Fractures of the clavicle are among the most common injuries in the upper extremity. While they generally heal without major functional limitation, they can be associated with serious neurovascular injuries. Patients generally present after a fall, particularly from a bicycle, or motor vehicle crash with pain and reluctance to move the shoulder. Inspection and palpation will usually identify the location of the fracture. Most fractures can be identified on standard AP radiographs of the shoulder, but additional apical oblique views may assist in characterizing the injury.
Fractures of the clavicle are classified by the location of the fracture in the medial, middle, or distal third of the bone. Approximately 80% of clavicular fractures occur in the middle third and most of these are amenable to closed management. Fractures of the medial third are rare, but can usually be treated symptomatically if they are not associated with other injuries. Fractures of the distal third of the clavicle may be accompanied by injury to the CC ligament complex and are at particular risk for nonunion. Fractures of the middle third of the clavicle have in the past been treated nonoperatively; however, recent well designed studies have demonstrated an up to 15% nonunion rate74 as well as significant improvement in functional outcome with operative fixation.75,76
Sling immobilization is adequate nonoperative treatment for most isolated fractures of the clavicle. Two to 3 weeks are sufficient for a patient’s symptoms to diminish so that he or she can tolerate pendulum exercises. After 6 weeks, the sling can be gradually discontinued and gentle activities resumed. Heavy activities are avoided for 8 weeks or until union is achieved. Because of the clavicle’s subcutaneous location, fracture callus is often palpable and may even be visible. Malunion of the clavicle can result in a functional deficit, particularly if there is angulation or shortening due to comminution.77 Malunited fragments or hypertrophic callus may occasionally compress neurovascular structures requiring surgical treatment, also. In most patients, however, the concern is only cosmetic and slight misalignment does not interfere with daily activities.
Surgical treatment of fractures is generally reserved for displaced fractures of the lateral (distal third) clavicle, fractures of the middle third with more than 2 cm of shortening, comminution, open fractures, fractures causing skin compromise (by tenting skin over the edge of the fracture), symptomatic nonunions, or fractures with an associated neurovascular injury. Surgical stabilization of the clavicle may also be indicated in patients with a floating shoulder or other complex injuries to the shoulder girdle as this may improve overall stability of the upper extremity. Surgical treatment of a fracture of the clavicle can be performed with plate and screw fixation or with intramedullary implants.
As fractures of the scapula result from high-energy trauma,78 patients with these fractures should be closely evaluated with a high index of suspicion for other serious and life-threatening problems. These would include injury to the chest, cervical spine, or neurovascular structures. Initial evaluation of the patient should include a careful assessment of the neurologic and vascular status of the ipsilateral upper extremity. Scapular fractures can occur in the absence of an obvious shoulder deformity and may first be recognized on a routine chest x-ray. True AP, scapular Y, and axillary lateral views of the shoulder should always be obtained, and CT scans, particularly with 3D reconstructions, are often required to fully evaluate the injury.79 The majority of scapular fractures occur in the scapular body, while 25% of scapular fractures involve the glenoid neck and 10% are intra-articular. Scapular body fractures are generally treated nonoperatively. Open reduction and internal fixation is considered for displaced intra-articular and glenoid neck fractures. Intra-articular displacement of more than 5 mm or a glenopolar angle of less than 20° are potential indications for surgery, as well as loss of more than 25% of the glenoid surface or more than 2 cm medialization of the glenohumeral joint.80
Fractures of the Proximal Humerus
These are relatively common fractures and occur most often as the result of falls or a motor vehicle crash. The incidence increases with age, and the cause is typically a low-energy injury in the elderly patient.
Peripheral nerve injuries are common, especially involving the axillary nerve. Vascular injuries are also a concern, especially in an elderly patient who has calcification in vessel walls. It is important to note that a vascular injury may be present even if a radial pulse is palpable due to the presence of multiple collateral vessels around the shoulder. Shoulder dislocations and rotator cuff tears commonly occur in association with proximal humeral fractures, as well.
X-rays studies using the Grashy view and the lateral scapular Y view are diagnostic. For fractures treated operatively, a CT scan is usually performed for preoperative planning.
Nondisplaced or minimally displaced fractures are treated nonoperatively. Nonoperative management includes a shoulder sling for 2 weeks. Displacement is judged according to the Neer 4-part system classification where a fragment (or part) is considered displaced if it is rotated more than 45° or displaced more than 1 cm. Displaced fractures are generally treated operatively, with the exceptions of valgus impacted fractures and fractures in elderly low-demand patients. Surgical options include closed reduction and percutaneous pining, open reduction and internal fixation (most commonly with locked plating constructs), proximal humerus nailing, hemiarthroplasty and reverse total shoulder arthroplasty.
Fractures of the Shaft of the Humerus
Fractures of the shaft of the humerus have an incidence and mechanism of injury similar to that of proximal humeral fractures. The unstable brachium is of significant discomfort to the patient who typically presents supporting the injured arm with the uninjured extremity. Instability and crepitus at the fracture site are often readily apparent clinically, while standard AP and lateral x-rays are diagnostic.
