AO Principles 3rd edition sample chapters

AO Principles of Fracture Management Third Edition

Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Key features include: • Contributions from more than 60 highly renowned surgeons, scientists, and medical professionals • More than 2,500 high-quality illustrations and images, as well as access to over 200 video presentations • New chapters on periprosthetic fractures, knee dislocations, fragility fractures and orthogeriatric care and additional information on operating room setup and planning • Immediate access to AO’s continually evolving range of online educational offerings via QR codes for mobile devices including animations, webcasts, webinars, lectures, AO Surgery Reference, STaRT, ICUC cases, and more AO Trauma is pleased to bring you a new expanded, comprehensive, and updated edition of the AO Principles of Fracture Management for residents, fellows, course participants and faculty, trauma and orthopedic surgeons, and operating room personnel.

ISBN: 9783132423091

www.aotrauma.org

9 783132 423091

Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

AO Principles of Fracture Management

The new third edition of this book has been expanded to include new knowledge and explore state-of-the-art technology. It also addresses pressing challenges that face orthopedic surgeons today, such as the exponential rise in fragility fractures resulting from demographic changes and an aging population. The book aims to help surgeons to successfully rise to such challenges.

Third Edition

The AO Principles of Fracture Management has served many generations of surgeons around the world as the source of knowledge and essential reference in the field of orthopedic trauma surgery. The fundamental principles of fracture surgery have not changed in 60 years, but the biological and clinical knowledge, as well as technological advancements have extended new possibilities in surgical treatment and offered surgeons the opportunity to explore new ways of applying the AO principles.

Richard E Buckley Christopher G Moran Theerachai Apivatthakakul

AO Principles of Fracture Management Third Edition

1

Principles

Includes the ebook and online content via QR codes

1

Volume

Principles

Table of contents

Front matter

Reduction, approaches, and fixation techniques V

Foreword

VI

Introduction

VII

Acknowledgments Contributors

VIII

Abbreviations

XII

Online AO Educational Content

XIV

Reduction and approaches 3.1.1 Surgical reduction

117

Rodrigo Pesantez

3.1.2 Approaches and intraoperative handling of soft tissues

137

Ching-Hou Ma

3.1.3 Minimally invasive osteosynthesis

149

Reto Babst

Techniques of absolute stability

Volume 1–Principles

3.2.1 Screws

173

Wa’el Taha

3.2.2 Plates

AO philosophy and basic principles 3

1.1 AO philosophy and evolution

9

Boyko Gueorguiev-Rüegg, Martin Stoddart

27

1.3 Implants and biotechnology

3.2.3 Tension band principle

209

Markku Nousiainen

Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

1.2 Biology and biomechanics in bone healing

185

Mark A Lee

Techniques of relative stability 3.3.1 Intramedullary nailing

217

Martin H Hessmann

Geoff Richards

39

1.4 Fracture classification James F Kellam

3.3.2 Bridge plating

241

Friedrich Baumgaertel

1.5 Soft-tissue injury: pathophysiology, evaluation, and classification

51

3.3.3 External fixator

253

Dankward Höntzsch

Brian Bernstein

3.3.4 Locking plates

269

Christoph Sommer

Decision making and planning 2.1 The patient and the injury: decision making in trauma surgery

73

Christopher G Moran

2.2 Diaphyseal fractures: principles

83

Piet de Boer

2.3 Articular fractures: principles

93

Chang-Wug Oh

2.4 Preoperative planning

105

Matthew Porteous

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AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Table of contents

General topics 4.1 Polytrauma: pathophysiology, priorities, and management

Complications 311

5.2 Aseptic nonunion 331

Rami Mosheiff

4.3 Soft-tissue loss: principles of management

529

Olivier Borens, Michael S Sirkin

5.4 Chronic infection and infected nonunion 379

513

R Malcolm Smith

5.3 Acute infection 357

Yves Harder

4.4 Pediatric fractures

493

Mauricio Kfuri

Peter V Giannoudis

4.2 Open fractures

5.1 Malunion

547

Stephen L Kates, Olivier Borens

Theddy Slongo, James Hunter

4.5 Antibiotic prophylaxis

421

Susan Snape

4.6 Thromboembolic prophylaxis

429

Hans J Kreder

4.7 Postoperative management: general considerations

437

Liu Fan, John Arraf

4.8 Fragility fractures and orthogeriatric care

451

Michael Blauth, Markus Gosch, Thomas J Luger, Hans Peter Dimai, Stephen L Kates

4.9 Imaging and radiation hazards

481

Chanakarn Phornphutkul

XVII

Table of contents

Volume 2–Specific fractures Scapula and clavicle

Femur and periprosthetic fractures 565

6.1.1 Scapula

6.6.1 Femur, proximal

Michael McKee

573

6.1.2 Clavicle

6.6.2 Femur, shaft (including subtrochanteric fractures)

Ernest Kwek

6.6.3 Femur, distal

587

6.6.4 Periprosthetic fractures

Chunyan Jiang

607

John Williams

623

6.2.3 Humerus, distal

Knee 6.7.1 Patella

David Ring

6.7.2 Knee dislocations

865

James Stannard, Mauricio Kfuri

6.3.1 Proximal forearm and complex elbow injuries

637

Stefaan Nijs

657

Tibia 6.8.1 Tibia, proximal

John T Capo

877

Luo Cong-Feng

673

6.8.2 Tibia, shaft

Matej Kastelec

899

Paulo Roberto Barbosa de Toledo Lourenço

699

6.8.3 Tibia, distal intraarticular (pilon)

Douglas A Campbell

913

Sherif A Khaled

Pelvis and acetabelum

Malleoli and foot 717

6.9 Malleoli

Daren Forward

6.5 Acetabulum

853

Mahmoud M Odat

Forearm and hand

6.4 Pelvic ring

837

Michael Schütz

6.2.2 Humerus, shaft

6.3.4 Hand

815

Jong-Keon Oh

6.2.1 Humerus, proximal

6.3.3 Distal radius and wrist

789

Zsolt J Balogh

Humerus

6.3.2 Forearm, shaft

773

Rogier KJ Simmermacher

933

David M Hahn, Keenwai Chong

745

6.10.1 Hindfoot—calcaneus and talus

Jorge Barla

961

Richard E Buckley

6.10.2 Midfoot and forefoot

983

Mandeep S Dhillon

Appendix Glossary

A1

Christopher L Colton, Christopher G Moran

Index

XVIII

A15

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Michael McKee

6.1.1 Scapula Michael McKee

1

Introduction

2

Evaluation and diagnosis

1.1

History

2.1

Case history and physical examination

Fractures of the scapula have traditionally been treated without surgery. Nonunion of the scapula following fracture is extremely rare, and malunion was accepted with the expectation that most patients would have reasonable functional outcome with little or no pain. However, recent evidence has demonstrated that scapular malunion can be associated with significant functional disturbance, especially with greater degrees of deformity. This has prompted an increased interest in scapular fracture treatment including improved 3-D imaging, indications for surgery, fixation methods, and patient-related outcomes.

1.2

Epidemiology

Fractures of the scapula are relatively rare (0.4–1.0% of all fractures), usually seen in polytrauma patients, and are typically caused by severe force. For this reason, the patient must be carefully evaluated for other life-threatening injuries including flail chest, blunt aortic injury, hemothorax or pneumothorax, and lung contusion together with other fractures (especially of the clavicle, seen in 25% of cases) [1]. Isolated fractures are usually caused by a direct blow to the back and are typically stellate in nature. Fractures of the anterior or posterior glenoid rim are usually a result of glenohumeral dislocation or subluxation (“bony Bankart” lesions) [2], and the treatment focus is on restoring joint stability.

1.3

Special characteristics

The scapula is a complex bone that serves as an important origin for shoulder musculature and the scapulothoracic joint is integral to shoulder stability and motion. The bone in the scapular body is thin and most points for screw fixation are available around the borders of the scapula. ­Additionally, the scapula has a number of important processes (coracoid, acromion, scapular spine) that are important for shoulder function and also serve as potential sites for screw purchase. Goss [3] introduced the concept of the superior shoulder suspension complex to explain the biomechanics of some shoulder injuries.

The clinical symptoms of a scapular fracture are nonspecific and frequently masked by the symptoms of concomitant injuries. Open fractures are rare. With a fracture of the scapular neck, the suprascapular nerve is at risk of being injured as it runs through the scapular notch at the superior border. Suspected lesions of this nerve have to be ruled out by an electromyogram. The same holds true for suspected lesions of the axillary nerve.

2.2

Imaging

The radiological examination consists of three trauma views of the shoulder (AP in scapular plane, lateral in scapular plane, and axillary projection). Involvement of the glenoid requires a computed tomographic (CT) scan to determine the number and size of the fragments as well as the extent of the articular displacement. Given the complexity of the scapula, 3-D CT reconstruction is becoming increasingly popular for preoperative planning. The clavicle should always be assessed as associated fractures are common.

3

Anatomy

The scapular body is broad and flat, thin in the middle area and thicker around the axillary and vertebral borders. The scapular spine is a prominent structure posteriorly and the best surgical access to the scapular body and spine is posterior. The deltoid muscle envelopes most of the superior aspect of the scapula and must be reflected or split, depending on the approach selected. The coracoid and acromion are separate processes that are best accessed through an anterior and superior approach, respectively.

565

Specific fractures 6.1.1 Scapula

4

Classification

6

Preoperative planning

4.1

AO/OTA Fracture and Dislocation Classification

6.1

Timing of surgery

The scapula is numbered bone 14 [4]. It is divided into the three locations process (14A), body (14B), and glenoid fossa (14F).

5

Surgical indications

Surgical indications remain controversial. Operative intervention is reserved for active healthy patients with low intrinsic operative risk. Older, sedentary patients with medical comorbidities are best treated nonoperatively. The indications listed are relative, not absolute, and the decision to proceed with surgery is made only after a careful evaluation of the risks and benefits for the individual patient.

• G lenoid rim (anterior, inferior, or posterior) fracture with associated shoulder joint instability • Intraarticular joint displacement of 5 mm or greater involving more than 25% of the joint surface • Glenopolar angle < 22° • Medial displacement of glenoid neck fracture > 2 cm • 100% displacement or > 45° angulation of a scapular body fracture • Completely displaced process fracture (acromion, coracoid, scapular spine) • Significant malangulation (retroversion or anteversion) of the scapular neck • Young polytrauma patient • Disrupted superior shoulder suspensory complex (two breaks in the ring)

Acute fixation of scapular fractures is rarely indicated and there is sufficient time for stabilization of the patient (especially in the polytrauma setting) and obtaining preoperative imaging. As with any fracture surgery, success depends on careful planning, a medically optimized patient and robust soft-tissue coverage of the anticipated fracture fixation. Softtissue coverage is rarely an issue. It is now “standard of care” that imaging includes preoperative CT scanning (with 3-D reconstruction if available) to plan surgical fixation. Glenoid/ scapular fracture surgery is a difficult procedure on an ­irregular, complex bone that should be carried out in optimal conditions, ie, a stable patient, thorough preoperative imaging and planning, and skillful surgery performed on a carefully positioned patient by a well-rested, experienced surgeon with a variety of potential implants handled by orthopedic surgical support staff.

