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Trauma to the Upper Extremities

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Trauma to the Upper Extremities 7 Trauma to the Upper Extremities Contents 7.1 Sternoclavicular Joint 192 7.1.1 Sternoclavicular Joint Dislocation 192 7.1.2 Clinical Signs to Suggest Dangerous Posterior Dislocation 192 7.1.3 Reduction Manoeuvre 192 7.1.4 Main Pitfall 193 7.1.5 Complications (Posterior Injuries) 193 7.2 Acromioclavicular Joint Dislocation 193 7.2.1 Rockwood Classification 193 7.2.2 Management 193 7.3 Shoulder Dislocation and Instability 195 7.3.1 General Concepts 195 7.3.2 Facts and Myths of Shoulder Dislocation 195 7.3.3 Investigations 196 7.3.4 Anterior Dislocation: Treatment Principles 196 7.3.5 Key Points: Anterior Dislocations 198 7.3.6 Pearl 198 7.3.7 Posterior Dislocations 198 7.3.8 Pearl 199 7.3.9 Is It Multi-Directional or Voluntary Instability? 199 7.3.10 Dx of Multi-Directional Instability 199 7.3.11 Appendix on Multi-Directional Instability 200 7.3.12 A Word About Arthroscopy 200 7.4 Fractured Clavicle 200 7.4.1 Pathomechanics 201 7.4.2 Fractured Clavicle Classification 201 7.4.3 Classification of Lateral Third Fractures 201 7.4.4 Conservative Treatment: Majority of Patients 201 7.4.5 Operative Indications 202 7.4.6 Reason for the Trend Towards Fixing Displaced Clavicular Fractures 202 7.4.7 Choice of Fixation 203 7.4.8 Choice of Fixation of Lateral Third Fractures 203 7.4.9 Weaver-Dunn Procedure 204 7.4.10 Complications 204 7.4.11 Treatment of Non-Unions 204 7.5 Fractured Scapula and Glenoid 204 186 7 Trauma to the Upper Extremities 7.5.1 Ideberg Classification of Glenoid Fractures 205 7.5.2 Rn of Scapula Body Fractures 205 7.5.3 Rn of Extra-Articular Glenoid Fractures 205 7.5.4 Rn of Glenoid Intra-Articular Fractures 206 7.5.5 SSSC Concept 206 7.5.6 SSSC and Floating Shoulder 206 7.5.7 Concomitant Fractured Clavicle and Glenoid Neck 206 7.6 Lateral Scapula Dissociation (Closed Traumatic Fore-Quarter) 206 7.7 Fractured Proximal Humerus 207 7.7.1 Introduction 207 7.7.2 Neer's Classification 207 7.7.3 Criticism of Neer's Classification 208 7.7.4 Other Recent Criticism of Neer's Classification 208 7.7.5 AO Classification 208 7.7.6 New Binary Classification 209 7.7.7 Humeral Head Blood Supply 209 7.7.8 Associated Injuries 209 7.7.9 Work-up 210 7.7.10 Minimally Invasive Reduction of Proximal Humerus Fractures 210 7.7.10.1 Indications 210 7.7.10.2 Advantages of Minimally Invasive Technique 210 7.7.11 Management of Individual Fractures 211 7.7.11.1 Two-Part Anatomical Neck 211 7.7.11.2 Two-Part Greater Tuberosity Fractures 211 7.7.11.3 Two-Part Lesser Tuberosity Fractures 211 7.7.11.4 Two-Part Surgical Neck 212 7.7.11.5 Three-Part Fractures 213 7.7.11.6 Valgus-Impacted Four-Part Fracture 216 7.7.11.7 Other Four-Part Fractures 216 7.7.11.8 Articular Fractures of the Humeral Head 216 7.7.11.9 Appendix: Cx of Hemi-Arthroplasty for Fractured Proximal Humerus 216 7.7.11.10 Possible Improvement in Future: CAOS 217 7.7.11.11 Possible Improvement in Future: Fracture-Specific Implant 217 7.8 Humeral Shaft Fractures 217 7.8.1 Introduction 217 7.8.2 Epidemiology 218 7.8.3 Work-up 218 7.8.4 Conservative Rn 219 7.8.5 Operative Indications 219 7.8.6 Late Operation Needed in Some Scenarios 219 7.8.7 Radial Nerve Injury and Humeral Shaft Fractures 219 7.8.8 Main Operative Rn Options 220 7.8.8.1 Common Options 220 7.8.9 Comparison Between Plating and Nailing 222 a Contents 187 7.8.10 Technical Pearl (with IM Nailing) 222 7.8.11 What About Flexible Nails? 222 7.8.12 Complications 222 7.8.13 Bring Home Message 223 7.9 Fractured Distal Humerus 223 7.9.1 Introduction 223 7.9.2 Alternative Classification 223 7.9.2.1 Extracapsular Fractures 223 7.9.2.2 Extra-Articular Intracapsular Fractures 224 7.9.2.3 Intra-Articular Bi-Column Fractures 224 7.9.3 New Classification of Intra-Articular Shearing Fractures 224 7.9.4 Radiological Assessment 225 7.9.5 Treatment Options 225 7.9.6 Operative Pearls 226 7.9.7 Traditional and Newer Implants 226 7.9.8 An Added Option in Osteoporotic Bone 226 7.9.9 Complications 228 7.9.10 Management of Non-Union 228 7.9.11 Non-Union and Elbow Stiffness 228 7.10 Fracture Dislocations Around the Elbow 228 7.10.1 Introduction 228 7.10.2 General Problems in the Elbow Area 229 7.10.3 Types of Elbow Dislocation 229 7.10.4 Mechanism of Elbow Dislocation 230 7.10.5 Method of CR 230 7.10.6 Concepts of Elbow Instability 230 7.10.7 Common Patterns of Elbow Instability 230 7.10.8 Spectrum of Posterolateral Elbow Instability 230 7.11 Elbow Fractures 231 7.11.1 Ring Concept of the Elbow in Analysing More Complex Elbow Fractures 231 7.11.2 Implications of the Ring Concept 231 7.11.3 Clinical Scenario: Lateral Column Injury 231 7.11.4 Clinical Scenario: LCL + Coronoid + Radial Head 231 7.11.5 Fractured Radial Head + Fractured Coronoid + Olecranon (and Ligaments) 231 7.11.6 Added Options in Complex Unstable Elbow Fracture Dislocation 232 7.12 Fractured Radial Head 232 7.12.1 Mason Classification 232 7.12.2 Hotchkiss Classification 232 7.12.3 Pathomechanics 233 7.12.4 Investigation 233 7.12.5 Management 233 7.13 Fractured Capitellum 233 7.14 Fractured Coronoid 233 188 7 Trauma to the Upper Extremities 7.15 Olecranon Fracture 234 7.15.1 Introduction 234 7.15.2 Associated Injuries 234 7.15.3 Classification 234 7.15.4 Schatzker-Schmeling Classification 235 7.15.5 Mayo Clinic Classification 235 7.15.6 Olecranon Fracture Management 235 7.15.7 Choice of Fixation 235 7.15.8 Added Option in Comminuted Fractures in the Elderly 235 7.15.9 Elbow Fracture Dislocation Involving the Olecranon 235 7.15.10 Prognosis 237 7.16 Fractured Forearm 237 7.16.1 Introduction 237 7.16.2 Work-up 237 7.16.3 Principles of Rn 238 7.16.4 Summary of Rn Options 238 7.16.5 Operative Indications 239 7.16.6 Surgical Approach for Plating 239 7.16.7 Implants of Choice 239 7.16.8 Complications 239 7.17 Monteggia Fracture Dislocations 239 7.17.1 Classification 239 7.17.2 Management 240 7.17.3 Complications of Monteggia 240 7.18 Concept of Longitudinal Instability of the Forearm 240 7.18.1 The Basics 240 7.18.2 Injury Patterns 241 7.18.3 Management 241 7.19 Fractured Distal Radius 241 7.19.1 Introduction 241 7.19.2 Preferred Classification (Jupiter and Fernandez) 241 7.19.3 Classification of Intra-Articular Fractures 242 7.19.3.1 Melone Classification 242 7.19.3.2 Columnar Classification (Regazzoni) 243 7.19.3.3 Importance of Columnar Classification 243 7.19.4 General Work-up 243 7.19.4.1 Limits of Acceptable Alignment 243 7.19.4.2 Assessment of the Degree of Comminution 244 7.19.4.3 How to Predict Instability? 