4: Orthopaedic Emergencies

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Section 4 Orthopaedic Emergencies

Edited by Anthony F.T. Brown, Anne-Maree Kelly

4.1 Injuries of the shoulder 154
4.2 Fractures of the humerus 157
4.3 Dislocations of the elbow 161
4.4 Fractures of the forearm and carpal bones 163
4.5 Hand injuries 168
4.6 Pelvic injuries 174
4.7 Hip injuries 178
4.8 Femur injuries 182
4.9 Knee injuries 184
4.10 Tibia and fibula injuries 190
4.11 Ankle joint injuries 193
4.12 Foot injuries 197

4.1 Injuries of the shoulder

Anne-Maree Kelly

Essentials

1 Most clavicular fractures heal despite displacement, therefore reduction is not necessary.
2 Injuries to the shoulder region may also involve injury to local neurovascular structures.
3 Acromioclavicular joint injuries and fractures of the scapula are usually treated conservatively.
4 Posterior sternoclavicular dislocations require reduction.
5 In dislocation of the shoulder, careful examination of the axillary (circumflex) nerve, brachial plexus and axillary artery is mandatory both before and after reduction.
6 In anterior dislocation of the shoulder, surgical repair of the capsule is recommended for recurrent dislocators and first-time dislocators who are young and engaged in high-risk sports.

Fractures of the clavicle

Fractures of the clavicle account for 2.6–5% of all fractures and usually result from a direct blow on the point of the shoulder, but may also be due to a fall on the outstretched hand. The most common site of fracture is the middle third of the clavicle, which accounts for 69–82% of clavicular fractures. There are varying degrees of displacement of the fracture ends, with overlapping fragments and shortening being common. Owing to the strategic location of the clavicle, injury to the pleura, axillary vessels and/or brachial plexus is possible, but fortunately these complications are rare.

The clinical signs of clavicular fracture are a patient supporting the weight of their arm at the elbow and local pain and tenderness, often accompanied by deformity.

In non-displaced or minimally displaced fractures, treatment consists of an elbow-supporting sling (e.g. broad arm sling) for 2–3 weeks. For comfort, this may be worn under clothes for the first few days. The sling may be discarded when local tenderness has subsided. Note that clinical union precedes radiological union by weeks. Early shoulder movement should be encouraged within the limits of pain. Non-union is rare.

Midshaft fractures with complete displacement, comminution or fractures in the elderly or women with osteoporosis, have a higher rate of non-union and poorer functional outcome. Recent evidence suggests that this group may benefit from surgical stabilization with either plate-and-screw fixation or intramedullary devices. Fractures of the outer third of the clavicle may involve the coracoclavicular ligaments. If so, surgical management should be considered. This may be performed by open or arthroscopic techniques.

Late complications include shoulder stiffness and a local lump at the site of fracture healing, which is rarely of cosmetic significance.

Acromioclavicular joint injuries

Acromioclavicular (AC) joint injuries usually result from a fall where the patient rolls onto his/her shoulder. The degree of the injury relates to the number of ligaments damaged. The clavicle is attached to the scapula by acromioclavicular, trapezoid and conoid ligaments. In sprains and subluxations, only the AC ligament is damaged; in dislocations, the conoid and trapezoid ligaments are also ruptured and displacement may be severe.

On clinical examination of the standing patient, the outer end of the affected clavicle may be prominent and there will be local tenderness over the AC joint. The degree of damage can be ascertained by taking standing X-rays of both shoulders with the patient holding weights in both hands (stress X-rays) and by ultrasound. Stress X-rays may be normal in mild strains, but dynamic ultrasonographic techniques may better define the injury.

Treatment is with a broad arm sling. For minor sprains 1–2 weeks is usually sufficient; dislocations may require 4–6 weeks of immobilization. If there is gross instability, surgery should be considered.

Sternoclavicular subluxation and dislocation

Sternoclavicular injuries are uncommon and usually due to a fall on the outstretched hand or a blow to the front of the shoulder. Subluxation is more common than dislocation, with the affected medial end of the clavicle displaced forwards and downwards. Dislocations may be anterior or, rarely, posterior. In the latter case, the great vessels or trachea may be damaged.

Clinical features include local tenderness and asymmetry of the medial ends of the clavicles. The diagnosis is essentially clinical. X-rays can be difficult to interpret. They are not necessary for subluxations, but may be helpful to confirm major dislocations. CT scanning may assist in identification.

Subluxations should be treated in a broad arm sling for 2–3 weeks. Anterior sternoclavicular joint instability should also be treated conservatively; however, there is a significant risk of ongoing instability that is usually well tolerated and of little, if any, functional impact. For patients with posterior dislocation expeditious diagnosis and treatment are important. Closed reduction, performed under general anaesthesia, is usually stable and the joint can then be managed in a brace or sling for 4–6 weeks. Operative stabilization is required if closed reduction is unsuccessful or there is persistent instability.

Fractures of the scapula

Fractures of the scapula are uncommon, accounting for less than 1% of all fractures. They typically occur after high-energy trauma, and up to 90% of patients have other associated injuries.