Because of the risk of an associated neurovascular injury, a carefully performed and documented assessment of the patient’s status should be completed immediately on presentation and repeated after any treatment. The radial nerve is at highest risk of injury with a fracture in the distal third of the shaft, where it is closely associated with the bone in the spiral groove (Fig. 39-7).
An AP x-ray of a spiral fracture of the distal third of the humerus. This fracture is called a Holstein-Lewis fracture. It is frequently associated with radial nerve palsy.
Nonoperative treatment is effective for most uncomplicated fractures of the shaft of the humerus. As true cast immobilization of the brachium is impractical due to the inherent difficulty of immobilizing the shoulder, a coaptation splint can provide a more practical alternative. Gentle traction usually results in adequate reduction of even significantly displaced injuries. For this reason, some have advocated the use of a hanging arm cast for a brief period, especially early in the course of treatment. This consists of a long arm cast, which hangs from a loop around the patient’s neck. The weight of the cast maintains longitudinal traction on the fracture fragments and helps to ensure adequate alignment. This does improve patient comfort, but requires an upright posture to be effective. The use of a fracture functional brace after a period of 7–10 days (acute fracture healing phase) has many benefits. It is usually effective in maintaining an adequate reduction and allows active motion of the elbow. The effectiveness of the functional brace depends on active muscle forces and daily brace tightening as the soft tissue swelling resolves. Therefore, functional bracing does not work well with the noncompliant patient. Many patients prefer to sleep in a reclining chair for the first few weeks because this allows the longitudinal traction provided by gravity to be effective in controlling the fracture even when they are somewhat recumbent. Union rates of over 95% have been reported with this device.81
Surgical treatment for fractures of the shaft of the humerus is indicated for open injuries, associated vascular injuries, comatose patients, fractures of the ipsilateral arm and forearm, or when there is failure to maintain acceptable reduction in a brace, which is less than 20° of anterior angulation, less than 30° of varus/valgus angulation, or less than 3 cm of shortening. In patients with multiple injuries, fixation of the humerus simplifies their care, improves pain control, and allows early mobilization. Surgical treatment is considered in patients who are intolerant of the extreme activity modifications closed treatment requires and in obese patients in whom it is a particular challenge to maintain an acceptable reduction. Operative fixation of the humerus classically involves compression plate and screw fixation, but intramedullary nailing is becoming more common and results are comparable.82 When intramedullary nailing is performed with limited exposure of the fracture site, there may be a lower risk of iatrogenic injury to the radial nerve; however, the union rate is slightly lower compared to plating of the humerus. Immediate weight bearing is usually allowed after surgery.
Injuries to the radial nerve occur in 12% of humeral fractures.83 Most nerve injuries associated with closed fractures of the humerus are neurapraxias, and at least 90% will resolve with expectant management. During recovery, patients benefit from splinting of the wrist and digits to improve function. Failure to improve (clinically or by EMG) over 3–4 months is an indication for surgical exploration of the nerve. Early surgical exploration is recommended in patients with open injuries where the risk of nerve transection is increased, as well.
Fractures of the Distal Humerus
The Orthopaedic Trauma Association system for classification of supracondylar and intracondylar humeral fractures includes the following: type A, which are extra-articular; type B, which are partial articular injuries of either the medial or lateral column; and type C, complete articular injuries in which both columns of the distal humerus are fractured from the shaft and from each other. The elbow is usually grossly unstable. Isolated fractures of the medial or lateral epicondyle occur, also. Although they are typically of lesser severity, they may require surgical treatment if significantly displaced.
Rarely is nonoperative treatment indicated for a supracondylar fracture of the humerus. Occasionally, a brief period of immobilization followed by early rehabilitation may be sufficient for a patient with very limited functional expectations due to preexisting health problems. A preferred alternative to this technique in elderly patients with highly comminuted intra-articular fractures or existing degenerative or rheumatoid arthrosis, is total elbow arthroplasty.84 In the vast majority of distal humerus fractures, open reduction and internal fixation is indicated. Surgical treatment is technically demanding, especially if there is significant fragmentation of the joint surface.85 The surgical approach to intra-articular injuries often requires an osteotomy of the olecranon. The ideal biomechanical construct continues to be debated, but most agree that plating of both the medial and lateral columns is usually indicated.86 The goal of surgical treatment is to obtain sufficient stability to allow early motion of the elbow while the fracture proceeds to union. Even when this goal is achieved, a permanent loss of some elbow motion is common.
