fractures of the Humeral Shaft (Lateral Straight Approach) Position and Preoperative Preparation • The patient is in the lateral position, with a pillow under the armpit for protection (Fig. 4.10a). The affected limb is free and placed on a radiolucent holder, and intraoperative C-arm auxiliary fluoroscopy is used (Fig. 4.10b). Operative Incision According to the Projection on the Body Surface • The lateral humeral epicondyle is labeled on the surface of the body, and the connecting line with the tuberosity of

104 Fig. 4.8 (a) The proximal port: Entering along the deltopectoral interval, the middle of the biceps is pulled inward, and the deltoid and cephalic vein are pulled outward. The deltoid muscle is dissociated outward to the tuberositas deltoidea and inward to the ridge of the greater tuberosity. (b) The distal port: Separation along the interval between the biceps brachii and brachialis muscle is performed to reveal the brachialis muscle. (c) With the elbow in flexion, sharp dissection is performed at the proximal side to separate the deltoid ending point and medial brachialis ending point, and longitudinal splitting of the brachialis muscle is performed to expose the humerus. Next, the fracture is reduced, and a stainless-steel plate is placed at the lateral biceps brachii

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a fascia over deltoid cephalic vein delitoid long head of blceps cephalic vein fascia over pectoralis major biceps

short head of blceps

brachialis coracobrachialis

pecloralis major biceps

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pectoralis major tendon biceps

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long head of biceps

periosteum deltoid brachialis short head of biceps

pectoralis major tendon biceps humerus covered with periosteum

the deltoid is the incision projection on the surface (Fig. 4.11). Surgical Techniques • Surgical approach (Figs. 4.12, and 4.13): –– The skin and the subcutaneous tissue are cut, with separation of the fascia under the skin.

–– The gap between the brachioradialis muscle and the brachialis muscle above the distal elbow plane is located, and the deep fascia of the muscle is cut. In this gap on the elbow plane, the radial nerve is retracted with the finger using a rubber band for protection. –– The radial nerve is pulled forward to expose the interval between the brachialis and brachioradialis muscle.

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Fig. 4.9  Postoperative X-ray images. (a) Anteroposterior position. (b) Lateral position

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Fig. 4.10  The patient is in the lateral decubitus position (a) on the unaffected side (b), with the affected limb placed on a radiolucent holder

This interval is sharply dissected to open the brachialis muscle forward, thus exposing the lateral and anterolateral side of the distal humeral shaft. –– The interval between the brachialis and triceps in the proximal end is identified, and the exposure distance is extended upward to reveal the radial nerve through the muscle interval. The upward separation process should be carried out under the periosteum to avoid damaging the spiral radial nerve running around the humerus. • Fracture reduction and fixation: refer to the previous sections (Fig. 4.14).

Brachioradialis

Biceps

Fig. 4.11  The line connecting the lateral humeral epicondyle and the tuberositas deltoidea indicates the preoperative incision mark by surface projection

Experience and Lessons • The middle-distal 1/3 part of the humeral shaft has an internal rotation of 20–30°, and thus, the steel plate must be re-shaped for better attachment if placed in the anterior lateral side (Fig. 4.15).

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a brachialis brachioradialis

brachioradialis

lateral antebrachial cutaneous n.

brachialis

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humerus biceps

periosteum

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lateral intermuscular septum radial nerve

brachialis brachioradialis brachioradialis

biceps humerus covered with periosteum

musculocutaneous nerve

brachialis

c c

Fig. 4.12 (a) A finger-assisted blunt separation is conducted to expose the brachialis muscle, brachioradialis muscle, and triceps. (b) The lateral cutaneous nerve of the forearm (LCNF) is identified in the gap between the biceps and brachialis muscle and protected using a rubber band. (c) The rubber band protecting the LCNF is placed in the gap between the biceps (medial) and brachialis muscle (lateral)

Fig. 4.13 (a) First, the interval between the brachioradialis muscle and brachialis muscle is located. Next, the biceps, brachialis muscle, and LCNF are pulled medially to expose the radial nerve in the distal interval, which is then pulled away for protection by a rubber band. (b) A separation is performed along the periosteal surface to expose the lateral and anterolateral sides of the distal humeral shaft; a stainless-steel plate is placed after fracture reduction. (c) During surgery, the radial nerve is identified in the interval between the brachialis muscle and the brachioradialis muscle and protected using a rubber band

4  Fracture of the Humeral Shaft Fig. 4.14 Postoperative X-ray images. (a) Anteroposterior X-ray image. (b) Lateral X-ray image

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Fig. 4.15  A stainless-steel plate is placed anterolaterally to fix a middle-­distal 1/3 humeral fracture: the distal end of the plate is rotated inward 20–30°, allowing close contact between the plate and the antero-

lateral humerus during surgery. (a) Re-shaping of stainless-steel plate. (b) Re-shaped plate. (c) Intraoperative fluoroscopy image

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4.2.2.3 Distal 1/3 Fractures of the Humerus (Posterior Approach) Position and Preoperative Preparation • The patient is in lateral position; with a soft pillow under the armpit, the elbow of the affected limb is in flexion and placed on a radiolucent holder; intraoperative C-arm auxiliary fluoroscopy is used (Fig. 4.16).