6.2

Implant selection

In general, small or mini-fragment implants are used for scapular and glenoid fixation. Glenoid rim fractures are stabilized with partially threaded 4.0 mm cancellous screws.

Fractures of the scapular body are treated with 1/3 tubular plates or reconstruction plate 3.5. Compression plates are too bulky and the added strength is not required in this setting. Typically, except along the borders, the scapular body is thin and will accept screws of only 12–14 mm. Fractures of the acromion, acromial spine, or coracoid can be managed with mini-fragment plates and 2.7 mm screws.

Precontoured plates designed for the scapula and its processes are available and may decrease the amount of time required for placement and contouring intraoperatively.

6.3

Operating room set-up

The area from the neck to the hand, including the axilla, is disinfected with the appropriate antiseptic. Draping should be done in such a way as to leave the posterior aspect of the arm exposed from shoulder to elbow. Then the hand and forearm are draped separately with a stockinette fixed pro­ perly to the forearm (Fig 6.1.1-1a). The image intensifier is also draped.

The anesthetist and anesthetic equipment are situated to the side of the patient. The surgeon and assistant stand on the side of the injury. The operating room personnel stand between (behind) the surgeons. When required, the image intensifier is introduced from the top of the operating room table. The image intensifier display screen is placed in full view of the surgical team and the radiographer (Fig 6.1.1-1b).

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7

Surgery

7.1

Surgical approaches

There are a number of surgical approaches to the scapula, and the choice of approach will depend on the fracture ­pattern and the fractures specifically targeted for fixation.

Many scapular fracture patterns are complex and it is not always necessary to stabilize every fracture line. The risks and drawbacks of added operative time and soft-tissue disruption must be balanced against the added reduction or stability gained by further fixation.

clavicle and scapular spine, laterally to just past the acromioclavicular joint. The fibers of the trapezius muscle are split. Depending upon the localization of the fragment, the supraspinatus muscle is carefully retracted posteriorly or anteriorly. The scapular notch is always identified to avoid damaging the suprascapular nerve. Isolated acromial fractures may also be stabilized through this approach by extending the incision more laterally. The exposure obtained in this approach is limited and is restricted to the superior glenoid and acromion. More extensive fracture patterns require a posterior approach.

7.1.1 Deltopectoral approach

7.1.3 Posterior approaches

This approach is used for fractures of the anterior and inferior glenoid rim. Following reflection of the subscapularis and an anterior arthrotomy, the humeral head can be subluxated posteriorly to visualize the anterior glenoid rim.

Since the stability of the joint is restored after fixation of the fragment, the capsule is closed anatomically and the transected or split subscapularis tendon is meticulously sutured to avoid any weakness and limitation of shoulder motion. This approach may also be used to expose and fix associated coracoid fractures. However, it does not provide adequate exposure for most glenoid neck or body fractures.

Most scapular body, glenoid neck, posterior glenoid, and scapular spine fractures are treated through this classic approach described by Judet (Fig 6.1.1-2). The patient is placed in a lateral decubitus or a prone position with the arm ­freely draped. The skin incision starts at the posterior corner of the acromion, follows the inferior margin of the scapular spine to the medial scapular border, and curves inferiorly along the medial border to the inferior angle. The deltoid muscle is detached from the scapular spine (leaving a small sleeve to facilitate reattachment) and the infraspinatus muscle can be completely detached from its lateral origin and elevated from the posterior aspect of the scapula. However, this classic dissection is only necessary for complex scapular fracture treatment as there can be soft-tissue complications from this extensive exposure.

7.1.2 Superior approach

This approach is used for superior glenoid fragments. The skin incision runs coronally in the middle between the

a

b

Fig 6.1.1-1a–b a Patient positioning and draping. b Setting up the operating room.

567

Specific fractures 6.1.1 Scapula

A lesser degree of dissection is often sufficient. In most cases only the posterior rim of the glenoid, the scapular neck, and the lateral border of the scapula need to be visualized. The skin incision for the simplified posterior approach starts 2 cm medial to the posterior corner of the acromion and runs parallel to the lateral border of the scapular spine.

The inferior border of the deltoid muscle is identified and elevated. The scapular bone and the posterior joint capsule are reached through the interval between the infraspinatus and teres minor muscles (an internervous plane). Abduction of the arm raises the inferior border of the deltoid muscle, allowing access to the cranial part of the joint capsule. Care must be taken not to injure the suprascapular nerve as it exits the scapular notch, and the axillary nerve as it exits the quadrangular space just below the teres minor muscle together with the circumflex artery.

7.2 Reduction 7.2.1 Fractures of the scapular processes

Nondisplaced fractures should be treated nonoperatively.

Displaced fractures of the scapular spine often require ­operative treatment because of their risk of nonunion and functional impairment after malunion. The spine is ­approached posteriorly and the deltoid is reflected from it.

Fixation is achieved with reconstruction plates 2.7, which are applied to the posterior aspect.

Isolated fractures of the coracoid can occur centrally or ­peripheral to the origin of the coracoclavicular ligament. In the more frequent central fractures, the ligament usually remains intact. Therefore, the fractured coracoid displaces with the lateral part of the clavicle if there is a concomitant dislocation of the acromioclavicular joint. In this unstable situation the coracoid process may be fixed with a 3.5 mm lag screw and the acromioclavicular joint is also stabilized.

3 1

4 5

2

2

7 6

a

b

Fig 6.1.1-2a–b Posterior approach to the scapula. a Lateral decubitus; incision from the tip of the acromion along the inferior margin of the scapular spine to the medial scapular border and curved inferiorly along the medial border to the interior angle of the scapula.

1 Suprascapular nerve and artery.

2 Posterior circumflex humeral artery/axillary nerve. b The deltoid muscle (3) is sharply dissected from the scapular spine and the base of the acromion with a small tissue border left on the spine to facilitate reattachment. The deltoid muscle is then carefully retracted laterally, avoiding damage to the axillary nerve and circumflex humeral artery (2). Approach the lateral margin of the scapula and the glenoid (4) by separating the infraspinatus (5) and the teres minor (6) muscles. A small arthrotomy is now possible. Be careful not to damage the circumflex scapular vessels (7).

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AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Michael McKee

Peripheral fractures are treated nonoperatively, unless the fragments have completely lost all contact due to the distracting force of the coracobrachialis muscle.

Displaced fractures of the acromion need to be reduced and fixed since malunion may lead to impingement upon the rotator cuff. Stable fixation is achieved with 2.7 mm lag screws or tension band wires.

instability of the glenohumeral joint. Through a deltopectoral approach the fragments and the attached glenoid labrum and joint capsule are reduced under direct vision and fixed with either 3.5 mm or 2.7 mm lag screws inserted from the outside of the joint capsule (Fig 6.1.1-3). Soft-tissue washers may be added to better hold the associated soft tissue. Because of the typical soft quality of the bone in this region, the screws should be long enough to get firm fixation in the posterior cortex of the scapular neck.

7.2.2 Fractures of the scapular neck

If the scapular neck is fractured, the glenoid fragment is usually displaced medially. This shortening leads to decreased tension and working length of the rotator cuff muscles, which may result in functional impairment. Additionally, the glenoid fragment may also be rotated. Due to the pull of the long head of the triceps brachii muscle, the articular surface most frequently faces caudal. According to some authors, this may lead to instability of the glenohumeral joint. Shortening of more than 1 cm and rotation of more than 40º was considered an indication for open reduction and internal fixation by another author [5]. Usually, a reconstruction plate 3.5 is applied on the lateral margin through a posterior approach.

7.2.3 Articular fractures

Displaced fractures of the anteroinferior glenoid rim (Bankart fractures) must be treated operatively to restore the joint surface and, even in small fragments, to avoid recurrent

a

b

Most authors recommend open reduction and internal fixation for displaced fractures (more than 5 mm) of the glenoid fossa to restore joint congruity and to reduce the risk of posttraumatic arthrosis. Ideberg [6], however, recommends nonoperative treatment for displaced articular fractures as long as the humeral head remains centered in the glenoid fossa. The decision to operate should be based on the displacement of the fragments, patient age and activity level, associated comorbidities, and the skill of the surgeon.

Depending upon the fracture morphology (CT scan), a superior or posterior approach is chosen. The articular fragments are fixed with 2.7 or 3.5 mm lag screws. In multifragmentary fractures involving the scapular body and the glenoid it is often sufficient to just anatomically restore the articular surface and to realign the reconstructed glenoid to the lateral margin, while the multiple fragments of the body are not touched at all.

c

Fig 6.1.1-3a–c a Intraarticular glenoid fracture with displacement of the anteroinferior fragment. b 3-D computed tomographic scan. c Reduction through partially open joint capsule, temporary fixation with a K-wire was followed by fixation with two lag screws.

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Specific fractures 6.1.1 Scapula

7.2.4 Fractures of the scapula and ipsilateral clavicle

Fractures of the scapular neck and the ipsilateral clavicle (the so-called “floating shoulder”) represent a double disruption of the superior shoulder suspension complex. This injury, if displaced, may lead to deformity where the glenoid faces caudal, decreasing the glenopolar angle and impairing function [3]. To avoid shortening of the shoulder girdle and poor function due to abduction weakness and stiffness, open reduction and internal fixation of the clavicle and possibly the glenoid neck may be indicated (Fig 6.1.1-4a–h), particularly in cases with significant medial displacement with shortening > 2 cm [7]. Recent publications, however, report equally good results with nonoperative treatment. Edwards et al [8] concluded that nonoperative treatment of floating shoulder injuries is appropriate, especially with those that are minimally (less than 5 mm) displaced. Egol et al [9] summarized that operative treatment cannot be ­recommended for all such injuries and that each patient must be treated individually. Van Noort et al [10] stated that this injury is not inherently unstable and, in the absence of caudal dislocation of the glenoid, nonoperative treatment achieves good functional outcomes. In general, operative intervention is indicated for displaced fractures. Residual deformity may be additive because multiple moderately displaced fractures may result in greater deformity than from a single fracture in isolation.

7.3

Fixation

In general, mini- and small fragment instrumentation is used for glenoid and scapular fixation. Reconstruction plates 3.5 and limited-contact dynamic compression plates 3.5 and 2.7 are standard (Fig 6.1.1-4f–h) but 1/3 tubular plates can also be used. Precontoured plates designed for scapular fixation are available, although their specific advantages and disadvantages remain to be defined.

7.4

Challenges

Challenges in this area include: evolving operative indications, imaging, surgical approaches, and implant selection.

While there are specific indications for surgery, they remain unclear and prospective comparative studies are needed to define when surgery is required. Understanding the fracture morphology in scapular fractures is a major challenge given the complex 3-D nature of the scapula and its various processes. For this reason, 3-D reconstruction of CT scans is helpful for many of these fractures (Fig 6.1.1-3b). The ­scapula is enveloped by a thick layer of soft tissue and muscle and exposure can be difficult. This is a procedure best suited for a surgeon with experience in both anterior and posterior approaches to the shoulder.