Supracondylar humeral fractures in children aged 5–7 years are common injuries. Almost all supracondylar humeral fractures in this age group are extra-articular with posterior displacement of the distal fragment. These extension type fractures are classified as type I injuries—nondisplaced or minimally displaced, type II injuries—displaced with an intact posterior cortex, and type III injuries—completely displaced fractures with disruption of the posterior cortex. Children may demonstrate only edema and pain in mild injuries or obvious hyperextension deformity in more severe cases. Most nondisplaced or minimally displaced injuries may be managed with casting for approximately 4 weeks, while surgical treatment is indicated in displaced injuries. In most cases, closed reduction and pinning of the fracture site is sufficient to obtain and maintain reduction. Pins are typically inserted from lateral to medial in order to avoid injury to the ulnar nerve and are spread across the fracture site. Because late stiffness is much less common in children, management typically consists of closed reduction and pinning followed by approximately 4 weeks of immobilization. If satisfactory closed reduction cannot be obtained, it may be due to interposed tissues such as the brachialis muscle or neurovascular structures. Open exploration and reduction are indicated in these patients and an effort should be made to operate during the first 12 hours.87,88
Associated injuries to the median nerve or its anterior interosseous branch often recover with expectant management. Injuries to the brachial artery are reported with some frequency, also. Because there is generally adequate collateral circulation, vascular reconstruction may not be required emergently if the extremity remains well perfused. The flexion of the elbow often required to maintain reduction of the fracture may further compromise blood flow, and patients should be carefully monitored for any signs of worsening vascular status or a compartment syndrome.89
Fractures of the Capitellum
Isolated fractures of the capitellum are relatively rare, are due to low-energy trauma, and are more common in women. Unless there is displacement, this injury may be easily missed on AP and lateral x-rays of the elbow. CT may be helpful if plain x-rays do not fully demonstrate the injury. There are four types of fractures as follows: type I fractures are a complete fracture of the entire capitellum from the remainder of the articular surface, type II injuries involve only a thin wafer of cartilage and subchondral bone, type III injuries are comminuted fractures of the capitellum, and type IV fractures are coronal shear injuries in which the capitellum as well as a significant portion of the anterior trochlea is fractured. Unless fragments are nondisplaced, open reduction and internal fixation is recommended when possible.90 In types II and III, the fragments are often so small that stable internal fixation is not possible. In these patients, excision of the fragments may be a reasonable alternative.
Fractures of the Olecranon/Coronoid Process of the Ulna
Injuries through the olecranon are frequent. Fractures with less than 1–2 mm of articular displacement may be treated nonoperatively with a 1- to 2-week period of splinting, followed by gentle early range of motion activities. Frequent x-ray follow-up is important to ensure that there is no increase in displacement. Most olecranon fractures have sufficient displacement to warrant operative treatment. The most common methods are tension band wiring and plate and screw fixation. Both may be effective in transverse or oblique injuries, but comminuted injuries require plate and screw constructs to prevent compression of the trochlear notch. Sufficient stability can usually be obtained to allow early motion, and a satisfactory outcome is likely. In elderly patients with extensively comminuted injuries, excision of up to half of the olecranon with advancement of the triceps muscle may be considered.
Fractures of the coronoid process of the ulna represent the loss of the major anterior skeletal buttress preventing posterior subluxation of the elbow. Type I fractures are avulsions of the tip of the coronoid, type II fractures involve less than 50% of the coronoid process, and type III fractures involve more than 50% of the coronoid. These injuries are typically seen in association with a posterior dislocation of the elbow, and the elbow should be carefully examined for stability even if it appears well reduced. If not associated with significant instability, an avulsion fracture of the tip can be treated nonoperatively, similar to a simple elbow dislocation. Consideration should be given to fixation of some type II and all type III injuries and is required if there is instability of the elbow.91 Posteriorly placed screw, suture, or wire fixation into or around the coronoid is often sufficient, but a more medial approach with an anterior buttress plate may be required to prevent displacement in the presence of an anteromedial coronoid fracture. If small coronoid fragments are not amenable to rigid fixation, they may be excised with repair of the anterior capsule.
Comminuted fractures of the olecranon that are accompanied by displacement of the coronoid process should be managed carefully. Even with anatomical fixation and union of the olecranon, the elbow may become unstable if the coronoid remains displaced. Stabilization of the coronoid process can be technically difficult, as access to the coronoid is extremely limited after fixation of the olecranon. Through a posterior approach, the proximal, fractured portion of the olecranon is retracted with the triceps muscle and the remainder of the ulna is subluxated dorsally, allowing access to the anterior portion of the joint. The coronoid process is reduced under direct visualization and stabilized as described above. Transolecranon fracture–dislocation of the elbow occurs when the distal humerus is driven distally through the proximal ulna. Displaced coronoid fragments are common in this injury pattern.92
Fractures of the Head of the Radius
Fractures of the head of the radius are common injuries and may occur in association with a dislocation of the elbow. The fractures are classified as follows: type I fractures are nondisplaced, type II fractures have single displaced fragments, type III fractures have comminuted injuries, and type IV are fractures of the head of the radius associated with a dislocation of the elbow. Patients may report relatively mild trauma, and physical findings may be subtle. Injuries to neurovascular structures are uncommon with this fracture. Standard x-rays are usually sufficient to make the diagnosis with occasional need for a radial head view. Once fracture is identified, the elbow should be carefully evaluated for stability and range of motion.
