Handbook of fractures 3rd edition

Handbook of Fractures, Third Edition. More Views. Add to Cart. Description Details Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product. Handbook of Fractures is the ideal portable resource for health care professionals who need to manage patients with musculoskeletal problems Written by leading orthopedic surgeons, this superbly illustrated pocket guide helps you expertly diagnose, classify, and, most importantly, manage every type of fracture and ligamentous injury commonly seen in clinical practice.

Organized by anatomic region and packed with high-quality line drawings and x-rays illustrating diagnostic and management procedures, this invaluable guide covers: Anatomy surrounding the fracture Diagnosis with physical and radiographic findings Differentiation of mechanisms of injury Fracture classification Indications for operative treatment Description of potential surgical options Expected outcome Management of late complications Summaries and reflections. Contents Handbook of Fractures 1.

Clinical Evaluation 2. Methods of Fixation 3. Nonoperative Techniques 4. Anesthetic Techniques 5. Radiologic Evaluation 6.

Fracture Healing and Bone Grafting 7. Injuries of the Glenohumeral Joint 8. Many surgeons have utilizccl T- or L-shapcd D. CUtralh:aticm plates or blade plates to trea1 displaced two-part surgical neck fractures.

Jt is probable that the new generation oflocldng plales wiD improve the msults shown in Table Antegtade intramedulWy nailing. The Jaulls ofboth mtegnlde lllliling Fig. The average age of the series delllillg wi1h this teclmique lies between those with K wires and plating and nonoperalive IDllll8.

The problem 8. A locked abort intramedullary nail is uaually ued. As widl all methods of treatmeDt, better results are gained in younger patients; but unlilce the case with K wiring and plating, 1he dift'erencc between the msults in the youug and older groups is less marbd.

Retrograde nailing is undeltalren using dUn. This teclmi. Nonoperative management wu used. However aualysill shows that whili: the outcome of A2. These are extremely rue and are treated in the same way as fraclmes of the pater tuberosity.

As with greater tuberosity fraduml, imagiDg of the rotator cuff is indicated, with repair being undertaken as required. If UDdisplacecJ.

Screw fixation is advised in youuger patienta. In three-part fractures, the smgi. In fom-part fractun:s, boch tuberosities aDd the surgical neck are fl:actuied, thus compromising the vascularity of the h11JDCftl head. These fractures are not associated with the same degree of vascular damage, and intemal fixation rather than joint replacement is often used to treat valgus impaction fracmres. The results of these tmdment methods are given in Table Courtesy of C.

Robinson, M. The results for nonopcrati. Table shows dlll1 the mclmiqae is ID four-part fnu:tuml, ilia betta'thall D. ODOpelldive managemmt but worse 1hanpercutaneous screw fixalion or 1he use of sUIIlres or cerclage wires. Unda Ouoroscopic control, miDimal dissection teclmiques are uaed to reduce the fragmmts into an atomic position and pem1taneous screws are used to fix die f'radure.

Calcium phosphate cement may be used to fill the void in the humeral head. The soft tissue dissection is lea than with pladng. The osteopenic nature of the bone in the majority of patients means thatreaultll are poor.

Intromedtdlmy NDiling Good results have been published, but then: are very few good studies, and up to Both antegrade and retrograde nailing provides good results in two-part fractures, but these teclmiques are not appropriate for more oomplex fractures. Anwnberof clifferentimplants FIG. They are inserted through an anterior deltopectoral approach, with the tuberosities being reconstructed after the prosthesis has been inserted. The literature clearly shows that their use is associated with good pain relief but relatively poor shoulder function, particularly in the elderly.

A number of factors have been shown to affect outcome. These are listed in Table Patient satisfaction is high and the operation is better than nonoperative management in the fit elderly. There has only been one prospective study comparing hemiarthroplasty with nonoperative management in elderly patients.

There has been no prospective study comparing hemiarthroplasty with operative reconstruction. The prognosis is worse than for three- and four-part fractures, with very high rates of avascular necrosis and shoulder dysfunction often being recorded. Hemiarthroplasty is the best treatment method. Valgus Impacted Fnctu, These fractures Fig.

The average age of patients with a valgus impacted fracture is 72 years. The incidence of avascular necrosis is less than in fractures associated with rotation of the head. Four-part impacted valgus fractures are best treated by percutaneous screw fixation or hemiarthroplasty, depending on the age of the patient. Operative treatment of three-part valgus impaction fractures is indicated if there is excessive valgus.