570

8

Aftercare

The postoperative regimen will depend on the nature of the fracture pattern fixed. However, the shoulder joint is commonly stiff after scapula surgery and insufficient rehabilitation. For anterior rim fractures, the arm is kept in the internally rotated position in a sling for 2 weeks followed by gradually increasing range of motion exercises. Full external rotation is allowed after fracture union (typically 6–8 weeks).

Posterior rim fractures are held in a “gunslinger” external rotation splint for 2–4 weeks, then allowed gradual mobilization. With stable fixation, most glenoid neck and body fractures are placed in a sling for comfort but may be rapidly mobilized as pain subsides with unrestricted active and passive range of motion exercises. Strengthening is allowed after fracture union, typically at 6 weeks after surgery.

9

Complications

• Stiffness—shoulder stiffness, especially restricted internal rotation, is the most common complication of clinical significance following fixation of scapular fractures.

In one large metaanalysis, 9 patients of 234 operative cases had dysfunctional postoperative stiffness [11]. If aggressive physiotherapy fails, disabling residual stiffness can be treated operatively with hardware removal, joint release, and manipulation.

• Infection—superficial infection can be treated with local wound care and systemic antibiotics. Given that the ­scapula is covered by a thick layer of muscle and soft tissue, deep infection is rare, reported in 0 of 84 cases in one series [12] and 0 of 234 cases [11]. It is treated by wound irrigation and debridement, retention of stable implants, identification of the organism, and systemic antibiotics.

• Hematoma—the large dead spaces in the periscapular area can be exacerbated by extensive surgical approaches and hematoma formation can result. If large enough to warrant intervention, treatment consists of evacuation, irrigation, and closure over drains.

• Suprascapular nerve palsy—the vulnerability of the suprascapular nerve to injury with scapular or glenoid fractures has been well documented. It can be trapped or lacerated by the fracture, or damaged during the surgical approach. If trapped in the fracture it can be extracted; however, there is little that can be done for a complete division of this nerve. Depending on the location of the injury, atrophy of both the supraspinatus and infraspinatus (above the spinoglenoid notch) or infraspinatus alone (at or below the spinoglenoid notch) will occur and this decreases the strength and range of external rotation.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Michael McKee

a

b

d

e

f

g

c

h

Fig 6.1.1-4a–h A 44-year-old man was involved in a motorcycle collision. The combination of fractures of the clavicle and scapular neck rendered the entire shoulder girdle unstable. The lateral fragment of the scapula rotated due to the weight of the arm. a AP x-ray of the right scapula and clavicle preoperatively. b Lateral x-ray of the right scapula preoperatively. c Axial x-ray of the right scapula preoperatively. d Preoperative chest computer tomography showed the foreshortened scapular fracture on the right side with a multifragmentary scapular neck fracture and soft tissue bleeding in the right shoulder region. e To restore stability, it is usually sufficient to fix the clavicle with reconstruction plates 3.5 or limited-contact dynamic compression plate 3.5, 2.7 or locking compression plate 3.5 supplemented with smaller plates as needed to assist with the reduction. This image shows the postoperative chest x-ray with the scapula and clavicle internally fixed. f–h Postoperative AP scapula, AP shoulder and clavicle, and lateral scapula x-rays showing the extensive reduction that was performed to achieve a stable result with both the right scapula and clavicle.

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Specific fractures 6.1.1 Scapula

10

Prognosis and outcome

ally those with more severely displaced fractures. A study of 32 patients with scapular body fractures found that a high Injury Severity Score and associated rib fractures compromised the functional outcome. Operative series have focused on more severely displaced fractures. A recent large series [12] of 84 patients with various scapular fractures treated through an extensile Judet approach reported ­excellent radiographic results (no nonunions and only three malunions) with no cases of infection. Another series [14] ­examining outcome after the fixation of scapular process fractures (13 acromion and 14 coracoid) reported healing of all fractures with full range of motion and no pain in any patient.

[13]

There are few prospective or comparative reviews in the literature but retrospective reviews demonstrate ­consistently good results with either operative or nonoperative treatment.

Two series focusing on scapular fractures (19 patients with a mean follow-up of 8 years, and 18 patients with a mean follow-up of 2 years) described the outcome of nonoperative treatment and found that Constant scores were good but declined in patients with a lower glenopolar angle (especially < 20°). Of another series of 13 patients with scapular neck fractures, all had good or excellent Constant scores but all patients had a glenopolar > 20°. Other series report poor results in 6–15% of nonoperatively treated patients, usu-

Classic references

11

References

1. McGinnis M, Denton JR. Fractures of the scapula: a retrospective study of 40 fractured scapulae. J Trauma. 1989 Nov;29(11):1488–1493.

2. Thompson DA, Flynn TC, Miller PW, et al. The significance of scapular fractures. J Trauma. 1985 Oct;25(10):974–977.

3. Goss TP. Double disruptions of the superior shoulder suspensory complex.

J Orthop Trauma. 1993;7(2):99–106.

4. Orthopaedic Trauma Association, Committee for Coding and Classification. Fracture and dislocation

compendium. J Orthop Trauma. 1996;10 Suppl 1:1–154.

5. Ada JR, Miller ME. Scapular fractures.

Analysis of 113 cases. Clin Orthop Relat Res. 1991 Aug;(269):174–180.

6. Ideberg R. Fractures of the scapula involving the glenoid fossa. In: Bateman JE, Welsh RP, eds. Surgery of the Shoulder. Philadelphia: BC Decker; 1984:63–66.

12

Review references

7. Rikli D, Regazzoni P, Renner N. The unstable shoulder girdle: early functional treatment utilizing open reduction and internal fixation. J Orthop Trauma. 1995 Apr;9(2):93–97.

8. Edwards SG, Whittle AP, Wood GW. Nonoperative treatment of ipsilateral fractures of the scapula and clavicle. J Bone Joint Surg Am. 2000 Jun;82(6):774–780.

9. Egol KA, Connor PM, Karunakar MA, et al. The floating shoulder: clinical and functional results. J Bone Joint Surg Am. 2001 Aug;83-A(8):1188–1194.

10. van Noort A, te Slaa RL, Marti RK, et al.

The floating shoulder. A multicentre study. J Bone Joint Surg Br. 2001 Aug;83(6):795–798.

11. Dienstknecht T, Horst K, Pishnamaz M, et al. A meta-analysis of operative versus nonoperative treatment in 463 scapular neck fractures. Scand J Surg. 2013;102(2):69–76.

12. B artonicek J, Fric V. Scapular body fractures: results of operative treatment. Int Orthop. 2011 May;35(5):747–753.

13. Anavian J, Gauger EM, Schroder LK, et al. Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures. J Bone Joint Surg Am. 2012 Apr 4;94(7):645–653.

14. Cole PA, Gauger EM, Schroder LK. Management of scapular fractures. J Am Acad Orthop Surg. 2012 Mar;20(3):130–141.

Acknowledgment

We thank Nikolaus Renner and Roger Simmermacher for their contribution to this chapter in the second edition of the AO Principles of Fracture Management.

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AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Ernest Kwek

6.1.2 Clavicle Ernest Kwek

1

Introduction

Fractures of the clavicle have traditionally been managed nonoperatively. Studies [1] published in the early 1960s reported nonunion rates of less than 1% and high rates of patient satisfaction with nonoperative treatment. However, contemporary literature has challenged this and surgical management has gained prominence in recent years.

1.1

ciation, neurological and vascular injuries. Clinically, patients exhibit swelling and ecchymosis, with deformity and tenderness localized to the fracture site (Fig 6.1.2-1a). Soft-tissue tenting should be noted as this may produce skin necrosis and ulceration (Fig 6.1.2-1b).

Epidemiology

In adults, between 2.6 and 5% of all fractures involve the clavicle. The middle third of the clavicle is involved in more than 66% of these injuries, followed by lateral third fracture in approximately 25%, and medial third fracture in 3%. A bimodal distribution exists with fractures occurring more often in male patients younger than 30 years and a smaller peak for patients older than 70 years [2].

1.2

Special characteristics

The goals of treatment for clavicle fractures include reduction of pain and restoration of shoulder function. Nonoperative treatment remains the mainstay of treatment in most fractures. This consists of sling treatment in the acute period, followed by early range-of-motion and strengthening exercises as the pain subsides, generally after 2–6 weeks.

The use of a figure-of-eight bandage should be discouraged, as it offers no benefits and can be complicated by axillary pressure sores and higher rates of nonunion [3].

2

Evaluation and diagnosis

2.1

Case history and physical examination

Clavicular fractures result from falls with direct impact on the point of the shoulder, typically from outdoor sporting activities in younger patients and simple falls in older patients. It is crucial to determine the mechanism of injury.

High-energy falls can be associated with injuries to the head and chest, whereas fractures after minimal trauma may result from a pathological fracture. Traction-type injuries require early and careful exclusion of scapulothoracic disso-

a

b Fig 6.1.2-1a–b a Clinical appearance of an acutely fractured clavicle, showing extensive ecchymosis. The proximal fragment can be palpated just under the skin (arrow). b A patient with tenting of the skin and ulceration from the underlying proximal fragment.

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Specific fractures 6.1.2 Clavicle

2.2

Imaging

3

Most clavicular fractures are diagnosed on a simple AP view (Fig 6.1.2-2a). A 20° cephalic tilt view eliminates the overlap of the thoracic cage. These x-rays should be taken with the patient upright to better demonstrate fracture displacement (Fig 6.1.2-2b). Weight-bearing stress views can help to assess the integrity of the coracoclavicular ligaments in lateral injuries involving the distal clavicle or acromioclavicular joint.

Computed tomography is indicated in complex shoulder girdle injuries, and also improves visualization of the medial end of the clavicle and sternoclavicular joint when injuries are suspected at this site. Chest x-rays are useful to exclude associated chest injuries, assess for shortening by comparing with the contralateral clavicle, and exclude scapulothoracic dissociation.

Anatomy

The clavicle is S-shaped with a convex curve medially and concave laterally. It is the only bony strut between the ­upper limb and the trunk, articulating with the acromion l­ aterally and the sternum medially. It transits from a triangular crosssection medially to a tubular midsection and ends in the flat but broad acromial end. The thinnest middle portion of the clavicle lies directly under the skin with minimal muscular attachments, making it most vulnerable to direct or indirect trauma. Its medial end is closely related to the subclavian vessels and the apex of the lung, whereas the brachial plexus runs underneath the middle portion. The three major branches of the supraclavicular nerves cross superficially to the clavicle and are at risk of injury during the surgical approach (Fig 6.1.2-3). The typical deformity seen in clavicular shaft fractures results from the pull of the sternocleidomastoid muscle on the medial fragment displacing it superiorly and posteriorly. The lateral fragment is displaced inferiorly by the weight of the arm and rotated by the pectoralis major. Finally, shortening of the clavicle is produced through the pull of the trapezius, pectoralis, and latissimus muscles acting on the shoulder girdle.

a

b

a

Fig 6.1.2-2a–b a AP x-ray of a multifragmentary clavicular shaft fracture. b A 20° cephalic tilt of the same fracture taken upright, showing more pronounced displacement.

b

Fig 6.1.2-3a–b Supraclavicular nerves exposed and preserved during the surgical approach with a transverse incision, and following fixation.