It is important to examine the wrist and forearm to identify any associated injuries to the distal radioulnar joint or interosseous membrane. If pain prevents motion, the intra-articular hematoma should be evacuated and lidocaine injected into the joint. A mechanical block to motion in the anesthetized joint is an indication for surgical treatment.
Type I and II injuries with less than 2 mm of displacement may be managed nonoperatively with early motion and follow-up to ensure that there is no interval displacement. Displaced type II injuries of the head and neck are typically treated with open reduction and internal fixation. It is important that implants do not interfere with the proximal radioulnar joint. The safe zone for implants in the head of the radius is the area between lines extended proximally from the radial styloid and Lister’s tubercle, both of which are palpable at the wrist.93 Headless screws may also be of value when fixation is necessary outside this safe zone.
Type III injuries are usually not amenable to open reduction and internal fixation, and excision of the head of the radius may be considered in some patients. This should not be performed if there is an associated dislocation of the elbow, coronoid fracture, valgus instability of the elbow, or longitudinal instability of the forearm, which would indicate an injury to the interosseous ligament. A fracture of the head of the radius with an associated injury to the interosseous membrane is termed an Essex-Lopresti fracture–dislocation.94 Clues to its presence include wrist pain, displacement at the distal radioulnar joint, and/or proximal migration of the radius evident on x-ray. If signs of instability in any plane are present, every attempt should be made to preserve the head of the radius or perform an arthroplasty with a metallic implant.
The floating elbow occurs when there are ipsilateral fractures of the humerus and bones in the forearm. This injury is the result of high-energy trauma and is often associated with injuries to neurovascular structures. The elbow segment is unsupported proximally and distally, and both injuries need to be stabilized. The prognosis for return of full function in these injuries is guarded, especially if the fractures are periarticular.95
Fractures of the Shaft of the Ulna
Isolated fractures of the shaft of the ulna, commonly referred to as “nightstick fractures,” are usually amenable to a short period of long arm casting. This is followed by functional bracing when there is less than 10–15° angulation and at least 50% contact area between fragments. Displaced fractures are usually treated with compression plating or, in the distal third, fixed-angle locking plates. Intramedullary nailing in adults has limited application, but may be indicated with some segmental fractures, those associated with severe loss of soft tissue, or in patients with polytrauma. External fixation is really only indicated as a bridge to more definitive fixation.
Special circumstances in the management of ulnar fractures involve those associated with distal radial fractures, isolated fractures of the head of the ulna, and Monteggia fractures.
Fracture of the distal ulna associated with distal radial fracture may or may not require fixation; however, when the integrity of the distal radioulnar joint (DRUJ) is compromised, consideration should be given to fixation.96 Restoration can be by fixation of an ulnar styloid base or plating of the head of the ulna, usually with a small condylar blade plate or a small locking plate. Addressing the ulnar component of these fractures in this manner can often greatly facilitate initiation of early motion.
Fractures of the Shaft of the Radius
Isolated radial shaft fractures are relatively rare and are typically treated with compression plating. A Galeazzi fracture–dislocation should always be ruled out. Galeazzi fracture–dislocation is a complex traumatic disruption of the distal radioulnar joint (DRUJ) that is associated with an unstable fracture of the radius.97 In these fractures, the injury to the DRUJ can be a pure ligamentous disruption or associated with a fracture of the ulnar styloid. Most commonly, the site of fracture is the junction of the middle and distal thirds of the radius. This injury can be associated with a low-energy fall from a standing height or associated with a high-energy mechanism, such as a fall from a height or a motor vehicle crash. This fracture has also been referred to as a “reverse Monteggia fracture” or “the fracture of necessity” since, in adults, operative intervention is almost always required for a good outcome.
X-ray evaluation of these fractures demonstrates a short appearing radius relative to the ulna because of the pull of the pronator quadratus muscle (Fig. 39-8). On the PA view there will often appear to be an increase in space between the distal radius and ulna where they articulate.
Galeazzi fracture–dislocation. A true lateral radiograph of the forearm showing a fracture of the distal third of the radius. The ulnar head is dorsal to the radius indicating a dislocation of the radial head. Anatomical reduction of the radius and internal fixation should reduce the distal radioulnar joint.
Definitive treatment is by operative fixation of the fracture of the shaft of the radius, usually through a volar approach. This is followed by an intraoperative examination of the DRUJ for instability, predominantly in supination. The intraoperative examination is the definitive test that determines a need to address the DRUJ, not the x-rays.98 Treatment of the unstable DRUJ is by fixation of the radius to the ulna in supination using two Kirschner wires, with or without direct repair of the ligamentous component or fracture of the styloid. This is followed by 6 weeks of above-elbow casting.
Fractures of the Radius and Ulna
The forearm long-bone complex should be considered as a single joint, requiring anatomic reduction of both bones in order to restore full range of motion and function. Simultaneous fractures of the radius and ulna are relatively common injuries. Associated neurovascular injuries do occur, and a compartment syndrome may develop. AP and lateral x-rays that include both the elbow and wrist should be obtained. Fractures are classified based on their location as proximal, middle, or distal third, with or without comminution. While closed management is usually acceptable in children, open reduction with fixation using a compression plate has become the accepted standard of care for these fractures in adults.99 Fixation of both bones should not be attempted through a single incision in order to reduce the risk of synostosis. Early mobilization after surgery is recommended.
Fractures of the Distal Radius
Fractures of the distal radius are the most common long-bone fracture of the upper extremity.100 Two primary age groups are involved with varying mechanisms. High-energy comminuted intra-articular fractures occur primarily in young patients, while low-energy extra-articular fractures occur predominantly in elderly patients.
During physical examination a careful assessment of median nerve function should be performed to rule out an acute carpal tunnel syndrome that is an indication for urgent surgical release. The goals of surgical repair are for anatomical restoration of radial length, radial inclination, and volar tilt and, ultimately, restoration of function of the wrist.
The three anatomical goals are based on the normal anatomy of the distal radius. This includes 21° of inclination, 12° of volar tilt, and length defined by baseline relationship to the ulna, which can be determined in most instances from the uninjured wrist. The ability to restore and maintain these relationships, as well as to restore articular congruity, is the prime determinant of the need for operative intervention.101 Because of the dorsal comminution that usually exists with the apex volar malformation that usually accompanies these fractures, maintenance of what appears to be a good reduction in the ED requires continued vigilance and early operative intervention if loss of reduction occurs.
While no consensus exists for treatment of fractures of the distal radius, the recent addition of fixed-angle locking plates and fragment-specific fixation have led to more aggressive early range of motion in both intra- and extra-articular fractures, including highly comminuted fractures. In the elderly low-demand patient population, which comprises a large proportion of these patients, there seems to be no added value to operative fixation over nonoperative fixation.102 These patients can be managed by a volar splint that allows full finger motion for six weeks, followed by full range of motion exercises and gradual return to full weight bearing.
Fractures of the Scaphoid
Fractures of the scaphoid account for over half of all isolated fracture of the carpal bones. The true incidence of injury to this bone, however, may be higher. This is because many fractures are not appreciated until later when they convert to a symptomatic nonunion, and many remain asymptomatic throughout life.103
Fractures of the scaphoid usually result from a fall onto an outstretched hand with the wrist extended and the forearm pronated. Fractures most commonly occur at the waist (75%), followed by the proximal pole (20%), and, least often, at the distal pole or tuberosity (5%). Location of the fracture is an important factor in prognosis for healing because of the blood supply of the scaphoid. As an intra-articular bone, the scaphoid receives its blood supply through ligamentous attachments, with the primary entry at the distal pole. This leaves the proximal pole with a consistently poor blood supply, which makes these fractures susceptible to nonunion or avascular necrosis. Other factors playing a role in the development of nonunion and malunion are stability of the fracture pattern and displacement.
The diagnosis of a fracture of the scaphoid is first suggested by the mechanism of injury associated with the onset of wrist pain and/or swelling. Examination may show tenderness on palpation within the anatomical snuff box and over the scaphoid tubercle. Pain may also be elicited by pronation and ulnar deviation or by applying an axial load to the first metacarpal (scaphoid compression test); however, no maneuver is specific for injury to the scaphoid and appropriate x-rays are critical.104
Routine x-rays should include a posteroanterior, lateral, and oblique view in 45° of pronation and a posteroanterior view in slight ulnar deviation (“scaphoid view”). Even with a thorough examination and appropriate x-rays, a nondisplaced fracture may be missed. An appropriate course of action in the presence of negative x-rays, but positive clinical signs, would be an immediate MRI or application of a thumb spica cast with more definitive tests scheduled in 72 hours.105
The concept of an immediate MRI is based on its sensitivity to detection of early fracture-associated edema of the marrow. In addition, numerous studies have now demonstrated a cost benefit to this approach versus the classic approach of repeat x-rays, followed by more definitive studies if these remain negative.106,107 In centers that cannot perform the test expeditiously, a bone scan or a scheduled MRI in 72 hours is better than repeat x-rays over the course of several weeks.
Surgical treatment is indicated for all displaced fractures of the scaphoid. An aggressive approach is supported by data reporting a 50–92% nonunion rate with displaced scaphoid fractures and development of degenerative joint disease with as little as 1 mm of displacement. An open approach through a dorsal or volar incision, followed by placement of a screw, is the most common means of treating these fractures. Percutaneous placement of a screw, with or without arthroscopically guided reduction, is becoming increasing popular as a minimally invasive option (Fig. 39-9).108,109
Right scaphoid fracture (A) repaired by volar approach and cannulated screw placement (B).