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acromion

Operative Incision According to the Projection on the Body Surface • The posterolateral corner of the acromion and olecranon are labeled and connected on the body surface. The appropriate incision site is selected according to the position of the fracture (Fig. 4.17). Surgical Techniques • Surgical approach (Fig. 4.18): –– An incision is created along the center of the posterior approach to directly reach the olecranon; the skin, subcutaneous tissue, and fascia are cut to find the distal thick and white triceps tendon.

a

Fig. 4.17  The preoperative incision mark by surface projection is the line connecting the posterolateral corner of the acromion and olecranon; the length of the incision is determined according to the location of the fracture

–– Blunt separation is carried out along the proximal triceps between the long head and the lateral head, and the soft tissue under the periosteum in the humeral surface is pushed toward both sides. –– After a sharp vertical split of the triceps tendon in the distal end, the muscle tissue is retracted to both sides. –– The medial head of the triceps is located deep on the b long and lateral head. The radial groove separates the starting point of the medial head from the starting point of the lateral head. Therefore, the radial nerve should be found in the proximal end of the medial head of the triceps and pulled out using a rubber band for protection. –– The medial head of the triceps is split to retract the muscle tissue toward both sides and expose the distal fracture of the humerus. • Fracture reduction and fixation: See the previous sections (Fig. 4.19). • Closure of the incision: The triceps muscle fascia and the superficial fascia tissue can be sutured with an absorbable Fig. 4.16 (a) The patient is in the lateral decubitus position, with a soft suture, followed by suture of the subcutaneous tissue and pillow under the armpit and the affected limb placed on a holder; the skin. affected limb is placed on a holder with the elbow in flexion. (b) C-arm-­ assisted fluoroscopy

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deltoid muscle axillary nerve posterior circumflex humeral artery superior lateral brachial cutaneous nerve profunda brachii (deep brachial) artery radial nerve lateral head of triceps brachii muscle posterior brachial cutaneous nerve long head of triceps brachii muscle the nerve innervating the anconeus muscle passes under the medial head of triceps brachii muscle

Inferior lateral brachial cutaneous nerve middle collateral artery radial collateral artery medial head of triceps brachii muscle

ulnar nerve

posterior antebrachial cutaneous nerve lateral supracondylar of humerus

medial supracondylar of humerus olecranon (of ulna)

b

anconeus muscle

c

long head of triceps lateral head of triceps humeral periosteum

medial head of triceps capitellum

olecranon (of ulna)

triceps tendon

Fig. 4.18 (a) The medial head of the triceps is located deep in the long and lateral heads. The radial groove separates the starting point of the medial head from the starting point of the lateral head. (b) Proximal: The long and lateral heads are separated to expose and protect the deep

radial nerve and deep brachial artery. (c) After a sharp longitudinal split of the triceps tendon in the distal end, the muscle tissue is retracted to both sides to expose the distal fracture fragment of the humerus

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Fig. 4.19  A distal 1/3 fracture of the humeral shaft. (a) Preoperative X-ray image: The fracture is located at the distal 1/3 of the humeral shaft and is a Type B1 fracture according to the AO classification. (b)

4.2.2.4 Closed Reduction of Percutaneous Minimally Invasive Internal Fixation Position and Preoperative Preparation • The position is the same lateral approach as before. Operative Incision According to the Projection on the Body Surface • The coracoid process, deltopectoral interval, intertubercular groove, and biceps lateral margin are labeled on the body surface using a marker pen. A 5–7-cm proximal incision is created from the coracoid process along the deltopectoral interval, and a 5–7-cm distal incision is created in the distal 1/3 upper arm along the biceps lateral margin. Surgical Approach (Fig. 4.20) • Proximal port: –– The skin and the subcutaneous tissue are cut to find the cephalic vein, which is used as a reference to identify the deltopectoral interval and perform blunt separation of the deltoid and the pectoralis major muscle. –– In the lateral side of the long tendon of the biceps, the deltoid muscle and the pectoralis major muscle are separated, and the ending point of the pectoralis major is partially cut off to facilitate the placement of the steel plate. • Distal port: –– The skin and the subcutaneous tissue are cut, and the deep fascia of the upper arm is cut along the direc-

c

Postoperative anteroposterior X-ray image demonstrating fixation using a posterolateral anatomical locking plate of the humerus combined with lag screws. (c) Postoperative lateral X-ray image

tion of the incision to find the interval between the biceps and brachial muscle. Separation along this interval is carried out, and the biceps is pulled inward. Note that the lateral forearm nerve is located in this interval and should be carefully protected by pulling inward. –– Longitudinal splitting of the brachialis muscle is carried out. The separation can be performed outside the periosteum between the deep surface of the brachialis and the humerus. • Tunneling: –– A stripper with a blunt tip is inserted from the distal port to separate strictly close to the anterior of the humerus and pierced upward in the upper margin of the brachialis, with convergence to the proximal port. If necessary, a stripper can be inserted through the proximal port to achieve the convergence of the two operating ports. Fracture Reduction and Internal Fixation (Fig. 4.21) • Fracture reduction: –– Reduction is performed by manual traction. Note that for this fixation method, the comminuted fracture area does not require anatomical reduction. Only the large and sharp fracture fragments require anatomical reduction to protect the surrounding soft tissue. –– In manual reduction, rotation deformity must be corrected, and a shortening deformity of 2  cm is acceptable.

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proximal incision (deltopectoral groove)

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deltoid

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radial n.

distal incision (lateral biceps)

brachialis

pectoralis major tendon long head of biceps

musculocutaneous n.

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finger inserted beneath biceps along humerus

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brachialis split to bone elevator advanced beneath brachialis along humerus

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elevator exits superior border of brachialis to meet fingertip

biceps (retracted)

e

elevator exits superior border of brachialis to meet fingertip

Fig. 4.20 (a) To establish the proximal port, an incision is made along the interval of the deltoid and the pectoralis major muscle below the acromion; to establish the distal port, the incision is made along the lateral margin of the biceps. (b) In the proximal port, the separation is made along the gap between the deltoid and the pectoralis major muscle, and in the distal port, the biceps is retracted medially to expose the

brachialis muscle in the deeper layer. (c) To establish the proximal port, the ending point of the pectoralis major may be cut off. (d) After splitting of the brachialis muscle, a stripper with a blunt tip is inserted along the periosteal surface to create a tunnel connecting the two ports. (e) The operator can place one finger through the proximal port to meet the stripper on top of the brachialis muscle