244 7.19.4.4 Goal of Reduction (CR or OR) 244 7.19.4.5 Clues to Possible DRUJ Instability 244 7.19.5 CR Technique 245 7.19.6 Management: Metaphyseal Bending Fractures 245 7.19.6.1 Studies on Management of Unstable Bending Fractures of the Distal Radius in the Elderly 245 a Contents 189 7.19.6.2 Other Findings of McQueen's Study 246 7.19.6.3 The Case for Non-Bridging EF 246 7.19.6.4 Current Recommendation for the Use of Different Rn Options 246 7.19.7 Management: Articular Shearing Fractures 247 7.19.8 Management: Avulsion Fractures 247 7.19.9 Managing Intra-Articular Fractures 248 7.19.9.1 Investigation of Complex Intra-Articular Fractures 248 7.19.9.2 Indication of Mini-Open Techniques 248 7.19.9.3 Methods of Reduction of Articular Fractures 248 7.19.9.4 Role of Arthroscopy 248 7.19.9.5 Summary of Rn Options for Intra-Articular Fractures of the Distal Radius 249 7.19.10 Overview of Different Techniques 249 for Unstable Distal Radius Fractures 249 7.19.10.1 Comparison of the Use of EF Vs. Different Plating Methods in Unstable Distal Radius Fractures 249 7.19.10.2 External Fixation 249 7.19.10.3 Volar Plating 251 7.19.10.4 New Volar Plates 251 7.19.10.5 Dorsal Plating 251 7.19.10.6 Newer Dorsal Plates 252 7.19.10.7 Double Plating 253 7.19.10.8 Bi-Columnar Plating 254 7.19.11 Operative Decision-Making 255 7.19.12 Complications After Distal Radius Fractures 255 7.19.12.1 Malunion 255 7.19.12.2 Osteoarthritis 255 7.19.12.3 Resultant DRUJ Problems 256 7.19.12.4 Soft Tissue Problems 257 7.19.12.5 Other Complications 257 7.20 Carpal Instability and Perilunate Dislocations 258 7.20.1 Definition of Carpal Instability 258 7.20.1.1 Incidence 258 7.20.1.2 General Comment 258 7.20.1.3 Kinematics of the Proximal Carpal Row 258 7.20.1.4 Carpal Instability ± Pathomechanics 258 7.20.1.5 Aetiology 259 7.20.1.6 Traumatic Aetiology 259 7.20.1.7 Symptomatology 259 7.20.1.8 Carpal Instability ± Classifications (Dobyns) 259 7.20.1.9 Carpal Instability ± Classifications (Taleisnik) 259 7.20.1.10 Other Carpal Instability Classifications 259 7.20.1.11 Carpal Instability ± Common Clinical Scenarios 259 7.20.2 Lunate and Perilunate Dislocations 260 7.20.2.1 Introduction 260 190 7 Trauma to the Upper Extremities 7.20.2.2 Anatomy of Palmar Side Ligaments 260 7.20.2.3 Dorsal Side Ligaments 261 7.20.2.4 Mayfield Stages (Based on Cadavers) 261 7.20.2.5 Mayfield Classes 261 7.20.2.6 Investigation 261 7.20.2.7 Radiological Interpretations 261 7.20.2.8 Treatment Principles 262 7.20.2.9 CR and OR 262 7.20.2.10 CR in Lunate Dislocations 262 7.20.2.11 Technical Tip 262 7.20.2.12 Delayed Cases 263 7.20.2.13 Principle of Rn of Chronic Injury 263 7.20.3 SL Instability 263 7.20.3.1 Biomechanics of SL Instability 263 7.20.3.2 Sequential Pattern of OA Changes 264 7.20.3.3 SL Ligament Anatomy 264 7.20.3.4 Clinical Exam 264 7.20.3.5 Radiological Assessment 264 7.20.3.6 Treatment Options 265 7.20.4 LT (Lunotriquetral) Instability 265 7.20.4.1 Clinical Features 265 7.20.4.2 Goal of Treatment 265 7.20.4.3 Anatomy of LT Ligament 265 7.20.4.4 Physical Assessment 266 7.20.4.5 Radiological Assessment 266 7.20.4.6 Treatment Options
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