Other Fractures of Carpal Bones
Of the remaining seven bones in the carpus, the triquetrum is the next most frequently injured bone.110 Dorsal avulsion fractures are the most common form, and, while painful, surgical intervention is rarely indicated except to excise a persistently painful fragment. Body fractures and volar avulsion fractures may occur and may be difficult to detect by plain x-rays, also. Both CT and MRI have been used to diagnose or more clearly delineate these fractures and, occasionally, fractures of the body will require fixation. In most instances, 6 weeks of immobilization in a short arm cast will resolve the pain associated with these fractures even though radiographic union may not occur.
The pisiform is rarely fractured and, when this occurs, it is usually the result of a direct blow to the hypothenar eminence. Palpation of the pisiform elicits pain, and carpal tunnel and/or supinated oblique x-rays are required to adequately image this bone. CT may be indicated in the presence of persistent pain and negative plain films. A thorough evaluation of the integrity of the ulnar nerve is required when dealing with injuries to the pisiform because of its close proximity.111 This is particularly important if surgical intervention is being considered. Initial treatment with immobilization is recommended. Of interest, a persistently painful fractured pisiform can be excised as definitive treatment, with no significant sequelae.
Fractures of the trapezium are usually associated with a fracture of the first metacarpal or distal radius. These fractures may involve the body, margin of the metacarpal articular surface, or volar ridge. Volar ridge fractures may be associated with injury to the median nerve, and a thorough examination of both motor and sensory components of this nerve should be documented. X-ray diagnosis of any of these injuries requires a variety of special views including a hyperpronated “Roberts” view, a Bett’s view, and a carpal tunnel view, and CT may be required to further delineate a fracture of the ridge. Except for displaced body fractures, the initial treatment of trapezium fractures should consist of a 6-week period of immobilization. If, at the end of this time, persistent palmar pain is associated with a fracture of the volar ridge, then the fracture fragment should be excised. Displaced fractures of the body can usually be stabilized by lag screw fixation.112
Fractures of the trapezoid are exceedingly rare.113 Injury to this protected bone is often associated with a high-energy fracture–dislocation involving the index metacarpal bone. X-ray diagnosis of this injury is usually straightforward; however, an isolated injury or injury associated with a spontaneous reduction may require a CT scan to confirm diagnosis. Treatment of nondisplaced isolated fractures is by 6 weeks of immobilization. Displaced fractures or those associated with carpometacarpal (CMC) dislocations require internal fixation or, occasionally, formal CMC arthrodesis with bone grafting to achieve stability and pain relief.
Capitate fractures may be isolated, associated with a scaphoid fracture (“scaphocapitate syndrome”), or associated with another carpal injury. Isolated fractures are often nondisplaced and occur at the waist; however, similar to proximal pole fractures of the scaphoid, the proximal pole of the capitate is dependent on a distal blood supply and prone to avascular necrosis.114 Without treatment, symptomatic nonunion is a common occurrence and can lead to the need for midcarpal fusion if ignored. Both open reduction and percutaneous methods of primary fixation have been described.
Scaphocapitate syndrome is caused by a direct blow to the dorsum of the hand while flexed or a fall onto an extended wrist and results in malrotation of the proximal capitate fragment.115 Following closed reduction of the associated dislocation of the wrist, careful evaluation of the capitate is necessary to detect persistent malrotation. Open reduction with fixation of both the capitate and scaphoid bones is required to restore the normal relationships within the wrist and, hopefully, prevent avascular necrosis of the capitate.
Fractures of the hamate may involve the body, articular surfaces, and/or the hook/hamulus.116 Clinically, pain and tenderness on the ulnar aspect of the hand is present and is often associated with swelling. Injury to both the ulnar and median nerves may be associated with hook fractures, and a thorough examination of motor and sensory function should be documented. Standard x-rays may be inadequate to image the injury. A carpal tunnel view and an oblique view with the hand in 45° of supination and the wrist in radial deviation should be performed. CT may be required if symptoms persist in the presence of negative plain x-rays.117
Isolated fractures of the body are rarely displaced and are usually amenable to a period of immobilization. Those associated with high-energy injuries, such as CMC fracture–dislocations, require internal fixation.118
Fractures of the hamulus of the hamate (“hook fractures”) may be difficult to diagnose without CT, and this should be performed early when this fracture is clinically suspected. A delay in treatment of this fracture can result in rupture of the adjacent flexor tendon from attritional wear over the fracture site.119 Untreated, this fracture can cause chronic pain with many of the activities of daily living. Treatment is by excision of the hook, or open reduction and screw fixation. Neither method has been shown to have an advantage over the other.120
Fractures of the lunate are rare when one excludes those associated with idiopathic avascular necrosis or Kienbock’s disease. Accurate imaging to rule out predisposing avascular necrosis usually requires a CT and/or MRI in addition to plain x-rays. Acute fractures may involve the volar or dorsal lips or occur as transverse or sagittal fractures.110 Sagittal fractures and fractures of the dorsal lip are usually stable because of ligamentous support and require only a 6- to 8-week period of immobilization. Fractures of the volar lip and transverse fractures have a tendency to displace and require open reduction and internal fixation.