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Fig. 4.21  A Type B1 fracture of the humeral shaft. (a) Preoperative anteroposterior and lateral X-ray images. (b) Closed reduction using traction. (c) Selection of internal fixators according to the location and range of the fracture. (d) Pre-shaping of the proximal end of the stainless-steel plate to ensure close contact. (e) The stainless-steel plate was inserted into the pre-set tunnel from the distal port. (f) The plate was

locked through the proximal and distal ports or a small incision. (g) There were only two mini-incisions at the proximal and distal sides after surgery, reducing the operation-associated damage. (h) Postoperative anteroposterior and lateral X-ray images. (i) X-ray image 4 months after surgery illustrating good bone healing

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i

Fig. 4.21 (continued)

–– The situation of the reduction is observed under fluoroscopy. If the large fragments cannot be reset after traction, soft tissue may be incarcerated at the fracture ends, and open reduction is needed in this case. • Fracture fixation: –– First, the appropriate LCP plate is selected based on the location and extent of the fracture. –– The proximal end of the steel plate is pre-curved to enhance attachment. –– The steel plate is inserted in the pre-set tunnel from the distal port, and the position of the steel plate is appropriately adjusted. After adequate contact with the proximal end of the bone fragment, a screw can be used for temporary fixation. The location of the steel plate is determined under fluoroscopy to ensure that the steel plate is parallel with the humerus long axis in the lateral image. –– Next, a second screw can be screwed in at the proximal end of the fracture. After the position of the distal fracture fragment is adjusted and satisfactory, it is held with a bone clamp for the final fracture fixation. • Experience and lessons: –– Locking technique. –– For the percutaneous minimally invasive technique, the locking holes in the proximal and distal ports of the steel plate can be directly locked. –– For the remaining nail holes that must be locked, a steel plate with the same length can be used as a reference to create the percutaneous small incision and insert the locking sleeve for drilling and locking.

–– Selection of steel plate length: The length of the steel plate and the position of the screw will affect the load of the screw. The nearest screw to the fracture bears the maximum load. The length of the plate determines the arm of this screw. A longer plate has a longer arm, which will reduce the load on this screw. When the locking plate is used as an internal fixation bracket, it is mainly subjected to the bending force. When the distance between the ends of the adjacent fracture segments is too close, the bending effect on the steel plate will produce a strong local stress, and when the distance between the screws on the ends of the adjacent fracture fragments is too large, the stress will be dispersed to avoid fatigue damage to the implant (Fig. 4.22). To select the length of the implant in the comminuted fracture, the range of fractures should first be determined, and then a plate with a length of three times the length of the fracture should be selected. The ratio of the length of the plate to the length of the fracture area is referred as the span of the plate and should be >3. –– Position and number of screws: When the LCP plate is used as a bridging plate, the screw density should be 65 years), if the fracture was significantly displaced or severely crushed and it is difficult to maintain stability b

Fig. 5.38  Case example of a 56-year-old female patient who received vertical dual-plate fixation for a Type C fracture of the distal humerus. (a) Postoperative catheterization for subcutaneous brachial plexus block. (b) Functional exercise of the elbow was initiated on postoperative day 1

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after surgery, 1-stage elbow replacement surgery can be performed (Fig. 5.39). • For some patients with type C3 fractures, 1-stage elbow replacement should also be applied when the articular surface cannot be reconstructed or stable fixation is not available to meet the needs of early functional exercise. Fig. 5.39  Case example of a 75-year-old female patient who received the first-stage elbow replacement surgery for comminuted fractures of the humeral condyle complicated by a fracture of the radial capitulum. (a, b) Preoperative anteroposterior and lateral X-ray images illustrating comminuted fractures of the humeral condyle at a relatively low position, complicated by a radial capitulum fracture. (c, d) Postoperative anteroposterior and lateral X-ray images after first-stage elbow replacement surgery

5.2.3 Postoperative Complications and Their Prevention and Treatment • After internal fixation for the distal humeral fracture, the common complications include limited elbow movement, non-healing fracture, deformity healing of

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shortening of 1 cm will only have a mild effect on triceps strength (Hughes et al. 1997). • The selection of the implant: An implant with adequate strength should be selected for internal fixation to avoid early internal fixation failure. The common choice is the combination of a compression steel plate and steel reconstruction or the application of parallel and vertical compression plates or locking plate; the strength of 1/3 of the pipe plate is insufficient and may lead to failure of the internal fixation.

References

Fig. 5.40  For patients with osteoporosis or supracondylar bone loss caused by crushing fractures, stable connection of the metaphysis and diaphysis can be achieved with appropriate bone shortening. (a) Trimming of the distal fracture fragment of the humeral shaft. (b) After bone shortening, the metaphyseal portion can be connected to the humeral shaft through the parallel plate or vertical plates

the fracture, nerve injury, and damage of the elbow extension device. • Anatomical reduction of fracture: –– Anatomical reduction (including articular surface morphology and correct force line) can prevent instability of the elbow joint, restore the internal stability of the elbow, and reduce the burden on the internal fixation, which allows early full functional exercise. It is the core component for preventing postoperative limited elbow activity. –– The integrity of the articular surface: For patients with osteomalacia of the articular surface, the use of compression screws in the horizontal direction is erroneous and will cause a narrower width of the humeral trochlea, humeral capitellum, or both, resulting in limited elbow movement and traumatic arthritis. The correct approach is to attempt to restore the location of the small bone fragments with fixation using a headless screw or Kirschner wire, and then the fully threaded screw in the horizontal direction can be used for fixation. • Fixation of the metaphysis and diaphysis: For patients with osteoporosis or supracondylar bone loss caused by crushing fractures, stable connection of the metaphysis and the diaphysis can be achieved with appropriate shortening, and then the metaphyseal portion can be connected to the humeral shaft through the parallel plate or vertical plate (Fig.  5.40); The literature shows that metaphyseal

Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand. 1972;43(6):479–90. Anglen J.  Distal humerus fractures. J Am Acad Orthop Surg. 2005;13(5):291–7. Armstrong AD, Dunning CE, Faber KJ, et  al. Single-strand ligament reconstruction of the medial collateral ligament restores valgus elbow stability. J Shoulder Elb Surg. 2002;11(1):65–71. Bryan RS, Morrey BF.  Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188–92. Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia, PA: WB Saunders; 1985. p. 325–33. Campbell WC.  Incision for exposure of the elbow joint. Am J Surg. 1932;15:65–7. Crenshaw AH. Surgical approach. In: Crenshaw AH, editor. Campbell’s operative orthopaedics. St. Louis: Mosby; 1987. p. 88–94. Diederichs G, Issever A, Greiner S, et al. Three-dimensional distribution of trabecular bone density and cortical thickness in the distal humerus. J Shoulder Elb Surg. 2009;18:399–407. Doornberg J, Lindenhovius A, Kloen P, et  al. Two and three dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am. 2006;88:1795–801. Dunning CE, Zarzour ZD, Patterson SD, et al. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 2001;83-A(12):1823–8. Elkowitz SJ, Polatsch DB, Egol KA, et al. Capitellum fractures: a biomechanical evaluation of three fixation methods. J Orthop Trauma. 2002;16(7):503–6. Ergunes K, Yilik L, Ozsoyler I, et al. Traumatic brachial artery injuries. Tex Heart Inst J. 2006;33(1):31–4. Faber KJ. Coronal shear fractures of the distal humerus: the capitellum and trochlea. Hand Clin. 2004;20(4):455–64. Gabel GT, Hanson G, Bennett JB, et al. Intra-articular fracture of the distal humerus in the adult. Clin Orthop. 1987;216:99–108. Helfet DL, Schmeling GJ.  Bicondylar intraarticular fractures of the distal humerus in adults. Clin Orthop Relat Res. 1993;292:26–36. Hughes RE, Schneeberger AG, An KN, et al. Reduction of triceps muscle force after shortening of the distal humerus: a computational model. J Shoulder Elb Surg. 1997;6:444. Ilahi OA, Strausser DW, Gabel GT. Posttraumatic heterotopic ossification about the elbow. Orthopedics. 1998;21(3):265–8. Imatani J, Ogura T, Morito Y, et al. Anatomic and histologic studies of lateral collateral ligament complex of the elbow joint. J Shoulder Elb Surg. 1999;8(6):625–7.

5  Fracture of the Distal Humerus John H, Rosso R, Neff U, et al. Operative treatment of distal humeral fracture in the elderly. J Bone Joint Surg (Br). 1994;76:793–6. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992;15(7):825–33. Jupiter JB, Neff U, Holzach P, et  al. Intercondylar fracture of the humerus. J Bone Joint Surg. 1985a;67-A:226–39. Jupiter JB, Neff U, Holzach P, et  al. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985b;67(2):226–39. Kapandji IA. The physiology of the joints, volume 1: upper limb. 6th ed. London: Churchill Livingstone; 2007. p. 978–0443103506. Koval KJ, Zuckeman JD. Handbook of fractures. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2006. p. 139. Lockard M.  Clinical biomechanics of the elbow. J Hand Ther. 2006;19:72–80. Mac Ausland WR, Wyman ET.  Fractures of the adult elbow. Instr Course Lect. 1975;24:165–81. Marsh JL, Slongo TF, Agel J, et  al. Fracture and dislocation classification compendium-2007: orthopaedic trauma association classification, database, and outcomes committee. J Orthop Trauma. 2007;21(10 S):S1–133. McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996;78:49–54. Mehne DK, Jupiter JB.  Fractures of the distal humerus. In: Browner BD, Jupiter JB, Levine AM, et  al., editors. Skeletal trauma: fractures, dislocations, ligamentous injuries. Philadelphia PA: WB Saunders; 1992. p. 1146. Meissner M, Paun M, Johansen K. Duplex scanning for arterial trauma. Am J Surg. 1991;161(5):552–5. O’Driscoll S. The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions. Ortho Clin North Am. 2000;31:91–101. O’Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elb Surg. 2005;14(1SS):186S–94S. O’Driscoll SW, Morrey BF, Korinek S, et  al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res. 1992;280:186–97.

159 Paraskevas G, Papadopoulos A, Papaziogas B, et al. Study of the carrying angle of human elbow joint in full extension: a morphometric analysis. Surg Radiol Anat. 2004;26:19–23. Ring D, Jupiter JB. Fracture of the distal humerus. Orthop Clin North Am. 2000;31:103–13. Ring D, Jupiter JB, Gulotta L.  Articular fractures of the humerus. J Bone Joint Surg Am. 2003;85:232–8. Robinson CM.  Fractures of the distal humerus. In: RWHJ B, Court Brown C, Tornetta P, et al., editors. Rockwood and Green’s fractures in adults. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2005a. p. 1051–116. Robinson CM.  Fractures of the distal humerus. In: RWHJ B, Court-­ Brown C, Tornetta P, et al., editors. Rockwood and Green’s fractures in adults. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2005b. p. 1051–116. Robinson CM, Hill RM, Jacobs N, et al. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma. 2003;17(1):38–47. Ruchelsman ED, Tejwani NC, Kwon YW, et al. Coronal plane partial articular fracture of the distal humerus. J Am Acad Orthop Surg. 2008;16:716–28. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am. 2007;89(5):961–9. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. Surgical technique. J Bone Joint Surg Am. 2008;90(Suppl 2):31–46. Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma. 1994;8(6):468–75. Self J, Viegas SF, Buford WL Jr, et al. A comparison of double-plate fixation methods for complex distal humerus fractures. J Shoulder Elb Surg. 1995;4(1 Pt 1):10–6. Wadsworth TG. A modified postero-lateral approach to the elbow and proximal radioulnar joints. Clin Orthop. 1979;144:151–3.