Unfortunately there is as yet no definition as to what constitutes the extreme valgus of the humeral head, but consideration should be given to operative treatment of three-part impacted valgns fractures that show significant valgns of the head, particularly if they occur in younger patients.

In a study of consecutive proximal humeral fractures, only II 1. Five The highest incidence of nonunion is in the rare B2. This is followed by the B2. Nonunion can be extremely disabling. The humeral head becomes stuck and all movement is at the site of the nonunion. Treatment depends on the age and degree of infirmity of the patient, but symptomatic nonunion is best treated by internal fixation and bone grafting in younger patients and by hemiarthroplasty in older patients, in whom pain relief is the most important outcome.

Good results have been reported with locked antegrade nails and bone grafting. The results of hemiarthroplasty are also encouraging, but function is not as good as for primaiy hentiarthreplasty. Malunion Malunion is relatively common after proximal humeral fractures but rarely requires surgery. However, in younger patients, repositioning of displaced tuberosities may improve shoulder function and a proximal humeral osteotomy and refixation can be carried out.

More commonly, however, hemiarthroplasty is the treatment of choice for symptomatic proximal humeral malunion. If this condition is causing symptoms, it should be tteared by hemillrthroplasty.

Rarely, it is more severe and symptomatic. Under these conditions, excision can be carried out with indomethacin or with radiation therapy to minimize the risk of recurrence. Axillary Artery Damage This is extremely rare. It occurs in high-energy injuries, usually in younger patients.

The head of the humeros is forced into the axilla, damaging the artery. Vascular reconstruction is usually required. Neurologic Damsge Neurologic damage is surprisingly common after proximal humeral fractures. The lesion is usually a neuropraxia and treatment is expectant, although physical therapy may be required. Recovery is usually complete. These are based on the results detailed in the literature and are not followed by every surgeon.

The interpretation of age is particularly difficult. Surgeons should assess the patient's geneml health, degree of dependence, and functional requirements before making a decision regarding treatment. They should also remember that fracture treatment is constantly evolving.

The greater tuberosity carries the insertion of the supraspinatus superiorly and the infraspinatus and teres minor posteriorly. The lesser tuberosity is the site of insertion of the subscapularis. The long head of the biceps takes origin from the superior glenoid and lies in the intertubercular groove between the two tuberosities. The anatomic neck of the humerus is delineated by the area of the head covered by articular cartilage, whereas the surgical neck.

The anterior and posterior circumflex humeral arteries and the axillary nerve circle the proximal humerus at the level of the surgical neck. The vascular supply of the humeral head is through the anterior lateral ascending arcuate artery, which originates from the anterior humeral circumflex artery. The arcuate arteiy runs proximally along the lateral aspect of the intertubercular groove and enters the humeral head through foramina along its course. The glenoid serves as a fulcrum against which the muscles of the shoulder work to move the humerus.

The bony glenoid is a shallow socket that has an articular surface area of only one-third that of the humeral head. Although both the humeral head and the glenoid are typically retroverted with respect to their long axes, the scapula is protracted forward on the chest wall Fig.

Excessive posterior translation of the humeral head is therefore prevented by the strong buttressing action of the posterior glenoid. The glenohumeral articulation functions as a multiaxial ball-and-socket joint and is the most mobile joint in the body, at the expense, however, of intrinsic stability. The stability of the articulation is dependent on passive and active mechanisms.

Passive mechanisms of stability include the glenoid labrum, negative intraarti. The glenoid labrum deepens the glenoid fossa and consists of dense fibrocartilage. The anteroinferior labrum is usually detached from the rim of the glenoid during anterior dislocations of the shoulder Bankart lesion. The supraspinatus tendon, coracoacromialligament, and acromion form the roof of the glenohumeral articulation and, with other components of the rotator cuff, prevent proximal migration of the humeral head.

The capsule of the glenohumeral articulation is large and baggy, allowing the extensive range of motion of the shoulder. The three glenohumeral 6gaments superior, middle, and inferior are thickenings of the capsule and are major passive stabilizers of the joint.