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Ernest Kwek

4

Classification

4.1

AO/OTA Fracture and Dislocation Classification

The clavicle is designated as bone 15. It has three locations: 15.1 (proximal [medial]), 15.2 (diaphyseal), and 15.3 (distal [lateral]). The proximal (medial) and distal (lateral) end segments are divided into types A (extraarticular), B (partial articular), and C (complete articular). The diaphyseal segment is divided into types A (simple), B (wedge), and C (multifragmentary). However, the AO/OTA Fracture and Dislocation Classification presently has limited therapeutic and prognostic value, as it does not take into account the degree of displacement of the fracture.

4.2

Other key classification systems

The Allman classification is based on the location of the fracture (I: middle third, II: lateral third, III: medial third) [4]. Neer [5] specifically classified lateral third fractures, emphasizing the importance of the coracoclavicular (CC) ligaments: type I occurs distal to the CC ligaments with minimal displacement of the medial fragment; type II involves the CC ligaments and results in superior displacement of the medial fragment; type III extends into the acromioclavicular joint, with intact CC ligaments. Craig [6] combined the Allman and Neer classification systems and added subgroups for pediatric and multifragmentary fractures to the medial and lateral groups.

The Edinburgh Classification is a comprehensive system developed by Robinson [2] after analyzing 1,000 clavicle fractures. It is the first system to classify shaft fractures ­according to their displacement and degree of comminution.

Type 1 fractures involve the medial end, type 2 the shaft fractures, and type 3 the lateral end. The shaft fractures are divided into types A and B, depending on their presence or lack of cortical contact. Type 2A fractures are further subdivided into undisplaced (type 2A1) and angulated (type 2A2), while type 2B fractures are subdivided into simple or wedge (type 2B1) and multifragmentary (type 2B2). The medial and lateral end fractures are subdivided into subgroups 1 and 2 depending on the involvement of the adjacent joint.

5

Relative indications: • Concomitant ipsilateral upper limb injuries • Floating shoulder injuries • Polytrauma • Fractures associated with neurovascular injuries • Ipsilateral multiple rib fractures with chest wall deformity • Significant displacement (shortening and/or elevation) > 2.5 cm • Scapular winging because of shortening 5.1

Shaft fractures

There is controversy regarding the surgical indications in acutely displaced shaft fractures. The traditional belief that most midshaft fractures heal without functional deficit has been called into question by several prospective studies [7–11], which reported higher nonunion and symptomatic malunion rates (15–20%), lower functional scores as well as residual weakness with nonoperative treatment. Other studies [2] have suggested that specific fracture types with displacement of more than a clavicular width or significant comminution are at risk for poorer outcomes. A retrospective series [12] of 52 nonoperatively treated patients showed that initial shortening of 2 cm or more was predictive for nonunion and poorer results.

On the other hand, the surgical group is associated with a higher complication and reoperative rate, largely due to hardware-associated problems. Some [13] have therefore cautioned against overtreatment of all displaced midshaft clavicular fractures. With the current lack of consensus regarding which displaced fracture should receive surgical treatment, adequate counseling concerning the risks involved and expected outcomes is crucial.

5.2

Lateral-end fractures

Most fractures involving the distal clavicle are undisplaced and extraarticular. These generally progress to uncomplicated healing. Displaced fractures are associated with a high rate of nonunion (approximately 30%). However, data from several small studies suggest that radiographic nonunion does not always result in clinically important symptoms. It is therefore recommended that surgical treatment for displaced distal clavicular fracture be undertaken on a caseby-case basis [14].

Surgical indications 5.3

Absolute indications: • Open fractures • Fractures with impending skin perforation

Medial-end fractures

These fractures are usually managed nonoperatively unless significant posterior displacement produces mediastinal compromise.

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Specific fractures 6.1.2 Clavicle

6

Preoperative planning

6.1

Timing of surgery

for simple mid-shaft fractures (Fig 6.1.2-4). These implants cannot be locked although newer devices with this facility have recently become available [15].

Where there is an absolute indication for surgery, it should be undertaken without delay. For relative indications, delaying surgery beyond 2–3 weeks may impair the ease of fracture reduction, especially when closed reduction and fixation with percutaneous techniques is planned.

6.2

Implant selection

Fixation of the clavicle can be achieved using either ­intramedullary or extramedullary devices. Historically, ­intramedullary nailing of shaft fractures typically utilized stiff-threaded pins but was associated with a small but significant rate of severe complications due to pin migration into the thoracic cavity. More recently, titanium elastic nails inserted from a medial entry point have been used

a

a

576

The implants most commonly used for plating were the dynamic compression or reconstruction plates 3.5. The use of reconstruction plates facilitates contouring of the implants to the challenging shape of the clavicle (Fig 6.1.2-5). However, they are susceptible to deformation, which can lead to malunion or implant failure. Anatomically precontoured locking compression plates (LCP) have been developed for the clavicle, but it is vital to appreciate the great variability in the shape of the clavicle and the need for further intraoperative contouring to avoid hardware prominence. Locking head screws are an option for use in lateral fractures with a short-end segment and in elderly patients with osteoporotic bone. Biomechanical studies [16] have shown

b

Fig 6.1.2-4a–b Use of a titanium elastic nail inserted in an antegrade manner to fix a simple midshaft fracture.

b

Fig 6.1.2-5a–b Use of a lag screw and superiorly placed 7-hole reconstruction plate 3.5 to fix a midshaft fracture.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Ernest Kwek

locked plate fixation to be superior although clinical studies are still limited. A 2.7 mm screw or even 2.4 or 2.0 mm screws allow lag screw fixation of smaller, intermediate fragments to achieve anatomical reduction and fixation with absolute stability.

For displaced lateral-end fractures, precontoured anatomical plates have been introduced to allow insertion of more locking screws into the distal fragment. For fractures where the distal fragment is too small to provide reasonable screw purchase, clavicular hook plates have an offset lateral hook to engage the posterior aspect of the acromion. Techniques derived from the surgical treatment of acromioclavicular joint dislocations, such as coracoclavicular screws, suture and sling techniques, or suture tightropes can provide useful adjuncts to the primary fixation or serve as the primary reconstruction.

Fig 6.1.2-6 The patient in a beach chair position. The area of skin disinfection is highlighted and adhesive plastic drape has been applied to the operative field.

6.3

Operating room set-up

Once the surgeon is satisfied with the position of the patient, the surgical area is disinfected with the appropriate antiseptic. This area should include the base of the neck, sternum, pectoral area, upper arm, and posterior aspect of the shoulder. Particular attention should be given to disinfect the axilla (Fig 6.1.2-6).

The anesthetist and anesthetic equipment should be situated at the foot of the table. The surgeon and assistant stand on the side of the injury. The operating room personnel stand on the side of the injury. When required, the image intensifier can be introduced from the top of the table. The image intensifier display screen is placed in full view of the surgical team and the radiographer (Fig 6.1.2-7).

Fig 6.1.2-7 Positioning of operating room personnel and image intensifier.

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Specific fractures 6.1.2 Clavicle

7

Surgery

7.3 Fixation 7.3.1 Plating

7.1

Surgical approaches

Fixation is achieved with a compression plate 3.5, reconstruction plate, or precontoured LCP. Plates are usually applied either superiorly or anteriorly. The superior plate is biomechanically stronger especially when inferior comminution is present, and this is a simpler approach. Bicortical screws are required and great care must be taken when drilling because of the risk of injuring the underlying neurovascular structures, especially in the proximal third of the clavicle. Some surgeons prefer to use an oscillating drill in this situation. The vessels can also be protected with a blunt retractor positioned under the clavicle but the surgeon must avoid overstripping of the soft tissues. The anterior plate position is used as an alternative to provide a safer drill trajectory. Its other advantages include less plate prominence, ease of contouring, and the ability to insert longer screws in the wider AP clavicle diameter. When used in c­ ompression or protection mode, this form of fixation provides absolute stability, and can be secured with three bicortical screws on each side (Fig 6.1.2-8). When absolute stability is not possible, bridging plate principles with adequate plate length and screw, and plate density should be followed. The reconstruction plate 3.5 is not strong enough to use as a bridge plate as there are significant forces on the clavicle that can lead to the plate bending or breaking. Bone grafting is not necessary in the primary setting. Following fixation, it is vital to close the myofascial layer securely over the plate to ensure implant coverage and protect against infection.

The patient is positioned in a beach chair or semi-sitting position (Fig 6.1.2-6). A small bump or pad under the involved shoulder helps to elevate the clavicle for easier access, and the arm may be draped free to allow for manipulation. Either a transverse incision along the long axis of the clavicle or a saber-cut incision parallel to Langer lines can be utilized.

The transverse incision allows more extensibility, while the vertical incision reduces risk of injury to the supraclavicular nerves and gives better cosmesis. Whichever incision is chosen, the skin and subcutaneous layer should be mobilized as a single layer. Similarly the myofascial layer over the clavicle is incised in one layer. Preserving these two layers allows for layered closure of the wound over the plate and minimizes wound complications. The surgeon may choose to protect the supraclavicular nerves as they are identified.

7.2

Reduction

Avoid aggressive periosteal stripping of the bony fragments, especially in the posterior and inferior directions. Soft-tissue attachments of vertical, intermediate fragments should be preserved where possible, carefully removing enough to allow for direct reduction to the proximal or distal clavicle.

Small or mini-fragment screws can be introduced as lag screws, converting the fracture into a simple pattern. Reduction forceps are then used to manipulate the proximal and distal clavicle into anatomical alignment, and held with either additional lag screws or wires. Minimally invasive reduction combined with minimally invasive plate osteosynthesis (MIPO) using a precontoured plate and reduction screw or mini plate are some of the options for multifragmentary fractures.

b

a

578

Fig 6.1.2-8a–b a Multifragmentary clavicular shaft fracture before plate fixation. b Three months after fixation with multiple lag screws and a long protection plate showing good healing.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Ernest Kwek

7.3.2 Intramedullary fixation

Intramedullary fixation has several advantages, including smaller incisions, better cosmesis, less soft-tissue dissection, and lower risk for hardware prominence. Disadvantages include skin irritation or breakdown at the insertion point, often requiring implant removal and implant migration.

Static locking is not possible with current devices like the titanium elastic nail and this inability to control for length and rotation may result in secondary shortening when used in multifragmentary fractures. This technique should be reserved for simple, transverse, or oblique fracture patterns.

Closed reduction of clavicular fractures is not always easy and the surgeon should beware of excessive radiation exposure to their own hands during this procedure.