6

Fracture of the Proximal Ulna Hua Chen, Zhe Zhao, and Wei Zhang

6.1 Basic Theory and Concepts

at the lateral humeral shaft, and the medial head begins at the bottom of the radial nerve. 6.1.1 Overview –– The distal triceps converges into a common tendon and terminates at the olecranon. The distance from the ten• Fractures in young patients are mostly caused by high-­ don attachment point to the rotation center is the arm energy trauma, whereas those in elderly patients are of the elbow extension device. Based on mechanical mostly due to falling injury. fluoroscopy, in the partial resection of ulnar olecranon, • There are two basic types of proximal ulna fractures, and the triceps ending point should be reconstructed at the surgery is needed in most cases: posterior margin far from the articular surface, rather –– Olecranon fracture, accounting for approximately 10% than the articular margin close to the articular surface; of elbow injury (Karlsson et al. 2002). otherwise, the arm of the triceps will be shortened, –– Coronoid process fracture, accounting for 10–15% of thus affecting the power of the elbow. the elbow injury. Its combination with injury in other –– The efficiency of the triceps muscle is different for difparts often suggests elbow instability (Rommens et al. ferent elbow flexion positions (Fig. 6.1): 2004). For complete extension, the force of the muscle can • The half-moon shaped notch of the proximal ulna is the be divided into the component in the elbow extenmost important stable bone structure of the elbow, so the sion direction and the component pointing to the treatment goals for proximal ulna fractures are anatomical dorsal side of the rotation center (this component reduction to restore the proximal ulnar articular surface has no effect on the elbow extension movement). with the half-moon shaped notch, restore the length of the For partial flexion: In flexion of 20–30°, all muscle half-moon notch, and strengthen the internal fixation, strength is used to complete the elbow flexion, and thus allowing early postoperative functional exercise the efficiency is highest at this time; in further (Terada et al. 2000). elbow flexion, the muscle strength can be divided into the component in the elbow extension direction and the component pointing to the rotation center 6.1.2 Applied Anatomy (this component has no effect on the elbow extension movement). As the angle of elbow flexion • Elbow extension device: The elbow extension-related increases, the proportion of this component gradumuscles are the triceps and elbow muscle, in which the ally increases, while the efficiency of the triceps triceps plays a major role. muscle is reduced. –– The proximal part of the triceps has 3 starting points. For complete flexion, the triceps tendon reflexes in The long head of the triceps originates from the infrathe posterior olecranon and distal humerus, and this glenoid tubercle of the scapula. The lateral head begins anatomical structure provides a sufficiently long force arm to reduce the loss of the efficiency of the triceps muscle. H. Chen (*) · W. Zhang • Anatomy of the coronoid process and the attachment of Chinese PLA General Hospital, Beijing, China the surrounding articular capsule, ligament, and muscle e-mail: [email protected] (Fig. 6.2): Z. Zhao Beijing Tsinghua Changgung Hospital, Beijing, China

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_6

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162 Fig. 6.1 (a) In full elbow extension, the force of the triceps can be divided into the component in the elbow extension direction and the component pointing to the dorsal side of the rotation center. (b) In flexion of 20°–30°, all muscle strength is used to complete the elbow flexion, reaching the highest efficiency. (c) In further elbow flexion, the muscle strength can be divided into the component in the elbow extension direction and the component pointing to the rotation center. As the angle of elbow flexion increases, the efficiency of the triceps muscle is reduced. (d) In full elbow flexion, the triceps tendon reversely folds at the posterior olecranon and distal humerus, and this anatomical structure provides a sufficiently long force arm to reduce the loss of efficiency of the triceps muscle

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–– The partial anterior articular capsule is attached a few millimeters below the tip of the coronal and thus in coronoid process fracture, this bone may be attached to the torn articular capsule and isolated in the articular capsule. Surgical repair should be performed in this case (Bucholz and Court-Brown 2010). –– The anterior bundle of the medial collateral ligament is attached to the medial side of the base of the coronoid process and is one of the most important stable structures in the medial elbow joint. If the bone fragment in the base of the coronal fracture is large or the fracture involves the anteromedial surface of the coronoid process, the anterior bundle of the medial collateral liga-

ment at this area will be damaged, resulting in elbow instability caused by ligament failure. In this case, surgery should be performed to fix the ligament attachment and restore the stability of the elbow (Cage et al. 1995). –– The brachial muscle ends at the front of the distal coronal base, with a large range of ending points. Fracture involving the base of the coronoid process will involve this muscle ending point. However, regardless of how large the bone fragment is, it is difficult to damage all ending points of the brachial muscle. Part of the brachial muscle will still be attached to the ulnar bone. Thus, coronal fractures may not be avulsion fractures caused by brachial contraction.

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attachment points of the brachialis

anterior bundle of the medial collateral ligament

Fig. 6.2  Anatomy of the coronoid process and attachment of the surrounding joint capsule, ligament, and muscle. (a) Schematic diagram of the medial proximal ulna illustrating the attachment points of the brachialis and anterior bundle of the medial collateral ligament. (b) Schematic diagram of the anterior proximal ulna illustrating the attachment points of the brachialis and anterior joint capsule

• The correlation between the anatomical structure of the semicircular notch of the proximal ulna and the stability of the elbow: –– The length of the semicircular notch of the proximal ulna and the stability of the elbow (Fornalski et  al. 2003) (Fig. 6.3). When the olecranon fracture is severely comminuted and cannot be reconstructed, elbow extension function is usually restored by using the partially resected olecranon to reconstruct the ending point of the triceps. However, if the scope of olecranon resection is greater than 50%, the length of the semicircular notch will be too short, thus affecting the stability of the elbow, and elbow dislocation may easily occur in elbow flexion. When the coronoid process fracture is >50%, the ulnar angle of the opening should be measured (the angle between the connecting line from the olecranon tip to the coronoid process and the long axis of the ulnar shaft; the normal value is >30°). If this angle is reduced to 0°, the stability of the elbow will be seriously affected, easily leading to dislocation of the elbow (Bucholz and Court-Brown 2010). –– The anatomical morphology of the articular surface with the semicircular notch in the proximal of the ulna and the stability of the elbow: The section of the semicircular notch shows a unique anatomical morphology

with a protrusion in the middle and depressions on the 2 sides that matches the notch of the humeral trochlea. This specific anatomical structure provides internal stability for the elbow joint against the internal and external valgus. Studies have shown that resection of 1/4 of the olecranon will reduce elbow valgus resistance stability by 50%; in elbow extension, the humeroulnar joint provides 55% of the varus resistance; in 90° flexion, it provides 75% of the varus resistance (O'Driscoll et al. 2003). –– The basic requirement for the treatment of proximal ulna fractures is anatomical reduction of the articular surface while restoring the length of the semicircular notch of the ulna. • Comparison of several fixation methods for olecranon fractures: The specific features of the anatomical structure and biomechanics of the ulnar olecranon determine the diversity of surgical methods. At present, the most common surgical method is Kirschner wire tension band fixation and plate-screw internal fixation (Ring et  al. 1998) (Fig. 6.4). –– Resection of olecranon bone: As mentioned above, bone resection may affect the elbow extension force and elbow stability, and thus resection of the olecranon should be avoided if possible. This procedure should not be considered unless internal fixation is not possible with severely comminuted bone (Fyfe et al. 1985). –– Fixation technology with wire cerclage: Wire cerclage fixation is an ancient fracture fixation technology. In this surgical method for fracture fixation, holes are punched in the proximal and distal ends of the fracture for wire cerclage. Because this technique is not consistent with the principle of the tension band, it cannot effectively resist the tension of the brachialis and triceps, often resulting in fracture separation; consequently, this method is no longer in use. –– Non-interlocking intramedullary nail and intramedullary lag screw technique: As for the wire fixation technology, these 2 methods are limited in their ability to provide adequate stability, and gypsum-assisted fixation is needed. The triceps tension often generates a gap on the dorsal side of the fracture, resulting in fracture separation, articular surface gap, and fracture re-­displacement and eventually leading to fixation failure. –– Kirschner wire tension band technique: The tension band technique can be used to convert the tensile stress caused by the triceps muscle contraction into compressive stress, with reliable fixation and less soft tissue damage in the surgical process, which is conducive to bone healing. A disadvantage is that the soft tissue around the olecranon is poorly covered, resulting in complications of pain and exposure caused by the protruding internal fixation (An et al. 1986).

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Fig. 6.3  Schematic diagram illustrating the correlation between the anatomical structure of the semicircular notch of the proximal ulna and the stability of the elbow (red arrow: the flexion direction of the triceps; blue arrow: the flexion direction of the brachialis; green arrow: the dislocation direction of the elbow joint). (a) In the partial resection of the olecranon and reconstruction of the ending point of the triceps for treating comminuted olecranon fracture, it is necessary to preserve the ulnar

olecranon as long as possible because posterior dislocation of the elbow may easily occur in elbow flexion if the olecranon is too short. (b) The opening angle of the ulnar—the angle between the connecting line from the olecranon tip to the tip of the coronoid process and the long axis of the ulnar shaft, which should normally be>30°. (c) When the coronoid process fracture is >50%, anterior dislocation of the elbow joint may easily occur during elbow extension

–– Plate-screw internal fixation technique: When the olecranon fracture is severely comminuted, especially comminuted fracture involving the olecranon base, if good support between the bone fragments cannot be achieved, the gap between the bone fragments will further decrease after fixation with the tension band, resulting in a decrease in the length or opening angle of the ulnar half-moon notch and affecting the flexion and extension function of the elbow. Plate fixation can effectively maintain the location of the bone fragment and reduce the reduction loss caused by the decreased length or opening angle of the ulnar half-moon notch. A 1/3 tube plate was once commonly used for fixation, but due to its weak fixation strength, complications such as fatigue fracture of the plate and secondary fracture may occur. In recent years, a proximal ulnar

anatomical locking plate has been developed. The design of this plate includes an angle between the screw and steel that allows the screw to pass through and fix as many bone fragments as possible. The locking mechanism between the plate and screw enhances the overall holding force among the bone fragment, screw, and steel. Plate fixation can obtain satisfactory results even in some olecranon fractures with serious comminution (Heim 1991). –– A biomechanical study by Wilson et al. (2011) showed that, in the fixation of transverse ulnar olecranon fracture, compared with the steel plate tension band, the Kirschner wire tension band generated significantly lower pressure on the fracture ends under both static and dynamic conditions. In the dynamic test, the Kirschner wire tension band could not convert the ten-

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Fig. 6.4 (a) Kirschner wire tension band fixation for ulnar olecranon fracture: This method is suitable for simple fractures, through which the fracture fragments can support each other and are compressed by the tension band. (b) Plate-screw internal fixation technique for ulnar olecranon fracture: This method is suitable for severe olecranon comminuted fractures, especially comminuted fractures involving the base of the olecranon. Regular plate fixation with screws passing through fracture fragments can avoid the decrease in length or opening angle of the ulnar semilunar notch caused by piling and compression among frag-

ments, thus effectively maintaining the location of the bone fragment. (c) Proximal ulnar anatomical locking plate technique: This method is suitable for internal fixation for treating severe olecranon comminuted fractures. The design of this plate includes an angle between the screw and plate that allows the screws to pass through and fix as many bone fragments as possible. The locking mechanism between the plate and screws enhances the overall holding force among the bone fragments, screws, and plate

sion into pressure; instead, the pressure on the articular surface of the fracture ends was further reduced, in opposition to the traditional principle of the Kirschner wire tension band (Closkey et al. 2000).

non as a pile driver, resulting in ulnar olecranon fracture and elbow dislocation. Different positions of the elbow joint in the violent injury may result in different types of fractures of the olecranon, as well as associated injuries, such as coronoid process and radial head fractures (Rommens et  al. 2004; Nowinski et al. 2000). When the elbow receives direct violence in flexion, the distal humeral trochlea will strike the olecranon body, resulting in simple olecranon fracture, as indicated by a shift of the forearm to the palm side. The injury often involves the humeroulnar joint and rarely involves the radial structure, including injuries in the proximal radioulnar joint, radial ­ head, and radial collateral ligament.

6.1.3 Mechanisms of Injury • Direct violence: –– External force acting directly on the elbow, causing olecranon fracture and dislocation (Fig. 6.5): The elbow hits the ground to receive the direct violence, and the stress passes from the olecranon to the distal humeral trochlea. The reaction force generated in the distal humerus directly hits the olecra-

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Fig. 6.5  Olecranon fracture and dislocation. (a) When the elbow receives a violent impact during flexion, the distal humeral trochlea will strike the body of the ulnar trochlear notch, resulting in olecranon fracture, as indicated by a shift of the forearm to the volar side. The injury rarely involves the ulnoradial joint, radial head, and radial collateral ligament. (b) When the elbow receives a violent impact during full

When the elbow receives direct violence in extension, the distal humeral trochlea will directly hit the intersection of the olecranon and the base of the coronoid process, resulting in double fractures in the olecranon and the coronoid process. Collision of the humeral capitellum with the radial head can also lead to radial head fracture. The specific direction of violence often leads to fracture collapse on the articular surface. In surgery, the olecranon, coronoid process, and radial head fracture should be fixed, and the collapse of the articular surface should be restored. The operation is difficult, and the prognosis is poor. Some olecranon fractures may extend to the ulnar shaft, that is, proximal ulnar comminuted fractures, and will require steel plate fixation and other special solutions. • Indirect violence: –– The hand hits the ground when falling, and thus the violence is transmitted from the forearm to the elbow to cause indirect injury instead of directly acting on the elbow. At the moment of injury, depending on the forward or backward rotation of the forearm, the flexion or extension position of the elbow joint, and the flexion angle of the elbow, different anatomical parts of the elbow joint will receive different degrees and nature of mechanical load, resulting in various types of injury and dislocation in the elbow, such as coronoid process fracture, radial head fracture, posterolateral rotation injury, and posteromedial rotation injury.

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extension, the distal humeral trochlea will directly hit the intersection of the olecranon and the base of the coronoid process, resulting in double fractures in the olecranon and the coronoid process. Collision of the humeral capitellum with the radial head can also lead to radial head fracture

–– When the hand hits the ground with an elbow flexion angle of 30°, the humeroradial joint will bear a greater load, leading to radial head fracture. –– Posterolateral rotation injury can cause elbow dislocation and injury of the surrounding soft tissue. If the elbow bears the stress at the valgus position, radial head fracture and coronal fracture may occur, resulting in instability in posterolateral rotation (refer to the related sections for radial head dislocation and triad of the elbow). O’Driscoll et al. have described the mechanism of posteromedial rotation injury (Bucholz and Court-­ Brown 2010). The arm is extended when falling, and the forearm is in the forward rotation position. Consequently, the forces of axial direction, varus, and forward rotation are all on the elbow, causing a series of injuries. This type of injury can cause subluxation of the elbow. The stress on the lateral coronoid process can lead to compression fracture of the anteromedial coronoid process. The tension and stress on the lateral elbow can also be combined with lateral collateral ligament injury (Fig. 6.6).

6  Fracture of the Proximal Ulna Fig. 6.6 (a) Schematic diagram illustrating a posteromedial rotation injury: When falling with the arm extended and the forearm in the forward rotation position, the forces of the axial direction, varus deformity, and forward rotation are all on the elbow. Consequently, the stress on the medial coronoid process can lead to compression fracture, and the tension and stress on the lateral elbow result in lateral collateral ligament injury, which can further cause posteromedial rotation instability of the elbow. (b) CT scan of posteromedial rotation injury of the elbow joint demonstrating an anteromedial compression fracture of the coronoid process and avulsion of the lateral collateral ligament ending point. (c) A mini supporting plate is used to internally fix the coronoid process fracture, and suture rivets are used to repair the tear in the lateral collateral ligament

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6.1.4 Classification of Fractures • Schatzker classification of ulnar olecranon fractures (Fig. 6.7): This classification method is relatively simple and can guide the operation of the ulnar olecranon fracture and the selection of internal fixation. According to the fracture morphology, ulnar olecranon fractures are divided into 6 types: –– Type A: Transverse fracture generally occurs in the deepest half-shaped notch. This fracture can be ulnar

olecranon avulsion fracture caused by sudden contraction of the triceps muscle or by direct hit of the olecranon to the ground when falling. –– Type B: Complex transverse fracture, transverse fracture associated with comminution or compression of the articular surface. –– Type C: Oblique fracture, mostly caused by elbow excessive flexion. The fracture extends from the coronoid process of the half-moon shaped notch distally. –– Type D: Comminuted fracture, often caused by high violence directly on the elbow. In addition to commi-

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Fig. 6.7  Schatzker classification of ulnar olecranon fractures. Type (a): transverse fractures that generally occur in the apex of the semilunar notch; Type (b): complex transverse fractures, which refer to transverse fractures complicated by comminution or compression of the articular surface; Type (c): oblique fractures, which are mostly caused by elbow excessive flexion and extend distally from the coronoid pro-

nuted fracture of the olecranon, it can also be combined with coronal fracture. –– Type E: Oblique fracture of the distal ulnar olecranon. This fracture involves the coronoid process of the half-­ moon shaped notch extending to the ulnar shaft. In contrast to the C-type fracture, this type of fracture bears greater stress on the fracture ends. –– Type F: Radial head fracture with elbow dislocation, often accompanied by rupture injury of the medial collateral ligament. The olecranon, radial head, and medial collateral ligament must be reconstructed. • Regan and Morrey classification of coronal fractures (Fig. 6.8): The classification is based on the extent of coronoid process involvement of the fracture. The larger the involved coronoid process, the greater its impact on the stability of the elbow (Schatzker 2005). –– Type I: Avulsion fracture in the tip of the ulnar coronoid process. –– Type II: Single or comminuted fracture involving no more than 50% of the coronoid process. –– Type III: Single or comminuted fracture involving more than 50% of the coronoid process.

cess of the semilunar notch; Type (d): comminuted fractures of the olecranon with or without coronal fractures; Type (e): oblique fractures of the distal ulnar olecranon, which involve the distal part after the middle point of the semilunar notch; Type (f): ulnar olecranon fractures complicated by radial head fracture and elbow dislocation

I II III

Fig. 6.8  Regan and Morrey classification of ulnar coronoid fractures. Type I: avulsion fractures in the tip of the ulnar coronoid process. Type II: single or comminuted fractures involving no more than 50% of the coronoid process. Type III: single or comminuted fracture involving more than 50% of the coronoid process

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tip

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•

•

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Fig. 6.9  O’Driscoll classification of ulnar coronoid fractures (view of the proximal ulnar from the distal side, the marked fracture lines denote the fracture sites of each fracture type). Type I fractures involve only the tip of the coronoid process, Type II fractures involve the anteromedial coronoid process with or without affecting the tip of the coronoid process, and Type III fractures involve the base of the coronoid process

• O’Driscoll classification of coronal fractures (Fig. 6.9): In 2003, on the basis of the Regan and Morrey classification, O’Driscoll et al. emphasized the importance of the anterior medial side of the coronoid process and divided coronal fractures into 3 types (Bucholz and Court-Brown 2010): –– Type I: Fracture in the tip of the coronoid process. –– Type II: Fractures in the anterior medial of the coronoid process. –– Type III: Fracture in the basement of the coronoid process. –– The subtyping of this classification is not described in detail here, but it should be noted that the anterior medial side of the coronoid process is the attachment point of the medial collateral ligament, and fractures at this location often cause failure of the medial collateral ligament and thus warrant particular attention.

6.1.5 Assessment of Proximal Ulna Fractures 6.1.5.1 Clinical Assessment • Typical manifestations: The affected elbow is often in flexion position, commonly held by the hand on the contralateral healthy side. The area around the elbow is swell-

•

ing, and the swelling is often more obvious in the rear of the elbow. Subcutaneous bleeding or bruising can be observed in the affected area. While examining the elbow, an empty feeling, abnormal activities, and elbow flexion and extension dysfunction suggest fracture or dislocation. Examining elbow stability: For patients with no fracture shown in X-ray, a stress test should be performed with the varus and valgus of the elbow. Pain and instability suggest damage in the ligament and other soft tissue. For patients with pain in the forearm and wrist, tenderness between the ulna and radius and the presence of instability in the distal radioulnar joint should be further assessed to prevent misdiagnosis of combined injury of the radioulnar interosseous membrane (Essex-Lopresti fracture) and the distal radioulnar joint. Neurological function: The sensory function of the ulnar nerve innervation and motor function should be checked for early detection of ulnar nerve injury (Regan and Morrey 1989).

6.1.5.2 Imaging Assessment • X-ray examination: –– A conventional scan of the elbow joint at the anteroposterior, lateral, and oblique positions can basically reveal the scope of the fracture, the degree of comminution, and the involvement of the articular surface. The scope of the radiograph should be the X-ray of the full-length forearm including the elbow to clarify the dislocation of the radial head and injury in the distal radioulnar joint. –– In fracture of the medial coronoid process, the fracture fragments are often small, and thus missed diagnosis might occur in regular X-ray scanning. Observation of the double cortical line sign in the coronoid process during scanning in the lateral position suggests possible avulsion fracture in the anterolateral coronoid process caused by posteromedial rotation injury. • CT examination: –– Patients with suspected intra-articular fractures should receive CT scan and 3-dimensional reconstruction of the elbow joint to clarify the intra-articular fracture. –– In particular, anterolateral fracture of the coronoid process is not easy to identify by conventional X-ray examination. CT scan and 3-dimensional reconstruction can reveal occult fractures, thus reducing the rate of missed diagnosis (Fig. 6.10).

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H. Chen et al.

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Fig. 6.10  A fracture of the medial ulnar coronoid process. (a) In the anteroposterior radiographic image of the elbow joint, the cortex of the anteromedial coronoid process appears slightly rough, and the presence of fractures is uncertain, leading to a high risk of a missed diagnosis. (b) The lateral radiographic image demonstrates the coronoid process with dual cortical patterns, indicating an anteromedial fracture of the

coronoid process. (c) The CT scan-reconstructed 3D image of the elbow joint clearly demonstrates the size and dislocation of the fracture fragments of the anteromedial coronoid process

6.2 Surgical Treatment

Position and Preoperative Preparation • Brachial plexus anesthesia or general anesthesia. • The hemostatic belt is placed in the upper arm. The location of the belt should be as high as possible to fully expose the surgical area and facilitate the operation. • The patient is supine on the surgical bed, and the forearm is placed on the arm holding plate by the chest (Fig. 6.11). • C-arm fluoroscopy is used to monitor the reduction and fixation of the fracture.

6.2.1 Ulnar Olecranon Fracture Surgical Indications • For ulnar olecranon fracture with small displacement, articular surface step or separation