Fractures of the blade of the scapula are usually due to direct violence. Clinical features are local tenderness, sometimes with marked swelling. Healing is usually rapid, even in the presence of comminution and displacement, with an excellent functional outcome. Treatment is non-operative, with a broad arm sling and early mobilization.

Fractures of the scapula neck are often comminuted and may involve the glenoid. Swelling and bruising of the shoulder may be marked. Clinical examination and X-rays should ensure that the humeral head is enlocated. Computed tomography (CT) scans may be useful in defining the anatomy and the degree of involvement of the glenoid, including any steps in the articular surface. Surgery is often indicated for fractures involving the scapular neck or glenoid.

The ‘floating shoulder’ is an uncommon injury pattern. Although it is usually defined as an ipsilateral fracture of the clavicle and scapular neck, recent studies suggest that ligamentous disruption associated with a scapular neck fracture can give the functional equivalent of this injury pattern, with or without an associated clavicle fracture. Because the degree of ligament disruption is difficult to assess, indications for non-surgical and surgical management are not well defined. Minimally displaced fractures typically do well with conservative management. The degree of fracture displacement and ligament disruption that results in poor outcome with conservative management is not well defined and the indications for surgery are controversial, as is choice of surgical technique. Options include fixation of the clavicular fracture, which often indirectly reduces the scapular fracture, or fixation of both fractures.

Rotator cuff injuries

Rotator cuff injuries become more common with advancing age as degeneration weakens the cuff. Indeed, the presence of asymptomatic partial or complete tears identified on ultrasound or MRI may be as high as 40% in patients aged over 50.

Symptomatic injuries may follow minor trauma or the sudden application of traction to the arm. Many are acute on chronic in nature, rather than truly acute, and this can be defined with ultrasound or MRI if required. The clinical features of a strain include a painful arc of abduction centred at 90° of abduction, and tenderness under the acromion. If the tear is complete, no abduction at the glenohumeral joint will occur, although some abduction to 45–60% is possible by scapular rotation. In both cases there is a full passive range of abduction.

Treatment of rotator cuff strains is conservative, usually including analgesia and physiotherapy. Local injection of hydrocortisone may be useful if symptoms persist. Treatment of rotator cuff tears is controversial, with no clear evidence guiding the choice of operative versus non-operative therapy or the components or duration of non-operative treatments. Most experts would still recommend a trial of non-operative therapy before considering surgery. An exception to this may be the patient with a previously asymptomatic shoulder who sustains trauma with resultant weakness (after the pain from the injury subsides) in whom imaging studies indicate an acute full-thickness tear.

Dislocation of the shoulder

Dislocation of the shoulder results in the humeral head lying anterior, posterior or inferior to the glenoid. Of these, anterior dislocation is the most common.

Anterior dislocation

Anterior dislocation of the shoulder is most often due to a fall resulting in external rotation of the shoulder, for example the body rotating internally over a fixed arm. It is most common in young adults, often being related to sports. There is inevitable damage to the joint capsule (stretching or tearing), and there may be associated damage to subscapularis and the greater trochanter of the humerus. Complications may include damage to the axillary (circumflex) nerve (resulting in inability to contract deltoid and numbness over the insertion of deltoid) and, rarely, the axillary vessels and the brachial plexus.

Clinical features include severe pain, reluctance to move the shoulder, and the affected arm being supported at the elbow, often in slight abduction. The contour of the shoulder is ‘flattened off’ and there is a palpable gap just under the acromion where the humeral head usually lies. The displaced humeral head may be palpable anteriorly in the hollow behind the pectoral muscles. Dislocation is confirmed by X-ray. The dislocation may be evident on the AP film but cannot be ruled out on a single view. Additional views (e.g. an axial lateral, translateral, tangential lateral) are required. These may reveal an associated fracture of the greater trochanter, but this does not influence initial management.

The principles of management are the provision of adequate analgesia as soon as possible (ideally, this should take the form of titrated intravenous opioid), reduction of the dislocation, and immobilization followed by physiotherapy. There are more than 20 described methods for the reduction of anterior dislocations, with reported success rates ranging from 60% to 100%. These include the Spaso technique, the modified Kocher’s manoeuvre, the Milch technique and scapular rotation techniques. There is no high-quality evidence to assist in selecting the most effective. That said, the Hippocratic method is not recommended as the traction involved may damage neurovascular structures. Gravitational traction, having the patient lie face down with a weight strapped to the limb, is occasionally successful and may be worthwhile if there will be a delay until reduction by another method. All reduction methods require adequate analgesia. Intra-articular local anaesthetic may also be useful. Sedation, in an appropriately controlled environment, may be of assistance in augmenting analgesia and providing a degree of muscle relaxation and amnesia. Failure of reduction under analgesia/sedation is rare and mandates reduction under general anaesthesia.

Spaso technique

The patient is placed in the supine position. The affected arm is held by the forearm or wrist and gently lifted vertically, applying slight traction. While maintaining vertical traction, the shoulder is externally rotated, resulting in reduction.