Intramedullary implants may be inserted antegrade or retrograde. The former utilizes an anteromedial entry point in the medial fragment, while the latter uses a posterolateral entry point in the lateral fragment. The antegrade entry portal is recommended when using the titanium elastic nail as it is an easily localized landmark for insertion and removal. This landmark is 1–2 cm lateral to the sternoclavicular joint. A 2.5 mm drill hole is created in the anterior cortex and enlarged with an awl. A 2.0–3.5 mm elastic nail is then inserted into the medullary canal and is passed, under image intensifier guidance, across the fracture site. If closed reduction is not possible, or a narrow canal makes cannulation of the lateral fragment difficult, percutaneous reduction with pointed clamps can first be attempted. If this

b

a

c

fails, an incision is made over the fracture site for direct reduction and to guide the nail into the lateral fragment.

This is required in about 50% of cases. The tip of the nail is advanced to the distal cortex of the lateral fragment. The medial end of the nail is cut off and a blunt end cap is used to protect the nail end (Fig 6.1.2-4a–b).

7.3.3 Minimally invasive plating

Minimally invasive plate osteosynthesis of the clavicle has been proposed as a technique to introduce a biomechanically stronger implant without the disadvantages of open plating or intramedullary fixation. This technically demanding procedure requires the contouring of an LCP reconstruction plate 3.5 to the anterior surface of the clavicle. An anteroinferior plate is preferred as it is easier to contour, using the unaffected clavicle as a template, and its screw trajectory allows for insertion of longer screws [17]. Through a lateral window, the plate is tunneled medially under the pectoralis major muscle. A second medial window is created to secure the plate to the bone (Fig 6.1.2-9). Closed reduction can be effected using the joystick method with Schanz pins, or by using standard cortical screws through the plate as a reduction tool. Early concerns with this technique include supraclavicular nerve injury, malalignment or shortening leading to functional impairment and the potential for plate bending or breakage. Further studies are required to ­demonstrate if it is superior to conventional open plating.

Fig 6.1.2-9a–c Fixed f­racture with LCP (a) before (b) and after (c) wound closure. The required ­approach for this minimally invasive plate osteosynthesis procedure could avoid further skin damage. A standard open approach to this midshaft facture would have interfered with the soft-tissue injury.

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Specific fractures 6.1.2 Clavicle

7.3.4 Plate fixation of fractures of the lateral end of the clavicle

The choice of implant for plate fixation depends on the size of the lateral fragment. Fixation in the lateral fragment requires a minimum of three bicortical screws. Ideally, a lag screw should be placed across oblique fractures. If the fragment is too small to allow sufficient purchase, the clavicle hook plate may be used. The patient is positioned in

a

the beach chair or semi-sitting position, and the surgical approach is lateral to that used for midshaft fractures. The skin incision is centered on the distal end of clavicle, with extension of the wound 1 cm past the acromioclavicular joint. After dissection of the deep layer, the acromioclavicular joint is located with the aid of a hypodermic needle (Fig 6.1.2-10). The fracture is reduced and either held with a K-wire or, if the obliquity of the fracture line allows, a

b

Fig 6.1.2-10a–b Skin incision and surgical approach for lateral clavicular fractures. The acromioclavicular joint is marked on the skin (a), and located with the aid of a hypodermic needle after dissection (b).

a

c

580

b

Fig 6.1.2-11a–c Images showing the placement of the hook plate in the subacromial space, posterior to the acromioclavicular joint.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Ernest Kwek

lag screw. The subacromial space is then perforated with a curved scissors or artery forceps to create a path for the hook. An appropriate sized plate is selected and the hook is inserted into the subacromial space, posterior to the ­acromioclavicular joint. The plate is then reduced to the superior surface of the clavicle (Figs 6.1.2-11–12). This may also be performed with sequential insertion of cortical screws, using the plate as a lever to reduce the distal fragment to the proximal fragment. The hook plate is the most effective implant for maintaining reduction of this fracture but always results in subacromial impingement with painful restriction of shoulder movements. The patient must be informed that a second operation will be required to remove the plate once the fracture has healed. In general, recovery of shoulder function is good following plate removal.

7.3.5 Treatment of acromioclavicular joint dislocations

In fractures where the lateral fragment is large, anatomical precontoured lateral locking clavicular plates are now available which allow the insertion of a greater number of locking screws into the distal fragment (Fig 6.1.2-13, Fig 6.1.2-14e–g).

This avoids the potential complications of the clavicular hook plate.

Types I and II injuries are recommended for nonsurgical treatment with a period of sling immobilization. Management of type III injuries remain controversial, but current literature [19] suggests an advantage for nonoperative treatment in physically active young adults. They are left with a ­cosmetic

a

Acromioclavicular joint injuries represent 12% of shoulder girdle injuries and frequently occur in young athletes involved in contact sports. The most commonly used classification system was developed by Rockwood [18]. Type I is a sprain of the joint with intact coracoclavicular ligaments.

Type II is a tear of the acromioclavicular ligament but not of the coracoclavicular ligaments. Type III involves tears of both the acromioclavicular and coracoclavicular ligaments.

In type IV injuries, the distal part of the clavicle is displaced posteriorly into the trapezius. In type V injuries, both the acromioclavicular and coracoclavicular ligaments are completely torn and the joint is displaced > 100%. Type VI injuries are rare, where the distal clavicle is displaced inferiorly under the coracoid process.

b

Fig 6.1.2-12a–b X-rays of the same patient in Fig 6.1.2-10, showing the displaced lateral end fracture of the clavicle before and after surgery.

Fig 6.1.2-13 Floating shoulder injury with a sizeable distal clavicle fragment fixed with a precontoured anatomical plate.

Note the fractures involving the acromial process and scapula.

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Specific fractures 6.1.2 Clavicle

a

b Hamstring tendon

c

Hamstring tendon

d Hamstring tendon

e

g

582

f

Fig 6.1.2-14a–g a Acromioclavicular joint (ACJ) injury reduced and fixed with “tightrope”. b Suture anchor for ACJ injury. c Tendon sling for ACJ injury. d Reduced ACJ with use of hamstring tendon sling. e Lateral clavicular precontoured plate for reduction of a lateral clavicle fracture. f Reduction with plate supplemented with a hamstring tendon. g Cephalad view of lateral clavicle precontoured plate with supplemental lateral K-wire for lateral clavicular fracture.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Ernest Kwek

deformity but regain good function. In higher grade injuries (types IV–VI), surgical intervention is indicated. Various surgical techniques have been described [20]: • Bosworth technique of inserting a coracoclavicular screw, with or without primary repair of the ligaments (Fig 6.1.2-15) • Hook plate fixation similar to that used for lateral-end clavicular fractures (Fig 6.1.2-16)

a

• Arthroscopic or mini-open stabilization using suture tightropes (Fig 6.1.2-14a) or suture anchors (Fig 6.1.2-14b) • Suture or sling augmentation of the coracoclavicular ligaments, where a synthetic or tendon sling is created around the coracoid and clavicle (Fig 6.1.2-14c–d) Results of these surgical techniques have been satisfactory, with no clear consensus on which method produces superior outcomes, although some loss of reduction is expected [20].

b

Fig 6.1.2-15a–b Type V acromioclavicular dislocation treated with Bosworth screw and primary repair of acromioclavicular and coracoclavicular ligaments.

a

b

Fig 6.1.2-16a–b Acromioclavicular joint (ACJ) injury reduced and fixed with clavicular hook plate.

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Specific fractures 6.1.2 Clavicle

584

7.3.6 Treatment of fractures of the medial end of the clavicle and sternoclavicular joint dislocations

8

Aftercare

These injuries are rare and evidence-based management guidelines are limited. Medial clavicular fractures are usually minimally displaced and extraarticular, and can be managed nonoperatively. The medial clavicular physis is the last physis to close in the human body, and fuses between the ages of 23 and 25 years. Thus, many medial-sided injuries are actually physeal fractures, either Salter-Harris type I or II. Diagnosis on routine plain x-rays is not easy although a 40° cephalic tilt “serendipity” view may demonstrate displacement of the medial end of the clavicle in comparison to the normal side. A computer tomographic scan provides the best imaging. Anteriorly displaced fractures or dislocations are usually amenable to closed reduction but are frequently unstable and recur. As persistent dislocation or displacement often does not result in functional impairment, it is advisable that these are managed expectantly. Posterior displacement of the medial end of the clavicle may, rarely, result in superior mediastinal compromise, including vascular injury or even tracheal obstruction and airway compromise. Emergent closed reduction should first be attempted by retraction of the ipsilateral shoulder. If that does not work, then, percutaneous pointed bone clamps or a towel clip [21] may be used to reduce the joint. If this is unsuccessful, open reduction and stabilization is necessary and should be done in conjunction with a vascular surgeon.

If interventional radiology is available then a balloon catheter can be placed before surgery to allow proximal vascular control. Stabilization of medial fractures can be achieved through plate fixation with conventional or locking plates 3.5 if the medial fragment is large enough. Anatomical lateral clavicular plates may also allow more screws to be inserted for greater stability. For dislocations and fractures where the medial fragment is too small, the plate can be fixed to the sternum, bridging across the joint.

After surgery, the arm is supported in a sling and shoulder pendular exercises are commenced. A follow-up visit is ­recommended at 2 weeks to inspect the wound and obtain x-rays. The arm sling can be discontinued and unrestricted range-of-motion exercises initiated but the patient is cautioned against any lifting whatsoever. Patients feel well after this surgery and fixation failure may occur in patients who are not compliant. If there is evidence of bony union by 6 weeks, strengthening exercises are commenced. Patients should be advised to avoid contact or extreme sports for the first 3 months after surgery until the fracture has healed well.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Ernest Kwek

9 9.1

Complications Early complications

• Wound infection after surgery has been reported in up to 4.8% [8]. The risks may be reduced through careful soft-tissue handling, layered closure over the implant, and appropriate surgical timing.

• Infraclavicular numbness is the most common complication, reported in up to 83% of patients despite attempts at preservation of the supraclavicular nerves. Natural history studies [22] have shown that these symptoms diminish over time and although they may persist after 2 years, this is not associated with significant ­functional loss.

• Hardware prominence and irritation may occur depending on the surgeon’s choice of implant and fixation method, especially with the use of bulky plates or exposed nail ends. This may be reduced with the application of lower-profile, anatomically precontoured plates. Anterior plating has been suggested to reduce hardware prominence and irritation. Routine and early removal of plates is undesirable and exposes the patient to the risk of refracture.

• Refracture can occur after both surgical and nonsurgical treatment. Reinjury after surgical treatment may lead to implant bending or breakage, or fractures around the implant. Refracture at the original fracture site can also occur after implant removal. Internal fixation in such cases is often necessary as problems with union in a refracture setting are fairly common.

• Nonunion: –– The nonunion rate with nonoperative treatment of completely displaced midshaft fractures is 15%, and 2% with operative treatment [23]. This is a relative risk reduction of 86%.

–– Risk factors for nonunion include complete fracture displacement, shortening greater than 2 cm, smoking, increasing age, higher-energy trauma, and refracture [24].