Cuff repair Percutaneous screw fixation Nonoperative Percutaneous screw fixation Hemiarthroplasty Reduce and as for two-part fracture Hemiarthroplasty Hemiarthroplastv. An intact rotator interval is felt to be a major stabilizer, opposing posterior and inferior humeral diapl.

The DWScles of the rota1or cuff and the loDg head of the biceps comribute to active glenohumeral stability. The rotator cal'f'JiliiSclm function to maintain the humeral head agaiDst the glenoid and also laVe to tension the capsulolabral complex during movement of the shoulder. In addition. The majority of glenohumeral dislocations are anterior Fig. Posterior dislocations Fig. These injuries occur in all age groups and occur following eiJherhigbenei! Y injury or during seizures, which may be triggered either by epilepsy, diabetic hypoglycemia, c1ectrocution, or lllcchol or drug withdlawal.

IDI'erior dislocations are extremely uncommon and are known as traumatic luutlo ereda Fig, Mllltidirectional ilultJbi1ity refers to instability of the shoulder ill JDDie than one direction cbaraclerlJtk:ally antcrior, posterior, and inferior instability and is usually associamd with constitutional ligamentous laxity.

Glenohumeral dislocldiou are fmthcr classified as acute, chrcmic, or recurrent. Amte dlslocatlcms are diagnosed within the first 2 weeks after injury. Chrome dflloeatloas are diagnosed after 2 weeks, either because the dislocation wu miaaed by the phyaician initially or due to delayed presentation by the patimt. The elderly and patienu with posterior dislocations are at risk of substantial delay before the diagnosia ia made.

Instability may become reeurreat if the shoulder n:peatedly resubl. Anterior dislocations in the young are particulady at risk of Ibis complication.

Posterior glenohumeral dislocation. Superimposition of humeral head on glenoid Indicates posterior dislocation. Computed tomography indicates bilateral posterior fracture dislocations of the shoulder. Jmtability may also be classi1ied acconliDg to wbctha' or not it is Ulldcr volUDtary controL Velmttuy dJsloc:atlan is prodnc:ed willfully, umall. In the majority of patients, dislocation is not under voluntary CODirol and occurs acc:idmtally iDvelmttuy iallability.

A traumatic dislocation occurs fo1lowmg injury to the ahoul. In these patients there ill oftm. Fractures rommonly associated with gleoolmmeral dislocaticma include tuberosity f:ractums and f:ractums of the glelloid rim. Fractures of the surgical or anatomic neck of the llumerus may occur in association wi1h a dislocaticm, but they are best considered with odler prollimal humeral fractures see Part I of this chapter.

Careful review of 1be radiographs is required to determine the presence of fractures. It is important to be aware of the poaaibility of an nndisplaced fracture of the humeral neck, which may dispWle duriDg attempted reclucti. In this situatiou, to minimize 1he probability of displac:emmt, recluctioD is performed UDder general anesthesia with muscle relaxation and ia m. Both displaced fractures of the tuberosities and rotator cuff tears undermine the function of the rotator cuff muscles; they may lead to chronic pain and shoulder weakness if neglected.

Suspicion of a rotator cuff tear is raised by positive findings on physical examination inability to initiate abduction of the glenohumeral. The diagnosis is confirmed by arthrography, ultrasound, or MRI scanning. All significantly displaced tuberosity fractures and conlinned rotator cuff tears occurring after a traumatic dislocation should be treated by surgical repair in medically fit patients.

The neurologic injury most frequently associated with glenohumeral dislocation involves the axillary nerve, although injury to the entire brachial plexus or other individual nerves, trunks, or divisions may occur. Injury to the axillary nerve is confumed by the presence of hypoesthesia in the cutaneous distribution of the nerve the "sergeant's badge area" and lack of voluntary contractions of the anterior and middle portions of the deltoid muscle.

It is a mistake to assume that weakness of the shoulder following a dislocation is due entirely to an axillary nerve palsy; a concomitant rotator cuff injury must always be suspected and treated if present. Most dislocations with closed nerve injuries will be treated expectantly; the prognosis for recovery following an isolated nerve injury is usually better than when a more proximal plexus lesion is present. Axillary artery injury is very uncommon and more likely to occur following a high-energy injury, in older patients, and in association with a brachial plexus injury.

Physical signs include an expanding hematoma in the axilla and absent pulses at the elbow and wrist. Rupture of the axillary artery is an absolute surgical emergency.