Modified Kocher’s manoeuvre

While applying traction to the arm by holding it at the elbow, the shoulder is slowly externally rotated, pausing if there is muscle spasm or resistance. External rotation to about 90° should be possible, and reduction often occurs during this process. The elbow is then adducted until it starts to cross the chest, and then internally rotated until the hand lies near the opposite shoulder.

Scapular rotation

This technique is traditionally performed with the patient prone, but can be performed on a seated patient. For both variations, the scapula is manipulated by adducting (medially displacing) the inferior tip using thumb pressure while stabilizing the superior aspect with the other hand.

Post-reduction X-rays confirm reduction, and neurovascular status must be rechecked. The arm should be immobilized in a sling under clothes for several days and the patient advised not to abduct or externally rotate the arm. This should be followed by an external broad arm sling and physiotherapy. The duration of immobilization and the timing of physiotherapy are controversial.

If there is an associated fracture of the greater trochanter, it usually reduces when the shoulder is reduced. If it remains displaced, open reduction and internal fixation may be required.

Primary surgery, usually by arthroscopic techniques, is recommended for patients having suffered recurrent dislocations and should be considered for first-time dislocators, especially those who are young, as surgery has been shown to significantly reduce the risk of recurrent dislocation.

Recurrence is rare in the elderly, but approaches 50% in younger patients.

Posterior dislocation

Posterior dislocation is frequently mentioned in medicolegal reports as it is easy to miss, especially in the unconscious. It may result from a fall on the outstretched or internally rotated hand, or from a blow from the front. It is also associated with seizures and electrocution injuries, where it is not uncommonly bilateral. The dislocation is usually not apparent on an AP film, so additional views are required. Reduction is performed by traction on the limb in the position of 90° abduction, followed by external rotation. Aftercare is the same as for anterior dislocation.

Posterior dislocation is prone to recurrence. Good functional outcomes are associated with early detection and treatment, a small osseous defect, and stability following closed reduction. Poor prognostic factors include late diagnosis, a large anterior defect in the humeral head, deformity or arthrosis of the humeral head, an associated fracture of the proximal part of the humerus and the need for an arthroplasty. The indications for surgery are controversial.

Inferior dislocation

This type of dislocation is rare and usually obvious, as the arm is held in abduction. Neurovascular compromise is a significant risk requiring careful examination and prompt reduction. Reduction is by traction in abduction followed by swinging the arm into adduction. Aftercare is the same as for anterior dislocation.

Controversies

• The role of surgery for midshaft clavicular fractures.
• Timing of mobilization after dislocation of the shoulder.
• The role of surgery in rotator cuff tears.
• The best technique for reduction of anterior dislocation of the shoulder.
• Surgery for first dislocations of the shoulder.

Further reading

Bicos J, Nicholson GP. Treatment and results of sternoclavicular injuries. Clinical Journal of Sport Medicine. 2003;22:359-370.

Canadian Orthopaedic Trauma Society. Non-operative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multi-center randomized clinical trail. Journal of Bone and Joint Surgery. 2007;89A:1-10.

Kuhn JE. Treating the initial anterior shoulder dislocation – an evidence-based medicine approach. Sports Medicine and Arthroscopy Review. 2006;14:192-198.

Miljesic S, Kelly AM. Reduction of anterior dislocation of the shoulder: the Spaso technique. Emergency Medicine. 1998;10:173-175.

Oh LS, Wolf BR, Hall MP, et al. Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research. 2007;455:52-63.

Zlowodzki M, Bhandari M, Zelle BA, et al. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. Journal of Orthopaedic Trauma. 2006;20:230-233.

4.2 Fractures of the humerus

Timothy Rainer, Raymond Chi Hung Cheng

Essentials

1 Fractures of the proximal humerus occur primarily in the elderly, whereas distal humerus fractures occur more often in children.
2 Falls producing fractures in elderly patients are often precipitated by an underlying medical problem that should be sought and managed.
3 Most proximal humeral fractures do not require surgical intervention.
4 The aim of treatment is to minimize pain, to maximize the return of normal function as soon as possible, and to achieve acceptable cosmesis.
5 Humeral shaft fractures, displaced distal humeral fractures and fractures associated with neurovascular compromise require early orthopaedic review.
6 Low-force fractures, especially in the elderly, suggest the presence of osteoporosis. ‘At-risk’ patients not already identified as having osteoporosis should be referred for bone density scans and vitamin D testing and treatment.

Introduction

The function of the upper limb depends on an intact shoulder girdle that is in turn affected by the integrity of muscles, tendons and ligaments, bones, joints, blood vessels and nerves. Fractures of the humerus severely limit efficient function of the upper limb, and may be divided into proximal (neck), middle (shaft) and distal (supracondylar) segments.

Fractures of the proximal humerus

Patterns of injury

Fractures of the proximal humerus represent 5% of all fractures presenting to emergency departments (ED) and 25% of all humeral fractures. The fracture typically occurs as a result of an indirect mechanism in elderly, osteoporotic patients who fall on their outstretched hand with an extended elbow. These injuries are important to understand, as the majority do not require surgical intervention and may initially be treated in the ED. A subset with non-viable humeral head requires early surgical intervention, and it is therefore important to identify this group. Fractures of the humerus may also occur in patients with multiple injuries or in the elderly with associated fractures of the neck of femur.1

Clinical assessment

History and examination

Patients typically present soon after injury holding their arm close to the chest wall. They complain of pain, and exhibit swelling and tenderness of the shoulder and upper arm. Although crepitus and bruising may occur, the former should not be elicited because it causes excessive and unnecessary pain. Bruising is usually delayed, occurring several days after injury. It appears around the lower arm rather than at the fracture site as a result of gravity and blood tracking distally.

A neurovascular examination is essential as the axillary nerve, brachial plexus and/or axillary artery may be damaged. The axillary nerve is the most commonly injured, and presents with altered sensation over the badge area (insertion of the deltoid) and reduced deltoid muscle contraction (which may be hard to assess because of pain). The axillary artery is the commonest vessel to be injured and may present with any combination of limb pain, pallor, paraesthesia, pulselessness, poor limb perfusion and paralysis.

As these injuries frequently occur in elderly patients, careful attention must be paid to the reason for the fall, as an underlying acute medical condition may have precipitated the event and require management in its own right.

Investigations

Three radiographic views – anteroposterior, lateral and axillary – will allow most proximal humeral fractures to be correctly diagnosed.

Fracture classification

Although the majority of these fractures are easily managed in the ED, the challenge is to differentiate these from the minority that require orthopaedic intervention.

Neer classification system

In this system, fractures are classified first according to four anatomical sites (anatomical and surgical necks, greater and lesser tuberosities); second, according to the number of fragments (one to four parts); and third, according to the degree of fracture displacement, defined as 1 cm separation or >45° angulation (Figs 4.2.1 and 4.2.2).

image

Fig. 4.2.1 Neer classification with two-part fractures of (a) the anatomical neck, (b) the surgical neck, (c) the greater tuberosity and (d) the lesser tuberosity.

image

Fig. 4.2.2 Neer classification with three-part fractures of (a) the greater tuberosity and anatomical neck, (b) the lesser tuberosity and anatomical neck, and (c) four-part fracture involving the anatomical neck, greater tuberosity and lesser tuberosity.

One-part fracture

One-part fractures account for 80% of proximal humeral fractures. Any number of fracture lines may exist, but none are significantly displaced.

Two-part fracture

Two-part fractures account for 10% of proximal humeral fractures, and usually one fragment is significantly displaced. Two-part fractures of the humerus may involve the anatomical neck (Fig. 4.2.1a), the surgical neck (Fig. 4.2.1b), the greater tuberosity (Fig. 4.2.1c) or the lesser tuberosity (Fig. 4.2.1d).

Three- and four-part fracture

Three- and four-part fractures account for the remaining 10% of proximal humeral fractures, with two or three significantly displaced fragments (Fig 4.2.2a–c).

Management

One-part fractures (both displaced and undisplaced) and undisplaced two-part fractures can be treated with a collar and cuff sling, adequate analgesia and follow-up. Early mobilization is important, and the prognosis is good.

Definitive management of displaced two-part fractures may include open (intraoperative) or closed reduction depending upon neurovascular injury, rotator cuff integrity, associated dislocations, likelihood of union and function. Early orthopaedic assessment is recommended.

For undisplaced three- and four-part fractures, the consensus is for open reduction and internal fixation. However, recent reviews suggest that there is little evidence that surgery is superior to the non-operative approach.2

For displaced proximal humeral fractures, surgical management remains varied and controversial.3 Small randomized controlled trials suggest that external fixation may confer some benefit over closed manipulation,4 and that conservative treatment is better than tension band osteosynthesis.5 A recent study shows that the decision should be made according to the viability of the humeral head. Locking plate technology may also provide better outcomes in patients with unstable displaced humeral fractures having a viable humeral head.6 Other small-scale studies suggest that some bandaging styles may be better than others,7 that early physiotherapy may improve functional outcome, but that pulsed high-frequency electromagnetic energy gives no additional benefit.8

Special cases

Fracture of the anatomical neck and articular surface

Fractures at these sites are uncommon, but are important to recognize as they have a high incidence of compromised blood supply to the articular segment, may result in avascular necrosis and may require a humeral hemiarthroplasty.

Fracture dislocations

Fractures of the greater tuberosity accompany 15% anterior glenohumeral dislocations and may be associated with rotator cuff tears. Although the fracture may be grossly displaced, reduction of the dislocated shoulder usually also reduces the fracture. In patients who require the full range of movement of their shoulders, surgical repair of the cuff may be required.

Fractures of the lesser tuberosity are associated with posterior glenohumeral dislocations.

Disposition

Most patients with undisplaced one- and two-part fractures may be discharged from the ED with a collar and cuff sling, analgesia, early mobilization and appropriate follow-up. High-risk cases, including displaced three- and four-part fractures, all open fractures, and the special proximal humeral fractures described above, require orthopaedic consultation and admission, as do those with medical problems requiring investigation or treatment.

Low-energy fractures, especially in the elderly, suggest the presence of osteoporosis. ‘At-risk’ patients not already identified as having osteoporosis should be referred for bone density scans and vitamin D testing and treatment.

Fractures of the shaft of humerus

Patterns of injury

Fractures of the humeral shaft commonly occur in the third decade (active young men) and in the seventh decade of life (osteoporotic elderly women). The commonest site is the middle third, which accounts for 60% of humeral fractures. The close proximity of the fracture to the radial nerve and brachial artery commonly leads to neurovascular deficits.

Direct blows tend to produce transverse fractures, whereas falls on the outstretched hand produce torsion forces and hence spiral fractures. Combinations of the two mechanisms may produce a butterfly segment. Pathological fractures are also common, most resulting from metastatic breast cancer.

The angle and degree of displacement of the fracture depends on the site of injury and its relationship to the action and attachment of muscles on either side of the injury (Fig. 4.2.3).

image

Fig. 4.2.3 Relationships between humeral fracture site and the actions of inserting muscles determine bony angulation and displacement.

Clinical assessment

History and examination

Patients typically present complaining of pain and supporting the forearm of the injured limb, flexed at the elbow, held close to the chest wall. Examination of the limb reveals tenderness, swelling, shortening and possibly deformity. The skin should be assessed for tension or disruption, and particular attention should be paid to the shoulder and elbow regions for associated fractures or dislocations. Initial and post-reduction assessments of the brachial artery and vein, and ulnar, median and radial nerves are essential.

The commonest complication is radial nerve injury resulting either from injury or reduction of the fracture, and evidenced by wrist drop and altered sensation in the first dorsal web space. A recent systemic review reported that radial nerve injury occurs in 11% of mid-shaft humerus fractures.9

Investigations

Two radiographic views – anteroposterior and lateral – will allow the correct diagnosis in most cases.

Fracture management and disposition

Uncomplicated, closed fractures account for the majority of injuries and may be treated by immobilization, analgesia, a functional brace such as a hanging or U-shaped cast (Fig. 4.2.3), and a broad arm or collar and cuff sling. The acceptable deformity is 20° anterior/posterior angulation, and 30° valus/valgus deformity.10 The union rate is usually higher than 90%. Early specialist follow-up is recommended.

Some departments may prefer a humeral brace rather than U-shaped plaster for immobilization, as the former may permit greater functional use without affecting healing or fracture alignment.11 For oblique/spiral fractures some orthopaedic surgeons prefer an operative approach for a better functional outcome.12

Open fractures and complications affecting the vessels require surgical repair. Although the majority of radial nerve injuries are neuropraxia and recover without surgical intervention, each case should be considered individually by an orthopaedic surgeon with a view to possible operative exploration.

Fractures of the distal humerus

Classification and patterns of injury

Unlike in children, fractures of the distal humerus in adults are very uncommon and patterns of injury tend to reflect the anatomical two-column construction (condyles) of the humerus. Several classification methods have been used, such as the Riseborough and Radin, Mehne and Matta classifications, but the simplest and most commonly used are the AO/ASIF classifications.13 These classify injuries into three categories: type A are extra-articular fractures, type B are partial articular, and type C are complete articular fractures. Practically, distal humeral fractures may be classified into supracondylar, intercondylar and other types. Supracondylar fractures lie transversely, whereas intercondylar T or Y fractures include an additional vertical extension between the condyles.

Mechanisms of injury usually involve a direct blow to the flexed or extended elbow. In the former, the olecranon is driven upwards, thereby either splitting the condyles apart producing a T or a Y pattern, or shearing off one condyle.

Clinical assessment

History and examination

Patients typically present with a swollen, tender, deformed elbow. As very little subcutaneous or other tissue separates the bone from skin, any disruption of the skin should be carefully examined for the possibility of a compound fracture. Distal neurological and vascular injury must be assessed carefully, as the possibility of nerve injury has been reported to be as high as 12–20%.14

Investigations

Two radiographic views – anteroposterior and lateral – should be obtained. Some authors suggest that an internal oblique view may improve the diagnostic accuracy.15 Pain and inability to extend the elbow often result in poor-quality radiographs. Although high-quality radiographs are essential for operative planning, repeat films should not be attempted in the ED as they rarely provide the desired result. When there is any suspicion of severe injury, either from the history or from gross soft tissue swelling, early CT scanning should be considered to give better detail, especially of intra-articular fractures.

Undisplaced fractures may not be visible on radiography but may be suggested by posterior or anterior fat pad signs, which result from fat displaced by an underlying haemarthrosis. Ultrasonography, CT and MRI may all improve diagnostic precision. They alter management and improve outcome in patients with occult fractures, mostly of intra-articular type.

Fracture management and disposition

Uncomplicated, undisplaced, closed fractures with minimal swelling should be immobilized for 3 weeks in 90° flexion with an above-elbow cast and a broad arm sling, followed by active mobilization.

Patients with severe swelling, compound fractures, displaced fractures or neurovascular compromise require orthopaedic intervention.

Controversies

Guidance for management is based primarily on experience rather than rigorous research evidence.

• For humeral shaft fractures, it is unclear whether hanging plasters are better than U-shaped plasters for pain relief, fracture healing and position.
• Small-scale studies suggest that bracing may yield better functional results than U-shaped plaster immobilization for fractures of the humeral shaft.
• Low-intensity pulsed ultrasound may be useful in the treatment of non-union. Whether it may enhance normal fracture healing is not known.16
• The role of magnetic resonance imaging in the diagnosis of bone bruising and humeral fracture has not been studied.

References

1 Mulhall KJ, Ahmed A, Khan Y, Masterson E. Simultaneous hip and upper limb fracture in the elderly: incidence, features and management considerations. Injury. 2002;33:29-31.

2 Handol HHG, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Systematic Review. (4):2003. CD000434. DOI: 0.1002/14651858.CD000434

3 Weber E, Matter P. Surgical treatment of proximal humerus fractures – an international multicenter study [In German]. Swiss Surgery. 1998;4:95-100.

4 Kristiansen B, Kofoed H. Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus. A controlled clinical trial. Journal of Bone and Joint Surgery. 1988;70:821-824.

5 Zyto K, Ahrengart L, Sperber A, Tornkvist H. Treatment of displaced proximal humeral fractures in elderly patients. Journal of Bone and Joint Surgery. 1999;79:412-417.

6 Vallier HA. Treatment of proximal humerus fractures. Journal of the Orthopaedic Trauma. 2008;21(7):469-476.

7 Rommens PM, Heyvaert G. Conservative treatment of subcapital humerus fractures. comparative study of the classical Desault bandage and the new Gilchrist bandage. Unfallchirurgie. 1993;19:114-118.

8 Livesley PJ, Mugglestone A, Whitton J. Electrotherapy and the management of minimally displaced fracture of the neck of the humerus. Injury. 1992;23:323-327.

9 Shao YC, Harwood P, Grotz MRW, et al. Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. Journal of Bone and Joint Surgery. 2005;87-B:1647-1652.

10 Klenerman L. Fractures of the shaft of the humerus. Journal of Bone and Joint Surgery. 1966;48B:105-111.

11 Camden P, Nade S. Fracture bracing the humerus. Injury. 1992;23:245-248.

12 Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional brace treatment of diaphyseal humerus fractures. Journal of Trauma. 2007;62:1157-1158.

13 Diana JN, Ramsey ML. Decision making in complex fractures of the distal humerus: current concepts and potential pitfalls. Orthopaedic Journal. 1998;11:12-18.

14 Ramachandran M, Birch R, Eastwood DM. Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children, the experience of a specialist referral centre. Journal of Bone and Joint Surgery. 2006;88B:90-94.

15 Song KS, Kang CH, Min BW, et al. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. Journal of Bone and Joint Surgery. 2007;89A:58-63.

16 Nolte PA, van der Krans A, Patka P, et al. Low-intensity pulsed ultrasound in the treatment of nonunions. Journal of Trauma. 2001;51:693-702.

Further reading

McRae R, editor. Practical fracture treatment. Churchill Livingstone, Edinburgh, 1994, 99-127.

Uehara DT, Rudzinski JP. Injuries to the shoulder complex and humerus. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine. A comprehensive study guide. New York: McGraw-Hill; 2000:1783-1791.

Willet K. Upper limb injuries. In: Skinner D, Swain A, Peyton R, Robertson C, editors. Cambridge textbook of accident and emergency medicine. Cambridge: Cambridge University Press; 1997:601-617.

4.3 Dislocations of the elbow

Raymond Chi Hung Cheng, Timothy Rainer

Essentials

1 Elbow dislocations are the third most common large joint dislocation.
2 Surgical intervention is rarely required for simple elbow dislocations.
3 Surgical intervention may be required when fractures of the radius, ulnar and humerus are associated with elbow dislocation, or when neurovascular injury occurs.
4 The commonest neurovascular complication involves the ulnar nerve.
5 After reducing elbow dislocations, it is important to reassess joint stability and potential neurovascular complications.

Introduction

Elbow dislocation, along with glenohumeral and patellofemoral joint dislocations, is one of the three most common large joint dislocations.1 The elbow joint is a hinge-like articulation involving the distal humerus and proximal radius and ulna. Owing to its strong muscular and ligamentous supports, the joint is normally quite stable and rarely requires operative intervention, even for acute instability after dislocation.

Elbow dislocations can be classified as either anterior or posterior. Posterior dislocation is the most common type and can be further divided into posteromedial or posterolateral. It usually results from a fall on the outstretched hand with some degree of flexion or hyperextension at the elbow. The radius and ulna commonly dislocate together. Similarly, anterior dislocation can also be divided into anteromedial or anterolateral. This type is less common and is usually due to a direct blow to the dorsal side of the elbow.

Uncommonly, the radius or ulna alone may dislocate at the elbow. In such cases there is always a fracture of the other bone. One common example is in Monteggia fractures, where anterior or posterior radiohumeral dislocation occurs alongside a fracture of the ulna shaft (Fig. 4.3.1). A rarer example is a posterior ulna–humeral dislocation with fracture of the radial shaft. So, although elbow dislocations may appear to be isolated, it is essential to look for associated intra-articular or shaft fractures.

image

Fig. 4.3.1 Monteggia fracture dislocation. Fracture of the ulnar shaft may be associated with (a) anterior radiohumeral dislocation or (b) posterior radiohumeral dislocation.

Clinical assessment

History and examination

Patients typically present holding the lower arm at 45° to the upper arm and with swelling, tenderness and deformity of the elbow joint. The three-point anatomical triangle of olecranon, medial and lateral epicondyles should be assessed for abnormal alignment, as this strongly suggests dislocation.

The commonest neurovascular injury involves the ulnar nerve, reported in 10–15% of elbow dislocations,2 but the median and radial nerves, and the brachial artery may also be affected.

The differential diagnosis is a complex distal humerus fracture which, in a swollen elbow, may be hard to differentiate clinically from an elbow dislocation.

Investigations

Anteroposterior and lateral radiographic views should be obtained and scrutinized for associated fractures of the coronoid process, radial head, capitellum and olecranon.

Magnetic resonance imaging (MRI) characterizes bony injury more accurately than radiography in children with elbow injuries, but its potential role for diagnosis and guiding management in adults has not been well evaluated.3 Duplex Doppler ultrasound can be use to identify early brachial artery injury.4

Management

Simple dislocation can be reduced using a closed method. With adequate sedation, gentle traction and counter-traction, the joint relocates quite easily. Medial and posterolateral dislocations may also require sideways correction. Dislocation of the stable elbow joint produces severe soft tissue injury and resultant instability, therefore, after reduction, signs and symptoms of compartment syndrome should be sought along with an assessment of joint instability. The reduced elbow joint should move smoothly. Any crepitation or resistance, particularly during the mid-range, suggests incongruent reduction or soft tissue interposition, which is commonly associated with coronoid process or epicondylar fractures. Inability to fully flex or extend the elbow suggests a loose bone or cartilaginous fragment, or a capsular tear. Post-reduction films should be assessed, not only for correct joint relocation, but also for associated fractures. After successful reduction the elbow should be placed in a posterior plaster slab in 90° of flexion. Cylinder casts are contraindicated because of the likelihood of severe soft-tissue swelling.

There is little evidence that surgical intervention improves outcome in patients with medial or lateral elbow instability after dislocation. One small randomized controlled trial showed no evidence that surgical ligamentous repair produced better results than conservative management.5 Another small study, a case series of patients with humeral medial condyle fracture, suggested good results after surgical management using absorbable implants compared to removal of the bony fragment.6 Current practice is to treat all Monteggia fractures by early reduction and stabilization of the ulnar facture. The majority could be treated very well with close reduction and percutaneous intramedullary K-wire fixation of the ulnar fracture.7 All late cases require open reduction and internal fixation; 45% of these cases are associated with complications and poor long-term functional outcome.8

Ulnar nerve injuries can occur both before and after closed reduction. The reported rate varies between 10% and 15%. Most of them are neuropraxia and will recover with conservative measures. The most sensitive sign and symptoms are numbness over the little fingers.

Compound fracture dislocation should be reduced by the open method.

Patients with irreducible dislocations, neurovascular complications, associated fractures or open dislocations require orthopaedic intervention.

Disposition

Current practice is that most patients may be discharged from the emergency department (ED) with analgesia, plaster slab support and a broad arm sling with appropriate follow-up. A recent prospective, randomized French study9 suggested that early mobilization is superior to plaster immobilization in terms of functional recovery, without any increased instability or a recurrence of dislocation for patients with uncomplicated posterior dislocations, so the duration of immobilization is controversial. Patients with irreducible dislocations, neurovascular complications, associated fractures or open dislocations require admission.

Controversies

• There are no large-scale randomized studies comparing operative and non-operative management of elbow dislocation. It is therefore unclear whether one method may produce better outcomes than another.
• Early mobilization may be superior to plaster immobilization after reduction of uncomplicated posterior dislocations.
• The epidemiology of elbow injury including dislocation in patients presenting to emergency departments has not been well described, and requires further studies.
• Roles for ultrasound, computerized tomography and magnetic resonance imaging in evaluating elbow injury and influencing management require further study.

References

1 Uehara DT, Chin HW. Injuries to the elbow and forearm. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine. A comprehensive study guide. New York: McGraw-Hill; 2000:1763-1772.

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2 Robert S, David R. Current concepts review: the ulnar nerve in elbow trauma. Journal of Bone and Joint Surgery. 2007;89A:1108-1116.

3 Griffiths JF, Roebuck DJ, Cheng JCY, et al. Comparison of radiography and magnetic resonance imaging in the detection of injuries after paediatric elbow trauma. American Journal of Roentgenology. 2001;176:53-60.

4 Ergunes K, Yilik L, Ozsoyler I, et al. Traumatic brachial artery injuries. Texas Heart Institute Journal. 2006;33:31-34.

5 Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. Journal of Bone and Joint Surgery. 1987;69:605-608.

6 Partio EK, Hirvensalo E, Bostman O, Rokkanen P. A prospective controlled trial of the fracture of the humeral medial epicondyle – how to treat? Annales Chirurgiae Gynaecologiae. 1996;85:67-71.

7 Lam TP, Ng BKW, Ma RF, Cheng JCY. Monteggia fractures in children a review of 30 cases. Journal of the Japanese Pediatric Orthopedic Association. 2004;13:193-195.

8 Reynders P, De Groote W, Rondia J, et al. Monteggia lesions in adults. A multi-centre Bota study. Acta Orthopaedica Belgica. 1996;62:78-83.

9 Rafai M, Largab A, Cohen D, Trafeh M. Pure posterior luxation of the elbow in adults: immobilization or early mobilization. A randomized prospective study of 50 cases. Chirurgie de la Main. 1999;18:272-278.

Further reading

McRae R. Practical fracture treatment. Edinburgh: Churchill Livingstone, 1994.

Willet K. Upper limb injuries. In: Skinner D, Swain A, Peyton R, Robertson C, editors. Cambridge textbook of accident and emergency medicine. Cambridge: Cambridge University Press; 1997:601-617.

4.4 Fractures of the forearm and carpal bones

Peter Wright

Essentials

1 Forearm fractures are among the most common fractures seen in the ED.
2 When assessing the need for, or success of, reduction the external appearance of the limb is a key feature.
3 Median nerve function must be assessed before and after reduction of all distal radial fractures.
4 Splinting or functional bracing may be sufficient for stable fractures. Early movement and load bearing aids functional recovery.
5 General indications for orthopaedic referral include fractures which are compound, unstable, associated with intra-articular or neurovascular injury, and those that have failed reduction in the ED.
6 Displaced, isolated fractures of the ulna or radius may be associated with a dislocation of the radius or ulna respectively (Monteggia and Galeazzi fracture-dislocations). These should be carefully sought, as there is high risk of long-term disability.
7 Significant or persistent symptoms with the absence of a visible fracture on plain X-ray may be due to an undetected fracture or significant soft-tissue injury. A high index of suspicion and review in 1 or 2 weeks are recommended. Further investigation with CT, MRI or repeat X-ray may be indicated.

Radial head fractures

Clinical features

History

Patients have usually had a fall onto their outstretched hand or received a direct blow to the lateral side of the elbow, and present with pain and restricted movement at the elbow.

Examination

Usually there is swelling and tenderness over the radial head. Sometimes, with more subtle injuries, rotating the forearm while palpating the radial head may be necessary to elicit tenderness. Elbow extension and forearm rotation are limited. Severely comminuted fractures may have proximal displacement of the radius, which can be associated with disruption of the interosseous membrane and subluxation of the distal radioulnar joint (Essex–Lopresti fracture-dislocation).

Imaging

Anteroposterior (AP) and lateral X-rays of the elbow are required. A radiocapitellar view may be necessary if the fracture is subtle. The presence of an anterior fat pad sign alone on X-ray is associated with an underlying radial head or neck fracture in up to 50% of patients. In this case a fracture should be assumed to be present if there is an appropriate mechanism and local signs. A follow-up X-ray or CT scan is indicated only in the presence or persistent pain, stiffness or locking.

Classification

Radial head fractures may be described as hairline, marginal (displaced and undisplaced), segmental (displaced and undisplaced) or comminuted. They may also be classified into four types (Fig. 4.4.1). Fractures of the radial neck may be undisplaced or have various degrees of lateral tilting.

image

Fig. 4.4.1 Mason–Hotchkiss classification of radial head fractures.

Management

Type I and minor type II radial head fractures without mechanical block may be managed with a bandage and sling. If there is severe pain, aspiration of the fracture haematoma, intra-articular bupivacaine or a back slab may be useful. Mobilization can occur after 1–2 days depending on symptoms. Prognosis is good, but full extension may not be possible for many months.

All type III and those type II fractures with the presence of a mechanical block to movement require surgical intervention. Mechanical block can be difficult to assess acutely due to pain. Intra-articular injection of bupivacaine may assist early assessment, or assessment may be deferred until pain has settled. Surgical options include open reduction and internal fixation, and excision of the radial head with or without implantation of a prosthesis.

Radial neck fractures with up to 20° tilts can be managed conservatively. More severe tilt can be reduced using intra-articular bupivacaine. The forearm is pronated until the most prominent part of the radial head is felt. Then traction is applied to the forearm and pressure applied to the radial head. Open reduction is indicated if closed methods fail or displacement is gross.

Complications

Neurovascular complications and compartment syndrome are uncommon. Most complications relate to disturbance of the relationships of the proximal radioulnar and radiocapitellar articular surfaces causing limitation of movement. This is uncommon with minor fractures and often responds to radial head excision.

Shaft fractures

History

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