–– Symptomatic patients with nonunions will require plate fixation for mechanical stability and possibly supplementary autogenous bone graft.

–– A structural or intercalary graft may be required in cases of recalcitrant nonunions with poor bone quality or excessive bone loss.

–– Nonunions of the lateral end of the clavicle are t­ reated with fixation with or without bone graft when the fragment is large. When the fragment is small, excision of the lateral end is preferred.

9.2

Late complications

• Osteoarthritis of the acromioclavicular joint occurs more frequently following intraarticular fractures (Edinburgh type 3B2). If symptomatic and not responding to nonoperative modalities, excision of the distal end of the clavicle can be performed either arthroscopically or open.

• Malunion: –– All displaced fractures treated nonoperatively heal with malunion of a varying degree.

–– Shortening of the shoulder girdle, coupled with malrotation of the distal fragment, can result in loss of maximal strength and endurance especially for shoulder abduction [7]. Narrowing of the thoracic outlet may also result in brachial plexus impingement symptoms. Scapular protraction, resulting from malalignment of the scapulothoracic joint, can give rise to periscapular symptoms of pain and muscle spasm.

–– Corrective osteotomy and plate fixation can be beneficial in well-selected patients where symptoms are clearly attributed to the malunion.

10

Prognosis and outcome

Recent studies have reported favorable outcomes following surgical treatment of displaced midshaft clavicular fractures.

In a metaanalysis of six randomized controlled trials [9], rates of nonunion and symptomatic malunion were significantly lower in the surgical group. The surgical group also experienced an early decrease in pain and improved Constant and DASH scores [9]. Despite this, it must be clear that these results apply to a specific subgroup of patients with poor prognostic indicators, including significant fracture displacement, shortening, and comminution. Most clavicular fractures are expected to progress to uncomplicated healing and return to normal function with nonoperative treatment. A recent review [25] helps to clarify treatment for acromioclavicular dislocations.

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Specific fractures 6.1.2 Clavicle

Classic references

11

References

1. Neer CS II. Nonunion of the clavicle. J Am Med Assoc. 1960 Mar 5;172:1006– 1011.

2. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998 May;80(3):476–484.

3. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures.

Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987 Feb;58(1):71–74.

4. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967 Jun;49(4):774–784.

5. Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res. 1968 May–Jun;58:43–50.

6. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA 3rd, eds.

The Shoulder. Philadephia: WB Saunders; 1990:367–412.

7. McKee MD, Pedersen EM, Jones C, et al.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006 Jan;88(1):35–40.

8. 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 Jan;89(1):1–10.

9. McKee RC, Whelan DB, Schemitsch EH, et al. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012 Apr 18;94(8):675–684.

12

Review references

10. Robinson CM, Goudie EB, Murray IR, et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures.

J Bone Joint Surg Am. 2013 Sep 4;95(17):1576–1584.

11. Kulshrestha V, Roy T, Audige L. Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. J Bone Joint Surg Am. 2011;25:31– 38.

12. H ill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997 Jul;79(4):537–539.

13. K han LAK, Bradnock TJ, Scott C, et al.

Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447–460.

14. B anerjee R, Waterman B, Padalecki Jeff, et al. Management of distal clavicle fractures. J Am Acad Orthop Surg. 2011 Jul;19(7):392–401.

15. K ing PR, Ikram A, Lamberts RP. The treatment of clavicular shaft fractures with an innovative locked intramedullary device. J Shoulder Elbow Surg. 2015 Jan;2481):e1–6.

16. Demirhan M, Bilsel K, Atalar AC, et al.

Biomechanical comparison of fixation techniques in midshaft clavicular fractures. J Orthop Trauma. 2011 May;25(5):272–278.

17. Sohn HS, Kim BY, Shin SJ. A surgical technique for minimally invasive plate osteosynthesis of clavicular midshaft fractures. J Orthop Trauma.

2013;27:e92–e96.

18. Rockwood CA Jr. Injuries to the acromioclavicular joint. In: Rockwood CA Jr, Green DP, eds. Fractures in Adults.

2nd ed. Philadephia: JB Lippincott; 1984;860–910.

19. Canadian Orthopedic Trauma Society.

Multicenter RCT of operative versus nonoperative treatment of acute displaced acromioclavicular joint dislocations: a multicenter RCT. J Orthop Trauma. 2015;29:479–487.

20. Li XN, Ma R, Bedi A, et al. Current concepts review: management of acromioclavicular joint injuries. J Bone Joint Surg Am. 2014 Jan 1;96(1):73–84.

21. G roh GI, Wirth MA, Rockwood CA Jr. Treatment of traumatic posterior sternoclavicular dislocations. J Shoulder Elbow Surg. 2011 Jan;20(1):107–113.

22. Wang L, Ang M, Kwek E, et al. The clinical evolution of cutaneous hypoesthesia following plate fixation in displaced clavicle fractures. Indian J Orthop. 2014;48:10–13.

23. Zlowodzki M, Zelle BA, Cole PA, et al.

Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: On behalf of the EvidenceBased Orthopaedic Trauma Working Group. J Orthop Trauma. 2005;19:504– 507.

24. Murray IR, Foster CJ, Eros A, et al. Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle. J Bone Joint Surg Am. 2013 Jul 3;95(13):1153–1158.

25. V irk M, Apostolakos J, Cote M, et al.

Operative and non-operative treatment of acromio-clavicular dislocation: a critical analysis review. J Bone Joint Surg. 2015 Oct;3(10):e5.

Acknowledgments

We thank Nikolaus Renner and Roger Simmermacher for their contribution to this chapter in the second edition of the AO Principles of Fracture Management.

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Chunyan Jiang

6.2.1 Humerus, proximal Chunyan Jiang

1

Introduction

2

Evaluation and diagnosis

1.1

Epidemiology

2.1

Case history and physical examination

Proximal humeral fractures are common and are mainly the result of low-energy injuries in the elderly population.

Most fractures of the proximal humerus are nondisplaced or minimally displaced and can be treated successfully by nonoperative treatment, only 10–20% of the fractures require surgery [1]. Fracture of the proximal humerus is the third most common fracture in the whole body, accounting for 4–10% of all fractures [1]. The annual incidence is reported between 31 and 250 per 100,000 in adults, and the incidence is rising steadily as the elderly population increases.

A detailed history should include the patient’s age, activity level, and the mechanism of the injury. Most proximal humeral fractures occur in elderly patients with a fall from standing height onto an outstretched arm [1], and osteoporosis plays an important role with increasing incidence in the elderly female population. Proximal humeral fractures in young patients usually occur with high-energy trauma.

They suffer more severe soft-tissue injury and multifragmentary fractures. Seizure or electric shock may also result in proximal humeral fractures with or without a dislocation.

1.2

A complete physical examination should assess the entire upper extremity and focus on other areas to exclude other injuries, including the neck and spine. Swelling and bruising may spread to dependent areas; severe swelling may occasionally be associated with vascular injury. Although open fractures are rare, severe closed fractures may cause severe tenting and pressure necrosis of the skin. Deformity of the shoulder joint may not be visible and obvious deformity suggests a dislocation. Restricted range of motion should be distinguished from rotator cuff injuries. The motor and sensory function of the axillary nerve should always be evaluated and if dislocation is present, assess the function of the brachial plexus and evaluate the wrist pulses.

Special characteristics

Proximal humeral fractures in patients with osteoporosis are challenging problems. A systematic review [2] of ­nonoperative treatment in elderly patients with proximal humeral fractures demonstrated high rates of healing and good functional outcomes. Nonoperative treatment of displaced fractures avoids implant-related problems that are common following surgical treatment. However, consistently satisfactory results cannot always be expected with nonoperative treatment [3–5]. Locking plates with angular stable screws provide more stability in osteoporosis but the complication rate remains high [6].

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2.2

Imaging

The standard axillary view (with the arm abducted to about 90°) is impossible because of pain and the risk of further displacement of the fracture (Fig 6.2.1-1e–f). Therefore, a modified axillary view (Velpeau view) can be obtained without excessive shoulder abduction (Fig 6.2.1-1g).

Plain x-rays are the best basic method to evaluate proximal humeral fractures. Trauma series x-rays in three views should be obtained, which include a true AP and lateral view of the shoulder joint along with an axillary view (Fig 6.2.1-1a–d).

30°

30°

a

b

30°

c

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d

Fig 6.2.1-1a–g Trauma series x-rays. With an acute fracture, all x-rays are taken with the patient standing or sitting and the arm ­supported to minimize pain. a–b True glenoid AP view. The patient must stand facing the x-ray source, with the posterior aspect of the affected side against the x-ray plate. The opposite trunk is rotated at least 30°. c–d Transscapular lateral view. The patient stands with the x-ray source on the ­opposite side and the affected shoulder is placed against the x-ray plate. The trunk is turned 30° away from the x-ray beam, which is then directed posteriorly along the scapular spine.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Chunyan Jiang

e

f

g Fig 6.2.1-1a–g (cont) Trauma series x-rays. With an acute fracture, all x-rays are taken with the patient standing or sitting and the arm supported to minimize pain. e–f Axillary view. The patient is supine with the x-ray plate placed above the shoulder. Abduction of about 30º is needed, which can be painful in an acute setting. g Velpeau view.

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Specific fractures 6.2.1 Humerus, proximal

A computed tomographic (CT) scan provides important additional information for evaluating complex proximal humeral fractures. Coronal, sagittal, and 3-D reconstructions provide further details of the fracture lines, the glenoid, and humeral head (Fig 6.2.1-2).

3

Anatomy

A thorough understanding of the anatomy of the proximal humerus and its surrounding soft tissue is crucial for fracture reduction and fixation. The central column diaphyseal (CCD) angle is 135°. The humeral head is normally retroverted on the neck, facing approximately 25° posteriorly (mean range:

a

c

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18–30°) relative to the distal humeral epicondylar axis. The four standard fragments of the proximal humeral fracture are humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [6]. The bicipital groove is made of dense cortical bone and the biceps tendon (long head) is an important landmark for reference. The greater tuberosity is the insertion for the supraspinatus tendon superiorly, the infraspinatus tendon posterosuperiorly, and the teres minor tendon posteriorly. The lesser tuberosity is the insertion of the subscapularis tendon (Fig 6.2.1-3). These important tendon attachments facilitate the reduction and fixation of osteoporotic proximal humeral fractures by using rotator cuff sutures.

b

d

Fig 6.2.1-2a–d A 2-D computed tomographic (CT) coronal (a), sagittal (b), transverse (c), and 3-D reconstruction CT (d) provide more detail of the fracture.

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Chunyan Jiang

Damage to the blood supply to the proximal humerus may cause avascular osteonecrosis [7]. The arcuate branch ascends from the anterior humeral circumflex artery and enters the humeral head. It was believed to provide the major blood supply to the articular portion of the humeral head. However, in a cadaveric study, Hettrich et al [8] found that the posterior circumflex humeral artery provides 64% of the blood supply to the humeral head. Thus, the posterior cir-

cumflex humeral artery may play a more important role in maintaining the perfusion of the humeral head in proximal humeral fractures (Fig 6.2.1-4). The length of the dorsomedial metaphyseal surgical neck spike is critical for the perfusion of the anatomical head of the humerus [9]. A valgus displaced surgical neck fracture opens up the medial hinge and may also disrupt the blood supply to the head of the humerus.