Diagnosis and Management Acute first-time dislocations. A clear history of when the injury occurred and whether there have been previous problems with instability must be determined. Traumatic anterior dislocation typically results from a contact sports injury or simple fall, whereas acute posterior dislocations result from either high-energy injury, an epileptic or hypoglycemic fit, alcohol or drug withdrawal, or electrocution.

Any patient with shoulder pain following a ''blackout" should have a posterior shoulder dislocation specifically excluded. Acute traumatic dislocations are typically painful and the patient is usually reluctant to move the ann. Anterior dislocations are recognized by "squaring off' of the normal deltoid profile, while posterior dislocations are associated with a fixed mechanical block to external rotational movements of the arm.

The physical examination of the patient with luxatio erecta is dramatic, with the humerus locked in greater than 90 degrees of abduction. Radiographic examination of the injured shoulder confirms the direction of the dislocation and delineates any associated fractures.

The patient with a glenohwneral dislocation is unable to move the arm so that a true axial view of the shoulder may be obtained. Therefore, in addition to the standard anteroposterior radiograph in the transscapular plane, a "modified" axial or Velpeau view, taken with the arm in a sling, is essential to confinn the diagnosis Fig. Specialized imaging. Acute dislocations sbou.

Prior to reduction, venous access is established, the patiCDt is seclab:cl. The reduction IDalll:UVer used is detmnined by the type of dislocation.

Anterior ctisl. Gentle iDtmJal. Co11Dfeltr8ction is applied by an assistant using a sheet wrapped around the patient's chest. The traction is firm and consistent. Stlmsoa's method involves haoging S to 10 lb of weight from the arm of the prone patient. After 10 to 20 min. Stimson's method is nseful as a last :resort for dislocations that ue difficult to reduce by other methods. The Rlppoeratle method involves applying l. Posterior dislocaaioDS are redw:ed. Following disengagement, the shoulder can usually be reduced by gentle extemal rotation of the LUDtio eftda is mJuced with 1Iacti.

Following reduction of the shoulder, a focused n:examination is perfonned to assess the inmgrity of the axillary DelVe and rotator cuff. The shoulder is immobilized in a sling, with the arm intemally rotated and in neutral fl.

Uncomplicated anterior dislocations ue usually stable in this position. The treatment options in this situation include either immobilization of the shoulder in a position of external rotation or an acute stabilization procedure to address the reverse Hill-Sachs lesion.

This may include either transplantation of the subscapularis tendon into the defect McLaughlin procedure or bone grafting of the defect with an allograft. These procedures should be perfonned by an experieru:ed shoulder surgeon. Most acute shoulder dislocations are treated by immobilization for the first 3 to 4 weeks in the sling, followed by a program of active physiotherapy to reestablish range of motion and strengthen the musculature of the shoulder girdle and rotator cuff.

Associated fmctores and rotator cufflesioos, typically in the middle-aged and elderly patient, should be treated on their merits as described above. Recurrent instability of the shoulder may be prevented by an acute arthroscopic Bankart repair to reattach the anteroinferior glenoid labrum within the first few weeks following an acute first-time anterior dislocation.

TIIis procedure requires considerable expertise. Recurrent instability. Recurrent instability, in the form of recurrent subluxation or dislocation, is usually a complication of an initial traumatic anterior dislocation, though recurrent posterior instability is being increasingly diagnosed and treated. The clinical assessment of the patient presenting with symptoms of recurrent shoulder instability is primarily directed toward identifying those individuals with predominantly traumatic instability, who would benefit from surgical treatment.

These patients must be distinguished from those with predominantly atraumatic or voluntary instability, who are best treated nonoperatively in the first instance. Details about the onset, duration, and frequency of the symptoms should be sought in the history. Physical examination should include screening for evidence of generalized ligamentous laxity and the use of provocative tests to define the direction and extent of instability.

A plain radiographic series is useful in delineating any associated bony pathology, including glenoid rim and humeral head defects. Further specialist radiologic investigation, examination under anesthesia, or diagnostic arthroscopy may be used for patients in whom the precise diagnosis is in doubt. MRI of the shoulder is superior to CT in the assessment of shoulder instability owing to the better definition of soft tissue provided byMRI.

Patients with atraumatic shoulder instability should be treated by an intensive 6-month course of physiotherapy, concentrating on proprioceptive exercises and rotator cuff strengthening. Emotionally disturbed patients may learn to dislocate a shoulder at will for secondary gain; it is important not to make the mistake of treating these patients by way of a surgical stabilization procedure. Psychological counseling is the mainstay of treatment for these individuals. Most patients with recurrent anterior traumatic instability are best treated by a surgical stabilization procedure to repair the Bankart lesion to the decorticated glenoid rim Bankart repair , combined with a procedure to retension the redundant, stretched anteroinferior capsule-ligamentous complex.

Increasingly nowadays, these procedures can be carried out arthroscopically, although the expected failure rate by that technique is slightly higher. Recurrent posterior shoulder instability is commonly associated with concomitant inferior or multidirectional instability. The results of surgical stabilization have previously been poor for this condition. However, there is evidence that targeted "lesion-specific" surgery, along similar lines to the treatment of anterior instability, particularly when performed arthroscopically, may be associated with a higher success rate.

Chronic dislocations. Most dislocations that present late occur in elderly patients and many of these are posterior in direction. The management of these injuries depends on the activity and health of the patient, length of time that the glenohumeral joint has been dislocated, and size of associated humeral head defect.

Nonoperative treatment is usually preferred if the patient is inactive or a poor surgical candidate. In these circumstances, closed reduction may be attempted, but often an open reduction is required to disengage the humeral head defect from the glenoid rim.

Ancillary stabilizing techniques, including soft tissue rebalancing and bone grafting of the humeral head defect, are often required to stabilize the shoulder following open reduction.

Four part fractures of the proximal humerus. J Orthop Trauma , Court-Brown CM. The epidemiology of proximal humeral fractures. Acta Ortlwp Scand , McQueen MM. Epidemiology and outcome in the older patient. J Bone Joint Surg ! The impacted varus A2. Acta Orflwp Scand, Techniques and principles of tuberosity fixation for proximal humeral fractures treated with hemiartbroplasty. J Shoulder Elbaw Surg , Minimally displaced proximal humeral fractures: epidemiology and outcome in cases. Acta Orthop Scand , Green A.

Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. Four-part impacted valgus fractures of the proximal humerus. J Bone Joint Surg , Outcome after primary hemiarthroplasty for fracture of the head of the humerus. A retrospective multi centre study of patients. Neer CS. Displaced proximal humeral fractures.

Part 1. Clsification and evaluation. OTAfracture and dislocation compendium. J Orthop Trauma 10 suppl1 , Two-part and three-part fractures of the proximalhumerus treated with suture fixation. J Orthop Trauma , Severely impacted valgus proximal humeral fractures.

Concurrent rotator cuff tear and brachial plexus palsy associated with anterior dislocation of the shoulder: a report of two cases.

J Bone Joint Surg 73k Matthews D, Roberts T. Intraarticular lidocaine versus intravenous analgesic for reductions of acute anterior shoulder dislocations. AM J Sports Med , Rowe CR, 2Mins B. Chronic unreduced dislocations of the shoulder. J Bone Joint Surg 64k, Capsulorrbaphy through an anterior approach for treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder.

J Bone Joint Surg 80A: , It stabilizes and serves as a fulcrum for the scapula. Without the clavicle, contraction of muscles that cross the glenohumeral joint e. The clavicle is S-shaped when viewed from above. The flat acromial end is covered by the deltoid origin anteriorly and the trapezius insertion posteriorly. The round sternal end gives rise to the origin of the pectoralis major anteriorly and the sternocleidomastoid posteriorly. The scapula is a fiat, triangular bone located on the posterior aspect of the chest.

It has three bony processes: the COiaCOid process; the spine; and the continuation of the spine, the acromion. It has two articulations: the acromioclavicular joint and the glenohumeral joint.

The scapula is buried in muscles. The costal, or anterior, surface is covered by the subscapularis muscle. The posterior surface is covered by the supra- and infraspinatus muscles. The spine is the origin of the posterior deltoid and the insertion of the trapezius. The short head of the biceps, the coracobrachialis, and the pectoralis minor originate from the coracoid process and insert on it.

