Approach to Fractures Rahij Anwar
Chapter Notes

Save Clear

1Upper Limb2

Shoulder and ArmCHAPTER 1

Clavicular fractures are caused by a fall on an outstretched hand or from a direct impact at the tip of the shoulder. The medial (proximal) fragment is often pulled upwards due to the action of the sternocleidomastoid muscle and the distal (lateral) fragment displaces inferiorly by the weight of the arm. Associated injuries to the brachial plexus, chest (including rib fractures) and subclavian vesssels may be present. Local tenderness, deformity and painful limitation of movements of the shoulder are important clinical features. A vast majority of these fractures unite following conservative treatment with a sling. Early shoulder mobilisation is encouraged. Open reduction and internal fixation may be considered in certain special situations especially if there is an associated vascular injury or the skin is at risk.
Injuries to the acromioclavicular joint are common after a direct impact at the point of the shoulder. The displacement of the clavicle depends upon the severity of trauma ranging from subluxation to gross disruption of the joint. Associated injuries (e.g. pneumothorax, clavicular fractures, etc.) may be present.5
zoom view
Figure 1.1: AP view of the shoulder showing a fractured clavicle. Most fractures of the clavicular shaft are treated conservatively using a sling
zoom view
Figure 1.2: AP view of the shoulder showing a non-union of the fractured clavicle. The sharp end of the medial fragment irritated the skin and caused pain
zoom view
Figure 1.3: AP view of the shoulder. Painful fracture non-union of the clavicle treated with open reduction, internal fixation and bone grafting
Minor displacements can be satisfactorily managed conservatively. Open reduction and internal fixation (using a plate, coracoacromial screw or suture) is indicated for the more severe types.
Dislocations of the shoulder joint usually occur after a fall on an outstretched hand. Most shoulder dislocations are anterior. Other types, posterior and inferior (luxatio erecta), are rare. Deformity of the shoulder is obvious on examination. Axillary nerve (tested by assessing deltoid function and sensations in the ‘regimental badge’ area) may be involved.7
zoom view
Figure 1.4: AP view of the shoulder showing disruption of the acromioclavicular joint
zoom view
Figure 1.5: AP view of the shoulder showing a disrupted acromioclavicular joint stabilised by open reduction and internal fixation using a hook plate
Associated injuries like fractures of the proximal humerus (e.g. greater tuberosity) may be present. Reduction is achieved by manipulation under intravenous sedation or general anaesthetic. Surgery is reserved for recurrent dislocations or in cases associated with significantly displaced fractures, especially in young patients.
zoom view
Figure 1.6: AP view of the shoulder showing anterior dislocation of the humeral head associated with a fracture of the greater tuberosity
zoom view
Figure 1.7: Y view of the shoulder showing an anterior dislocation of the humeral head
Fractures of the proximal humerus commonly occur in elderly patients, following trivial falls. They may be associated with subluxation or dislocation of the shoulder joint, axillary nerve involvement, chest 10injuries, etc. Undisplaced or minimally displaced fractures can be satisfactorily treated with a collar and cuff sling. Operative treatment (ORIF/Hemiarthroplasty) is reserved for grossly displaced fractures or those with joint involvement.
zoom view
Figure 1.8: Undisplaced or minimally displaced fractures of the proximal humerus can be satisfactorily treated conservatively
Fractures of the humeral shaft occur following violent trauma (e.g. road traffic accidents). The radial nerve is involved in about 10% cases. Conservative treatment (functional brace or plaster slab) is indicated for a majority of the fractures.11
zoom view
Figure 1.9: AP view showing a hemiarthroplasty (Neer's prosthesis) of the right shoulder following a comminuted fracture of the proximal humerus
Internal fixation (Intramedullary nailing or plating) is advisable if conservative treatment fails. Non-union is an important complication.12
zoom view
Figure 1.10: A trial of conservative treatment should be given for all humeral shaft fractures with acceptable alignment
zoom view
Figure 1.11: AP view of the arm showing an united fracture of the shaft of the humerus treated with intramedullary nailing and bone grafting