Fig 6.2.1-3 The rotator cuff tendons facilitate reduction and fixation of tuberosity fragments.

6 5

5

7 4

8 3 1 2

Fig 6.2.1-4 Vascular anatomy of the proximal humerus.

1 Axillary artery.

2 Posterior humeral circumflex artery.

3 Anterior humeral circumflex artery.

4 Lateral ascending branch of the anterior humeral circumflex artery.

5 Greater tuberosity.

6 Lesser tuberosity.

7 Tendon insertion of the infraspinatus muscle.

8 Tendon insertion of the teres minor muscle.

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Specific fractures 6.2.1 Humerus, proximal

4

Classifications

5

4.1

AO/OTA Fracture and Dislocation Classification

The selection of suitable treatment depends upon the type of fracture, quality of the bone, deforming forces, the surgeon’s skills (experience, preference), the patient’s compliance, and the patient’s expectations.

The severity of the proximal humeral fracture increases from A1 to C3, so the AO/OTA Fracture and Dislocation Classification can direct treatment and is also prognostic for the vascular supply of the humeral head and outcome (Fig 6.2.1-5).

4.2

Neer classification

In 1970, Neer [6] proposed a classification system based upon the anatomical parts of the proximal humerus and their displacement from each other. Malposition of > 1 cm and angulation > 45° is considered as displacement. The Neer classification is a widely used classification for proximal humeral fractures.

4.3

LEGO classification

Hertel et al [9] developed the LEGO classification system.

This classification emphasizes the location of the fracture line between each of the four parts of the proximal humerus and different combinations based upon the number of parts that are fractured.

11A

Surgical indications

Nondisplaced fractures and impacted fractures should be treated by sling immobilization for 2–3 weeks with early pendulum exercises and then active range of motion. Displaced fractures in patients with osteoporosis older than 75 years with low demands should be treated with the same nonoperative treatment. Closed reduction, if needed, is attempted under image intensification. If alignment is achieved and the reduction is stable, the arm is immobilized in a sling.

Indications for fracture reduction and stabilization include: • Displaced fractures (defined by Neer [6] as displacement of the fragment > 1 cm or angulation > 45°) • Head-splitting fractures • Combined neurovascular injuries • Open fractures • Unstable fractures with disrupted medial hinge • Floating shoulder • Polytrauma • Irreducible fracture dislocations

11B

11C

Humerus, distal end segment, 11A extraarticular, unifocal 2-part fracture (surgical neck) 11B extraarticular, bifocal, 3-part fracture 11C articular or 4-part fracture (anatomical neck) Fig 6.2.1-5 AO/OTA Fracture and Dislocation Classification—proximal humerus. Because of the unique anatomy of the proximal humerus, the classification is modified for this special area.

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6

Preoperative planning

6.1

Timing of surgery

Proximal humeral fractures rarely require immediate surgery and there are few studies on how timing of surgery affects clinical outcomes. Satisfactory results can be expected in delayed cases [10], but in comparative studies [10, 11] early surgical intervention seems to produce better functional outcomes, regardless of treatment provided.

may be indicated for complex fractures or fracture dislocations with osteoporotic bone in the elderly. However, union of the greater tuberosity fragment(s) is unpredictable after surgery [12] and may give poor function. Reverse total shoulder arthroplasty has gained more interest in the past decade.

Comparative studies [12, 13] show that reverse arthroplasty provides more predictable and higher functional outcomes than hemiarthroplasty alone but concerns about the longevity of these implants remain.

6.2

6.3

Implant selection

Operating room set-up

The choice of implants for proximal humeral fractures should be based upon the personality of the injury including fracture characteristics, patient features, and the soft tissues.

The function of the rotator cuff is also an important factor.

Threaded K-wires are mainly used in immature patients with open physeal plates, whereas sutures, tension band, or screws can be utilized in 2-part tuberosity fractures with good bone quality. Locking plates are widely used in displaced fractures but plate-related complications and bone quality should be taken into account. If a closed reduction can be obtained and maintained during surgery, minimal invasive technique such as percutaneous fixation, minimally invasive plate osteosynthesis (MIPO) technique, or intramedullary (IM) nailing can be performed to minimize further disruption of the blood supply at the fracture site. Arthroplasty

After disinfecting the entire arm and shoulder from the neck to the fingertips, the hand and forearm are covered in a waterproof stockinette. A U drape is applied with the split facing the axilla. The apex of the U is on the lateral chest wall and the two tails are stuck down anterior and posterior to meet at the root of the neck (Fig 6.2.1-6). The image intensifier also needs to be draped.

Fig 6.2.1-6 Patient is placed in the beach chair position with the right shoulder resting on a radiolucent part of the operating table.

The patient and image intensifier are then draped.

Fig 6.2.1-7 Setting up the operating room.

The surgeon stands facing the patient’s shoulder, adjacent to the operating table and the axilla, or he positions himself between the patient and the abducted arm facing the axilla.

The assistant can stand behind the patient’s shoulder. The operating room personnel set up between the two surgeons.

The image intensifier display screen is placed in full view of the surgical team and the radiographer (Fig 6.2.1-7).

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7

Surgery

7.1 7.1.1

Surgical approaches Deltopectoral approach

The deltopectoral approach is the most frequently used ­approach during open reduction and internal fixation or arthroplasty. The patient is usually placed in a beach chair position (Fig 6.2.1-6). The incision begins at the corocoid process proximally and passes just anterior to the deltoid, and extends to the middistal portion of the deltoid. The cephalic vein is dissected and retracted either laterally with the deltoid muscle or medially with the pectoralis major muscle (Fig 6.2.1-8). Next, the interval between the deltoid and the pectoral muscles is developed and the clavipectoral fascia is then opened. The coracoacromial ligament is identified. Blunt dissection in the subacromial space and underneath the deltoid, plus partial release of the deltoid insertion distally, can improve visualization. The arm is slightly abducted to relax the deltoid so that it can be easily retracted

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laterally without excessive tension. The anterior portion of the insertion of the deltoid on the acromion must be protected during surgery. The long head of the biceps lies in the bicipital groove between the tuberosities and is an ­important landmark to identify both the greater and lesser tuberosity.

The advantages of the deltopectoral approach are: • Better protection of the deltoid • Better visualization and release of the inferior capsule • Lower risk of axillary nerve injury The disadvantages are: • Plate placement can be difficult due to lateral deltoid obstruction • Poor visualization for the posterior aspect of the tuberosity • Exposure can be difficult in strong muscular individuals

AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

Chunyan Jiang

3

4

1

6 2 5

a

7

8 10 11

9

b

Fig 6.2.1-8a–b Deltopectoral approach. a Skin incision from the coracoid to the deltoid tuberosity.

1 Coracoid process.

2 Axillary nerve.

3 Acromion.

4 Lateral end of clavicle.

5 Axillary artery.

6 Brachial plexus. b The deltopectoral groove is opened.

7 Deltoid muscle.

8 Cephalic vein.

Muscle and vein are retracted to the lateral side exposing the humeral head.

9 Pectoralis major muscle.

10 Anterior humeral circumflex artery.

11 Long head of biceps brachii tendon.

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Specific fractures 6.2.1 Humerus, proximal

7.1.2 Transdeltoid approach (deltoid split)

This approach is indicated for greater tuberosity fractures, MIPO, proximal humeral fixation, or nailing. The incision starts at the anterolateral corner of the acromion and extends 5 cm down the lateral aspect of the proximal humerus. The deltoid is bluntly released between the anterior and the middle fibers down to the subdeltoid bursa (Fig 6.2.1-9). Carefully protect the axillary nerve throughout surgery. If the tuberosity is fractured and needs to be fixed or MIPO is to be applied, place a stay suture at the deltoid split 5 cm lateral and distal to the acromion to prevent axillary nerve injury. Internal and external rotation allows reduction and

fixation of the greater tuberosity. The lateral plate must be carefully inserted beneath the nerve.

The advantages of the transdeltoid approach are: • Better visualization of both tuberosities • Easy plate access on the lateral aspect of the proximal humerus The disadvantages are: • Risk of deltoid muscle damage • Axillary nerve injury

1

2 3

Fig 6.2.1-9 Transdeltoid lateral approach. Incision from the anterolateral corner of the acromion extending distally no further than 5 cm.

1 Acromioclavicular joint.

2 Axillary nerve.

3 Blue lines outline the "safe zone" for observing the axillary nerve and protecting it from surgical harm. This "safe zone" is not incised on the skin but the axillary nerve can be palpated from the above incision, inside and beneath the deltoid.

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7.2

Reduction and fixation

Traction sutures on the tendon-bone junction are helpful in managing and reducing the tuberosity fragments without further comminution of the fracture fragments (Fig 6.2.1-10).

For isolated 2-part tuberosity fractures, suture is more reli-

able than screws. For 2-part surgical neck fractures, reduction of the medial cortex is important, especially in varus type fractures. For more complex 3- or 4-part fractures, always restore the normal neck-shaft angle using the joystick technique (Fig 6.2.1-11) or using a periosteal elevator or bone

2

1 3 Fig 6.2.1-10 Traction sutures on the tendon-bone junction of the rotator cuff.

1 Subscapularis tendon.

2 Supraspinatus tendon.

3 Infraspinatus tendon.

a

b

Fig 6.2.1-11a–b Use the joystick to control the head and restore normal neck-shaft angle.

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Specific fractures 6.2.1 Humerus, proximal

tamp to manipulate the head fragment (Fig 6.2.1-12). Temporary K-wires from above the head to the shaft or anteriorly from the shaft to the head can be used to hold the reduction and avoid interfering with plate application (Fig 6.2.1-13). Indirect reduction techniques (eg, suture placed

into the tendons of the rotator cuff) are used to tie the tuberosity fragments together. This is recommended to avoid fragmentation of the thin tuberosity fragments and to protect their remaining blood supply (Fig 6.2.1-14).

a

b Fig 6.2.1-12a–b Periosteal elevator or bone tamp used to reduce the varus head back to valgus position.

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Fig 6.2.1-13 Temporary K-wire fixation of head and shaft avoiding the position of the plate.

a

b Fig 6.2.1-14a–b Sutures tie for indirect reduction of the tuberosities.

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Specific fractures 6.2.1 Humerus, proximal

Lag screws can be used in isolated tuberosity fractures, 2-part fractures with good bone quality, or in combination with other implants in complex fractures. The use of screws alone is not recommended as the strength of screw fixation is relatively poor in the metaphyseal part of the proximal humerus. In simple tuberosity fractures, the strength of suture

a

fixation is stronger than screw fixation. Using a suture anchor, the double-pulley technique can be used to achieve better reduction and fixation strength (Fig 6.2.1-15). Adjunctive suture fixation along with plate or nail fixation is mandatory for better biomechanical stability (Fig 6.2.1-16).

b

Fig 6.2.1-15a–b Isolated greater tuberosity fracture fixation with anchor suture.

a

b

Fig 6.2.1-16a–b Additional suture fixation to the plate provides more stability especially in osteoporotic bone.