Fractures of the Metacarpal Bones and Phalanges
These are the most common fractures of the upper extremity. Metacarpal fractures may involve the base, shaft, neck, or head, and may be articular or nonarticular.121 In addition, when the fracture is at the base, it may be associated with a dislocation. The second and third CMC joints are relatively immobile and are injured less frequently than the more mobile fourth and fifth CMC joints. Thus, the most common metacarpal base fracture involves the small finger metacarpal and is almost always associated with a dislocation. This injury is inherently unstable because of the pull of the extensor carpi ulnaris, and closed reduction and cast immobilization as definitive treatment is usually doomed to failure. Therefore, initial splinting should be followed by scheduled outpatient closed reduction and pinning. When this is performed, care must be taken during the approach to avoid injuring the dorsal sensory branch of the ulnar nerve or entrapping it in the fixation.
More complex injuries can result in the fourth metacarpal bone being dislocated with the fifth metacarpal bone or disruption of the entire finger ray. Both these injuries represent high-energy disruptions of the ligamentous support of these joints, and open reduction and internal fixation are usually necessary. In addition, concomitant injury to the ulnar nerve in these severe disruptions can lead to significant long-term morbidity.
Many fractures of the metacarpal shaft present as stable, nondisplaced fractures. These can be managed by placement into a clam-digger cast or thermoplast splint until the fracture is clinically nontender. At this point, despite x-ray evidence of a fracture line, the hand can be mobilized. In particular, isolated fractures of the third and fourth metacarpal bones are amenable to this type of management because of continued support by the stout transverse metacarpal ligament. Fractures of the metacarpal bones proximal to the index and small fingers will more often develop some degree of malformation often expressed by crossing over of the fingers with flexion “scissoring.” Therefore, these fractures should be treated by operative intervention. Modalities available include open reduction and internal fixation, closed reduction and percutaneous pinning with Kirschner wires, or closed reduction and intramedullary nailing.122
Multiple metacarpal fractures lead to an inherently unstable hand, and operative intervention is always indicated. These injuries will require not only fracture fixation but repair of associated injuries to tendons and soft tissue also. Principles of treatment of this type of injury are covered in the section “Compound, Complex, and Mangled Upper Extremities.” A fracture of the neck is the most common fracture of a metacarpal and usually occurs in the fourth or fifth bone. Acceptable closed reduction of these fractures depends on the digit involved, with fracture angulation of 50–70° tolerable in the fifth finger and only 10–20° in the index finger.123,124 Fractures of the neck of the fifth metacarpal bone are referred to as “Boxer’s fractures” and are almost always associated with a clenched fist striking a solid object. The result is an apex dorsal angulated fracture with volar comminution. This comminution is the reason that most acute reductions fail, with rapid relapse in a splint or cast to the post-injury state. Because of this, it has been recommended that the patient should initially be splinted in the intrinsic plus position. A reduction is then performed at 7–10 days when the fracture has begun to consolidate. Whether the hand is then splinted in extension to presumably enhance a “ligamentotaxis” effect and counteract the tendency to relapse into an apex dorsal deformity or splinted or casted in the classic “cobra” cast position makes little or no difference to long-term outcome. Four weeks should be the maximum period of immobilization after treatment of such a fracture.
Fractures of the head of the metacarpal bone are usually intra-articular and are often associated with a clenched fist or “fight bite” injury. Closed fractures with significant intra-articular displacement should undergo open reduction and screw fixation. When significant comminution is present, fixation is probably not possible. Either acute replacement of the joint should be performed or the fracture should be allowed to heal. If significant morbidity develops, then replacement of the joint should occur at a later time.
A fracture of the shaft of the first metacarpal bone requires less accurate reduction because of the mobility of the CMC joint; however, articular fractures of the base in the form of Bennett’s and Rolando fractures (see Fig. 39-9) do not have this latitude. Bennett’s fracture is essentially a fracture–dislocation of the CMC joint. Axial loading results in the strong palmar oblique ligament retaining a fragment of bone while the metacarpal bone is dislocated radially and proximally by the pull of the abductor pollicis longus muscle. Post-traumatic arthritis frequently follows a Bennett’s-type fracture, and operative intervention is recommended. Either closed reduction and percutaneous pinning or open reduction and internal fixation is acceptable and both have similar outcomes.125
The Rolando fracture is T- or Y-shaped fracture of the base of the first metacarpal bone and includes both the volar lip fracture seen in Bennett’s fracture and a large dorsal fragment (Fig. 39-10). These fractures are extremely difficult to manage and frequently lead to post-traumatic arthritis regardless of which technique is used for management. Surgical options include multiple K-wires, tension band wires, plates and screws, and external fixation.125
Bennett’s fracture (A) with a single fragment retained by the palmar oblique ligament and the metacarpal displaced proximally and radially by the pull of the abductor pollicis longus. Rolando fracture (B) demonstrating comminution of the first metacarpal base.
Phalangeal fractures are common in all age groups.100 The examination needs to differentiate between a fracture, rupture of the collateral ligament, rupture of the volar plate, and avulsion of a tendon, all of which may have similar signs on cursory inspection. At a minimum, PA, oblique, and lateral x-rays should be obtained.
Nondisplaced, stable proximal and middle phalangeal fractures can be effectively managed by either buddy taping or immobilization in a splint. Many proximal and middle phalangeal fractures, however, have articular involvement or have significant malformation because of the effect of the flexor tendons and/or extensor apparatus. Closed reduction to align displaced fractures can be performed by a combination of axial traction and reversal of the deformity. Even what initially appears to be a nondisplaced articular fracture has the potential to displace. Therefore, if nonoperative management is selected as the primary treatment, then close follow-up and frequent x-rays are necessary to avoid missing displacement.
Operative treatment of articular fractures entails closed reduction with placement of a percutaneous screw or Kirschner wire. More ridged fixation allows early initiation of range of motion. Pilon-type injuries require some type of traction fixation to allow motion with maintenance of articular congruity.126 Even with this type of approach, secondary arthroplasty procedures may be required.
Transverse, spiral, oblique, and comminuted fractures of a phalangeal shaft may occur. The apex of a proximal phalangeal fracture angulates in a volar direction due to the strong pull of the interosseous muscles. Deformation of middle phalangeal fractures depends on the location of the fracture in the shaft with relation to the insertion of the superficialis tendon. An apex volar deformation results when the fracture is distal to the insertion of the superficialis tendon, while an apex dorsal deformation results from fractures proximal to the superficialis insertion. A variety of methods have been employed to overcome these distracting forces. These include static casting in the intrinsic plus position for a proximal phalangeal fracture, with early mobilization at 4 weeks with buddy tape support to the adjacent finger. Traction has also been utilized, with force exerted through the skin, pulp, nail plate, or skeleton. Difficulties with this technique include the awkwardness of the device, joint stiffness, and skin problems. Operative techniques include external fixation, percutaneous pinning, and open reduction and internal fixation with plates, screw, or interosseous wires. Of these techniques, percutaneous pin fixation seems to have the least long-term morbidity (Table 39-9).
TABLE 39-9Fractures and Dislocations of the Upper Extremity—Surgical Indications ||Download (.pdf) TABLE 39-9 Fractures and Dislocations of the Upper Extremity—Surgical Indications
|Injury ||Surgical indications |
|Sternoclavicular dislocation || |
Acute posterior dislocation (thoracic surgeon on standby)
Chronic symptomatic dislocation
|Clavicle fractures || |
Middle third—neurovascular injury, skin compromise, open fractures, >2 cm shortening, ipsilateral displaced glenoid neck fracture
Distal third—displaced fractures
Grade IV, V, and VI (some grade III)
Acromion large displaced fracture
Coracoid large displaced fracture
Scapula neck displaced fracture
|Glenoid fractures || |
>2 mm displacement
Involvement of >25% of surface
Length of fracture > glenoid radius
Humeral head subluxation
Failed closed reduction
|Proximal humerus fractures/fracture–dislocations || |
Two-part displaced great tuberosity >5 mm
|Humeral shaft fractures || |
>20° anterior angulation
>30° varus/valgus angulation
>3 cm shortening
Bilateral humeral shaft fractures
|Distal humerus fractures || |
Children—displaced fractures (types II and III)
Displacement >2 mm
Simple—failed closed reduction (interposed soft tissue or unstable postreduction)
Fractures of the proximal ulna
Fractures of the coronoid process
Radial head fractures
Displacement >2 mm
Unstable type I–III
Articular displaced >2 mm
Isolated ulnar shaft fractures
Radial shaft fractures
>10% angulation or 50% displacement
Radius and ulna shaft fractures
|Distal radius fractures || |
Displaced intra- and extra-articular fractures (1–2 mm articular displacement, >15° dorsal tilt, >5 mm shortening)
Volar and dorsal rim fractures (Barton)
Displaced, unstable, proximal pole, nonunion
Displaced body fractures
Intra-articular displaced body fractures
Displaced or unstable fractures
Isolated—shortening >3 mm, angulation
>30°, scissoring of fingers
Neck fractures—second/third finger
>20° of angulation
Fifth finger (Boxer’s fractures) >50° angulation, extension gap
Head fractures—displaced, comminuted, or open (fight bite)
Thumb base—unstable fractures (Bennett’s, Rolando)
Dorsal complex dislocation
|Metacarpophalangeal dislocation || |
Proximal base fractures
|Phalangeal fractures || |
Collateral ligament avulsion—displaced
Compression intra-articular base fractures
Vertical shear fractures
Diaphyseal unstable fractures
Condylar displaced fractures
Distal base with >50% of the articular surface involved or volar subluxation
|Interphalangeal joint dislocation ||Failed close reduction, collateral ligament tear |