The IIapezius and levator scapulae elevate the scapula. The serratus anterior moves the scapula anteriorly, holding it against the chest wall. Paralysis of the serratus anterior results in "winging" of the scapula. The acromioclavicular joint is a diarthrodial plane joint. Its articular surfaces are covered by fibrocartilage and separated by a meniscus. The joint is stabilized by weak acromioclavicular ligaments, the deltoid and trapezius muscles, and the coracoclavicular ligaments i.

Disruption of the acromioclavicular capsule increases joint translation in the anteroposterior plane; the coracoclavicular ligaments are more efficient in resisting superior displacement. The range of motion through the acromioclavicular joint is 20 degrees, with most of it occurring in the initial 30 degrees of shoulder abduction. The sternoclavicular joint is a diartbrodial saddle joint. Its surfaces are covered with fibrocartilage, and the joint is completely divided by an articular disc.

This disc attaches to the articular border of the clavicle, first rib, and joint capsule. The sternoclavicular joint is strengthened by anterior and posterior sternoclavicular ligaments, the interclavicular ligament running between the clavicles behind the sternum, and by the costoclavicular ligament running between the first rib and the clavicle.

The clavicle abducts or elevates about 40 degrees through the sternoclavicular joint. This motion occurs throughout shoulder abduction up to 90 degrees. This ill important, because phyaeal injuriea will remodel and joint disloca! Behind the stmnoclavicular joillt are the major blood vessels, the trachea, and the caophagus. The brachial plexus md subclaWlll arteJy continue laterally, posterior to the clavicle, passing over the rust rib, md mterior to the scapulajust distal to the cotai:Oid.

Tbe costoclavicular space may be decreased by a fracture of the first nb or medial portion of the clavicle, resultillg in acuce ueurovii8CIIl. The uillaly nerve paases below the neck of the glenoid and ill frequently injured in shoulder dislocaliODll. The supiaSCapu]ar DCrVe passes tbrough the scapular notch medial to the base of the coracoid under the tranaverse scapular ligament. It continues distally through a fibroosseoiiS tunnel spiuoglenoi.

Tbe mechanism of injury ill either a direct blow or an axial load resultillg from a fall or blow on the laleral aspect of the shoulder. DJstal-thJrd fraduns are further claasified into three types Fig. Type I fractures are the most common and occur between intact coracoclavicular and acromioclavicular ligaments.

The ligaments hold the fragments in alignment. The weight of the ann pulls the distal f'l:agmalt inferiorly, and the trapezius and stmuocleidomastoid pull the proximal fragment superiorly. Type m fractures are illtraarticular, usually undisplaced, and frequently become aymptomatic yeaJB lata as posttnmmalic arthritis. Mldclle-tlltrd lraetures are the most common t,pe of clavicular fracture.

The proximal fragment ill displaced superiorly by mnl! Fradures of the prulmal tblnl of the clavicle, excluding injuries of the stemoclavicular joint, are uncommon and frequently pathologic.

Radiographs of proximal-third fractures may occasionally have to be angmented with computed tomography CT. ID fractures of the distal third of the clavicle antaopostcrior, rediographs ofboth acromioclavicl11arjointll with the use of S- to lb weights are obtaiDed to detmnine the Pft'seJWe of ligamentous dismptiou.

AsiGdablcliDjuriu AssocWcd injuries to the chest, brachial pkmls, and major vessels are mled out by histmy and physical ex. Viscend injmy is associated with high-energy tiauma, an open fractunl, and fractuRI of the fiist rib or acapu]a. Scapulotboracic dissociation is a devastating injury associated with clavicular fracture or dislocation. The diagnosis is confimled by lateral displacement of the scapula, with an aasocialed injmy of the clavicle, acromioclavicular joint, or slerOOCiavicublr joint 'Ibm is frequently an associated injury of the bracbia1 plexus or axillary artery.

Amlaey artery disruption can be managed by prompt vascular surgical Jqlllir. Jpsilateral fradure ofdle clavicle or acromioclavicular separation associated with an extraarticular fracture of the glenoid neck results in a "floating shoulder" Fig.

Courtesy of Dr. Ene6 Kanlic. Type n distal clavicular fl:actuml and the rare di8pW:ed type mfractures arc IIW! The distal clavicle is exposed through an illcision over its anterior IUbcutaneous border. The fracture is stabilized with aT or one-third tubular plate. Type n fractures of the distal third of the clavicle treated nonoperatively arc associated with a high rate of sympiDmatic nonunion Fig. Fractures of tbe middle IIDd pruimal third of the clavicle arc treated wid1 manipulative reduction and immobilization with a figure-of-eight splint thai holds the shoulders donally.

The splint is applied and tightened with the shoul. It will stretch and lc:men; therefore it must be tightened eVeJY moruiug for die first few days. A sliug supports the IIDil the first week. After 4 or S weeks, fracture healing has usually progreased to the point where immobilization is no longer required. Exposure of die clavicle is through an. A 89 the superior surface of the clavicle. Atrophic nonunions are radiograpbically obvious.

Tomography or fluoroscopic examillation may be requiml to demonst:nlfe die more common hypcrtmphic nonuoiDn. Management of symptomatic nommiona includes opm m1uction, int. Shoulder pain and wcalmeas are bqucntly associamd.

Symptomatic shormning or angulation resulting in tenting of the skin is lllliDIIgecl with osteotomy, with internal fixati Kemeutofthe fl:ac1:ute fragments at the time of injury, from associated injuries e. Dysesthesias on the ulnar side of the band and forearm as well as weakness and pain in the involved shoulder brougbl on by prolonged activity suggest a thoracic oudet syndrome and must be differentiated from symptoms associated with a hypmropbic nonunion.

Provocative testing. Subclavian vein obslmction between the clavicle and lint rib is characterized by prominence of the veins in the ipsilaferal. Fractures of the scapula are rare and often associated with other severe injuriea. Comminution and displaooment, the ''burst fracture. Scapular fractures are further classified according to the location: fractures of the body and spine.

Intraarticular fractlm:B of the glenoid are subdivided into undisplaced and displarerl fractures. Displaced fractnres are simple i. The ann is adducred and protected apinst motion. Ecx:hymosis and swelling are minimal due to the loca1ion of the scapula beneath layem ofmuscle. Loss of active abduction and forwmdelevation of the Bim,lmown as pseudoparalysil of the rotator cuff, is often UBociated with scapular fmdnre and is the result ofintramuscular hemorrhage and pain.

Radiogmphic Exomillation Radiographic evaluation of the scapula includes true anteroposterior and lal:eral views of the scapula and an axillary view. The anteroposterior view of the scapula will show fractures of the glenoid and glenoid neck. Associated Injuries The most important factor in the initial management of scapular fractures is their frequent association with life-threatening visceral injuries.

The most common associated visceral injuries include hemopneumothorax, pulmonary or cardiac contusion, aortic tear, brachial plexus injury, axillary artery injury, and closed head injury.

The most common associated osseous injuries are fractures of the ribs and clavicle. Fracture of the first rib is frequently associated with injury of the brachial plexus and subclavian vessels. Definitive Management Management of fractures of the body and spine is usually nonoperative. The muscles surrounding the scapula prevent further displacement. A sling and ice are used for the first few days to control pain. As the pain subsides, pendulum exercises in the sling are initiated.

Healing is rapid; usually, active motion can be initiated after 4 weeks. Burst fractures with proximal displacement of the lateral margin of the body may impinge on the glenohumeral joint capsule. When this occurs, the fracture is reduced and stabilized or the offending bony spike is osteotomized. Extraarticular fractures of the glenoid neck are the second most common type of scapular fracture and occur when the humeral head is driven into the glenoid fossa.

A CT scan may be necessary to confirm that the fracture does not involve the joint. Reduction is not attempted. The arm is supported in a sling, and management is as described for fracture of the body and spine.

The prognosis is good for near full return of function. Fractures through the neck of the glenoid with an associated clavicular fracture floating shoulder are unstable because of loss of the suspensory function of the clavicle. Lower Extremity Fractures and Dislocations. Pediatric Fractures and Dislocations. Download Link. You are commenting using your WordPress. You are commenting using your Google account. You are commenting using your Twitter account.

You are commenting using your Facebook account. Beri tahu saya komentar baru melalui email. Beritahu saya pos-pos baru lewat surat elektronik. Practical Plastic Surgery ». Handbook of Fractures is organized by anatomic site providing key information on fractures in adults and in children, including: epidemiology anatomy mechanism of injury clinical evaluation radiologic evaluation classification treatment management of complications Handbook of Fractures has an easy-access format featuring numerous charts, tables, diagrams, illustrations, and bulleted lists.