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Intramedullary nails minimize surgical exposure of the fracture site. First, bring the shaft into alignment with the head under the image intensifier and achieve reduction before nail insertion. A straight nail is inserted into the humerus over a guide wire. The newly designed multilock nail allows fixation of tuberosity fractures and helps with repair of the rotator cuff by sutures (Fig 6.2.1-17).

An IM nail can be used in 2-part surgical neck fractures and certain types of 3- and 4-part fractures with relatively intact proximal ring structures. Intramedullary nails are thought to be less invasive and provide sufficient stability for axial and torsional loading compared with locking plates [14].

Newly designed IM nails with multiple proximal interlocking screws have been introduced for the treatment of proximal humeral fractures. Biomechanical tests have proved that IM nails have better resistance to bending and rotational forces compared with plates. However, the placement of an IM nail may cause iatrogenic greater tuberosity fractures and rotator cuff injuries, which may lead to persistent symp-

toms and weakness postoperatively. Avoid stab incisions and use a straight nail, as the entry point is on the humeral head instead of through the rotator cuff footprint.

The locking plate is one of the most widely used implants for proximal humeral fracture fixation. The plate should be placed lateral to the bicipital groove. The calcar screws (two screws running tangentially to the medial curvature of the humeral surgical neck) are important in maintaining medial support (Fig 6.2.1-18), especially in the case of a varus displaced fracture with medial cortex comminution [15].

The correct plate position is (Fig 6.2.1-19): 1. About 5–8 mm distal to the top of the greater tuberosity 2. Aligned properly along the axis of the humeral shaft 3. Slightly posterior to the bicipital groove (2–4 mm) 4. To confirm the correct axial plate position, insert a Kwire through the proximal hole of the insertion guide.

The K-wire should rest on the top of the humeral head.

Calcar screws

Fig 6.2.1-17 The multilock nail with multidirectional screw and suture fixation.

Fig 6.2.1-18 The calcar screws provide medial support and prevent varus collapse.

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Specific fractures 6.2.1 Humerus, proximal

Minimally invasive plate osteosynthesis avoids excessive dissection of the soft tissues and decreases the chance of nonunion and infection [16]. Closed reduction is performed with an image intensifier. The proximal approach is a deltoidsplit approach and the distal approach is at the deltoid insertion. The plate is inserted close to the bone and deep to the

axillary nerve. The MIPO technique provides satisfactory clinical and radiological outcomes but is limited in treating complex fractures of the proximal humerus. If a closed reduction cannot be achieved for MIPO, then open reduction should be considered [16].

1

2 5-8 mm

3

a

b Fig 6.2.1-19a–b a Correct position of the PHILOS from the top of the greater tuberosity (1), along the axis of the humeral shaft (2) and posterior to the bicipital groove (3). b The guiding block and K-wire for positioning of the PHILOS from the greater tuberosity.

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Hemiarthroplasty or reverse shoulder arthroplasty also plays a role in the treatment of complex proximal humeral fractures with osteoporosis or fracture dislocation. Recent studies [12, 13] showed that the reverse shoulder arthroplasty is more predictable and reliable than the hemiarthroplasty in treating complex fractures in elderly patients.

7.3

Surgical treatment of specific fractures

1a) When best to use closed reduction and percutaneous pins or screws: • Simple fracture patterns in younger patients with good bone • Isolated fracture of the greater tuberosity • Valgus impacted fracture patterns 1b) When best NOT to use closed reduction and pinning: • Head-splitting fractures or fracture dislocations • Complex fracture patterns where the medial calcar is fragmented 2a) When best to use IM nailing: • Displaced fractures in which the proximal ring structure is relatively intact but the head complex remains unstable relative to the shaft • Completely displaced 2-part surgical neck fractures in the elderly 2b) When best NOT to use IM nailing: • Displaced 3- and 4-part fractures and head-splitting fractures of the proximal humerus 3a) When best to use open reduction and internal fixation and locking plates: • Both 2- and 3-part fractures with significant ­displacement or articular incongruity • Most 4-part fractures, especially in young patients • Excessive varus or valgus deformity 3b) When best NOT to use open reduction and internal fixation and locking plates: • Head-splitting fractures • Elderly patients with significant comminution, fracture dislocation, or displaced multipart fractures

4b) When best NOT to use hemiarthroplasty: • Senior patients with comminuted and osteoporotic tuberosity fractures • Salvageable fracture patterns • When there is substantial rotator cuff pathology 5a) When best to use a reverse shoulder arthroplasty to replace the proximal humerus: • Elderly patient with severe fracture dislocation • Concurrent rotator cuff deficiency 5b) When best NOT to use a reverse shoulder arthroplasty to replace the proximal humerus: • Young patients with salvageable fracture patterns 7.4

Challenges

Although the application of locking plates significantly improves the treatment of proximal humeral fractures [17], complications are widely reported. Screw penetration and loss of reduction after surgery are the most commonly published complications.

Osteoporosis presents great challenges to plate fixation, especially in complex fractures with thin cortex and weak subchondral bone, so there is poor purchase of the screws and even locking plates cannot provide sufficient stability to prevent loss of reduction. Continued load transfer then results in osteolysis, further loss of reduction and finally causes implant failure [18]. Shoulder arthroplasty may become more important in the treatment algorithm.

The integrity of the medial hinge is highly correlated with postoperative outcomes [15]. The medial calcar region contributes significantly to the outcome following proximal humeral fracture fixation and should be anatomically restored whenever possible. Medial comminution is reported to be correlated to loss of reduction after fixation of proximal humeral fractures [15]. Severe medial comminution with varus deformity can create a great challenge to satisfactory reduction and stable fixation. Double plating, intramedullary fibular strut grafting, and placement of calcar screws may enhance the biomechanical stability of the proximal humeral fracture fixation [19].

4a) When best to use hemiarthroplasty: • Middle-aged patient with severe 3- or 4-part fracture dislocation

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8

Aftercare

Rehabilitation is essential to maximize function following a proximal humeral fracture, regardless of whether it is treated operatively (by fixation or arthroplasty) or nonoperatively. Implant constructs should be sufficiently stable to allow passive motion during surgery and rehabilitation immediately after surgery. The same rehabilitation protocol (Table 6.2.1-1) is used for nonoperative and operative treatment and must start 10–14 days after surgery.

Phase

Duration (weeks)

Rehabilitation

1

0–6

Pendulum exercises

9

Complications

9.1

Screw penetration

This is the most commonly reported complication, and it may be due to a technical error intraoperatively or secondary to loss of reduction with impaction and varus malunion.

The fixed-angle screws cannot back out and joint penetration occurs. A less frequent cause is collapse of the humeral head because of avascular necrosis [17, 20]. Screw placement should be monitored by the image intensifier at all positions to confirm that screws are properly placed.

Passive range of motion exercises Avoid active range of motion exercises for 6 weeks 2

6–10

Orthopedic sling for 2–3 weeks If there is clinical evidence of healing and fragments move as a unit and no displacement is visible on the x-ray, then: • Active-assisted motion forward and side arm elevation • Week 6–8: partial functional use • Week 8: add active, nonassisted motion • Week 8: add isometric strength

3

> 10

If there is bone healing but joint stiffness, then: • Add manual therapy passive motion by physiotherapist • Add isotonic strength, concentric and eccentric

Table 6.2.1-1 Shoulder rehabilitation protocol.

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9.2

Avascular necrosis

Avascular necrosis of the humeral head is relatively frequent with the overall rate approaching 35%. This can lead to pain, decreased range of motion, and glenohumeral joint arthritis. Plate fixation seems to be associated with higher incidence due to soft-tissue dissection [17, 20].

The most important predisposing factors are [9]: • Length of the dorsomedial metaphyseal extension • Integrity of the medial hinge • Fracture type Despite the high incidence of avascular necrosis, it is frequently asymptomatic with 77% of patients still showing good to excellent functional results. This rate compares favorably with 80% of cases with “acceptable” results when primary arthroplasty is used.

9.3

Malunion and nonunion

Malunion is frequently accompanied with loss of the medial cortical buttress [17, 20], which leads to varus deformity.

Reduction of the medial cortical buttress is important. In osteoporotic fractures, where an anatomical reduction is not possible, it is recommended to impact the medial cortex of the shaft into the head to produce a more stable reduction.

9.4

Nerve injuries

Axillary nerve injury may occur during reduction of a fracture dislocation or severely displaced fragments. Careful surgical dissection when using the deltoid, split approach or when inserting retractors will reduce the risk of nerve injury.

Brachial plexus and axillary artery injury can be associated with dislocation of the humeral head into the axilla. Early reduction is essential and requires general anesthesia with muscle relaxation if there is an associated fracture of the neck of humerus. Emergent open reduction is sometimes required if there is an evolving nerve injury with a dislocation that cannot be reduced by closed manipulation.

10

Prognosis and outcome

Several factors are correlated with a good prognosis and outcome. The most important are the complexity and degree of displacement of the fracture and also the integrity of the rotator cuff. The length of the posteromedial metaphyseal head extension and the integrity of the medial hinge are associated with the vascular supply to the humeral head [9].

The integrity of the medial hinge, along with the comminution of the fracture, is an important indicator in fracture reduction and stabilization [21, 22]. Head orientation, impaction of the surgical neck, and displacement of the tuberosities correlate strongly with outcome [23, 24]. Age is ­associated with elevated risk of short-term complications [9]. Osteoporosis may decrease the fixation strength but there is no evidence that poor bone quality alone increases the risk of mechanical failure using a locking plate [25]. Reverse shoulder replacement is an alternative to hemiarthroplasty for the treatment of severe fractures [26].

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Specific fractures 6.2.1 Humerus, proximal

Classic references

11

References

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12

Review references

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15. Gardner MJ, Weil Y, Barker JU, et al.

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2014 Sep;23(9):1334–1340.

17. Sproul RC, Iyengar JJ, Devcic Z, et al. A systematic review of locking plate fixation of proximal humerus fractures.

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19. Schliemann B, Wähnert D, Theisen C, et al. How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data. Injury. 2015 Jul;46(7):1207–1214.

20. Jost B, Spross C, Grehn H, et al. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013 Apr;22(4):542–549.

21. Petrigliano FA, Bezrukov N, Gamradt SC, et al. Factors predicting complication and reoperation rates following surgical fixation of proximal humeral fractures. J Bone Joint Surg Am. 2014 Sep 17;96(18):1544–1551.

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The influence of local bone density on the outcome of one hundred and fifty proximal humeral fractures treated with a locking plate. J Bone Joint Surg Am. 2014 Jun 18;96(12):1026–1032.

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Acknowledgments

We thank Pierre Guy for his contribution to the second edition of the Principles of Fracture Management.

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AO Principles of Fracture Management—Third Edition Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul