Blows to the shoulder and head cause violent lateral flexion of the cervical spine and depression of the shoulder. This tears the upper part of the brachial plexus. In the UK about 90% of these injuries occur in motorcyclists landing on the head and shoulder (Fig. 12.1).

If the upper cords of the plexus are damaged at birth, the supinator, deltoid, wrist extensors and elbow flexors will be weak, causing a ‘waiter’s tip’ position of the arm (Fig. 12.2). This condition is known as Erb’s palsy, a term which is often applied to the same pattern of neurological deficit in the adult.

Injuries in which the arm is violently abducted can tear the lower part of the brachial plexus. The commonest mechanism is anterior dislocation of the shoulder, but the lesion can also be caused by a fall from a height in which the hand is caught so that the full weight is taken by the arm.

The end result of damage to the lower cords of the brachial plexus at birth is a Klumpke’s palsy, which consists of a weakness of the finger flexors and intrinsics.

Complications are often seen after this injury (Fig. 12.9).

Malunion. Because the fragments are displaced by the weight of the arm, malunion is unavoidable. Internal fixation with a contoured plate may give better anatomical results but the surgery has risks (neurovascular, skin etc.)

Damage to vessels. Splinters of bone can rupture the great vessels or the lung at the time of injury. It is said that Sir Robert Peel (the founder of the Metropolitan Police Force) died from this complication after being thrown by his horse.

Non-union is unusual and seldom causes symptoms. Internal fixation and grafting are required on the rare occasions when it does cause symptoms.

Deformity. Large spicules of bone around the fracture site can produce an unsightly appearance, as well as an unwelcome pressure area, and may need removing (Fig. 12.10).

The callus at the fracture site also produces a visible lump that interferes with the shoulder straps of bras and backpacks. The lump is particularly alarming to the parents of children with a greenstick fracture of the clavicle. The clavicle looks normal immediately after injury and the swelling may be mistaken for a malignant tumour. In time, the swelling diminishes as the bone remodels and the surrounding bone enlarges.

A sling to support the weight of the arm relieves pain at the fracture site, but the sling must not rub against the fracture. The sling can be removed after 10 days if pain permits. Greenstick fractures require very little support (Fig. 12.11).

A firm support such as a figure-of-eight bandage to pull the shoulders backwards also helps to relieve pain but it must be readjusted every few days (Fig. 12.12). The function of a figure-of-eight bandage is to support the fracture and not to reduce it. Harnesses and braces that attempt to reduce the fracture by pulling the shoulder blades backwards are doomed to failure: the arm weighs several kilograms and anything that exerts such a force on the shoulder is bound to cause pressure sores in the soft axillary skin, even without the sweat that is inevitable under a bulky dressing.

Internal fixation is seldom required for fractures of the clavicle.

Undisplaced non-articular fractures are treated conservatively with a sling, analgesics and early mobilization.

The fragment may fail to unite, causing a painful non-union. Excision of the un-united fragment may be needed if this occurs.

There are six grades of acromioclavicular separation. The grade determines the treatment:

If the injury is seen early, which is unusual, acute repair may be required. The decision to operate depends on the age and fitness of the patient and the severity of the injury. Left untreated, recurrent subluxation can occur. Soft tissue repair is difficult and the patient may prefer to accept the minor disability of recurrent subluxation instead.

Acromioclavicular injuries with little separation and intact coracoclavicular ligaments require no treatment. Rest in a sling is sufficient unless there is gross displacement of the fragments, when internal fixation may be needed to stabilize the joint.

Treatment is by support in a sling, analgesics and early mobilization. A good result is usual, but the shoulder girdle may be weaker than before because of muscle damage.

Unless there is gross displacement of the fragments, treatment is by early mobilization. Because the glenoid is not a weight-bearing joint, exact anatomical restitution of the joint surfaces is less important than early mobilization.

Neurological damage. Damage to the axillary nerve as it runs round the neck of the humerus (Fig. 12.17) causes partial or complete paralysis of the deltoid. When damage is suspected, the axillary nerve should be examined with an EMG 3 weeks after injury and again 3 weeks later. If there is no change between the two examinations, the nerve should be explored and, if necessary, repaired.

Brachial plexus injuries also occur if there has been a violent abduction strain.

Arterial injury. The axillary artery can be damaged by traction at the time of injury or by pressure from the humeral head. The radial pulse should be checked and its presence recorded.

Irreducibility. The humeral head sometimes ‘buttonholes’ through the subscapularis, making reduction impossible. Open reduction is then necessary.

If the shoulder is not reduced within a few days of dislocation, reduction may then be impossible. This is a particular problem in elderly patients in whom the shoulder can be dislocated with trivial trauma. Open reduction is a difficult and uncertain operation and it may be better left dislocated in an elderly patient who places little demand on the shoulder.

Joint stiffness. Because the shoulder depends upon muscle and soft tissue for stability, adhesions or fibrosis in the rotator cuff can cause serious loss of movement. Physiotherapy is important to prevent this.

Recurrent dislocation. Once dislocated, the shoulder is liable to do so again and may require stabilization. Adequate treatment of the initial dislocation is therefore important.

First, examine the shoulder radiologically, however obvious the diagnosis may be. Attempts to reduce the shoulder before radiographs are available are ill advised and may be dangerous if there is an associated fracture.

The humeral head must be reduced but, before attempting reduction, test the function of the axillary nerve, which runs around the surgical neck of the humerus. This nerve can be damaged either at the moment of dislocation or during reduction. Because the nerve is so vulnerable, it is important to test the function of the nerve and record it before reduction is attempted.

Motor function cannot be tested adequately but the area of sensory supply of the circumflex nerve, over the outer side of the deltoid, is easily tested. If there is any abnormality it should be clearly recorded and special care taken when the shoulder is reduced. If this is not done, any subsequent circumflex nerve dysfunction may be attributed to the reduction rather than the injury.

Manipulation under general anaesthetic (MUA). If there is no fracture of the humeral head, the shoulder can be reduced easily under general anaesthesia if required. No complicated manipulations are necessary; the arm can be pulled gently and the head pushed back over the lip of the glenoid.

Hanging-arm technique. An alternative is to place the patient face down on a couch and allow the arm to hang freely without the patient holding on to the leg of the couch or supporting the arm in any way (Fig. 12.18). The weight of the arm will then achieve reduction but intravenous pethidine or valium may be needed to achieve adequate relaxation. This technique avoids general anaesthesia and the 4 h or so discomfort that is necessary if the patient has a full stomach and has to wait for general anaesthetic.

Hippocratic method. In days gone by, the shoulder had to be reduced without full muscle relaxation and, for many years, Hippocrates’ technique was used. The Hippocratic technique involved laying the patient on the floor, lifting and pulling the arm upwards and pushing the humeral head back into its correct position with the unbooted forefoot (Fig. 12.19).

Kocher’s method was less spectacular and consisted of a slow external rotation of the arm to relax the spasm of the subscapularis muscle (Fig. 12.20). When full external rotation had been achieved, the humeral head could be easily replaced. This method was considered to have been first described by Kocher in the 19th century until, in 1970, an Egyptian surgeon noted that some of the paintings on the pyramids depicted injuries occurring while they were being built, together with their treatment. One such illustration unmistakably demonstrated Kocher’s manoeuvre (Fig. 12.21). The unknown artist therefore preceded both Kocher and Hippocrates in his description of manipulative reduction. If only he had published his work in a reputable journal, he would have received the proper recognition for his discovery!

Aftercare. Whichever technique is used, the arm should be brought across the body and bandaged in that position for 3 weeks, when the shoulder can be mobilized. Treating without immobilization runs the risk of recurrent dislocation (p. 365).

Reduction is easily done by pulling the arm gently forwards and externally rotating it, but the reduction is often unstable. Aftercare is the same as for anterior dislocation.

Reduction can be difficult but once achieved immobilization is not required.

Surgical repair is advisable in acute tears in young or active patients. Rehabilitation is prolonged.

Treatment is by support to the shoulder until the pain has settled, followed by physiotherapy 3–4 weeks later when the fragment has reattached. If the fragment is jammed in the joint, operation is needed to reduce and fix it.

Support to the limb in a sling or collar and cuff for 4–6 weeks, depending on the stability of the fracture, is often all that is required in undisplaced fractures. Mobilization can then be commenced and rehabilitation begun when pain allows.

Extensive bleeding and bruising around the fracture is usual but not of serious significance, though it may track down to the elbow and produce a spectacular discoloration. This should not delay mobilization.

Impacted fractures can be mobilized after 2 weeks, but the fragments can become disimpacted unless some protection is given until then.

Undisplaced or minimally displaced fractures almost always unite because the fracture is surrounded by muscle, and remodelling is good at the shoulder (Fig. 12.25). Fractures that are displaced or severely angulated may need operative intervention. In the young patient the fracture should be reduced and fixed with internal fixation. In the elderly it may be more judicious to proceed to a hemiarthroplasty, especially in four-part fractures (see Fig. 12.26).

Treatment is by rest in a sling. In children under the age of 12 any deformity will correct by remodelling and manipulation is hardly ever required.

Closed reduction is difficult. Open reduction may be needed in younger patients but in older patients it is preferable to accept some loss of function and institute early movement.

Severe fracture dislocations may need prosthetic replacement of the humeral head.

Twisting injuries of an arm produce a spiral fracture of the humerus (Fig. 12.27).

Transverse fractures of the humerus are caused by direct trauma or a fall onto the arm.

The humerus is a common site for metastases and pathological fractures are often seen.

The fragments are shaped like spikes and can damage the radial nerve or the vessels, as well as muscle, as they wind around the bone.

Brachioradialis is a useful guide to neurological function. If there is a neurological deficit involving brachioradialis and no clinical or electrical sign of recovery after 6 weeks, the radial nerve should be explored. In the longer term, flexor tendons may need to be transferred to restore extensor function.

Malunion may occur because the deltoid can abduct the upper fragment without opposition from other muscles or the weight of the arm.

Soft tissue, including the radial nerve and triceps, can be caught between the bone ends and lead to non-union.

Vascular problems. At the moment of greatest displacement the distal fragment and the forearm are pushed backwards, pulling the brachial artery and median nerve violently against the sharp lower end of the upper fragment (Fig. 12.32). The circulation must therefore be checked carefully and recorded, with special attention to the five ‘P’s:

The skin will be cool if the circulation is interrupted and there will be loss of passive finger extension because of oedema in the flexor compartment. If these signs are present before or after reduction, the following steps should be taken:

1. The splint and dressings should be removed, down to skin.

2. The elbow should be extended slightly, even if this loses the reduction.

3. If the circulation still does not improve, the brachial artery must be explored at the elbow. If the artery is in spasm, it can be painted with papaverine to relax the smooth muscle of the arterial wall. If this is ineffective, as it almost always is, the artery must be opened, intimal tears corrected, and a vein patch applied if necessary.

Compartment syndrome. The median nerve and radial artery can both be compressed by swelling within the anterior compartment of the forearm. If there are paraesthesiae in the median distribution with loss of finger extension, a fasciotomy is probably needed.

Volkmann’s ischaemic contracture is the end result of muscle necrosis caused by occlusion of the microcirculation from any cause. Untreated vascular insufficiency following a supracondylar fracture, perhaps aggravated by a compartment syndrome, is one cause. Masses of fibrous tissue replace patches of necrotic muscle in the flexor compartment and these contract, pulling the fingers into flexion and the wrist into flexion and pronation (Fig. 12.33). The result is disabling.

Median nerve damage. The median nerve, like the brachial artery, is vulnerable at the fracture site. Because the nerve is tough it is seldom divided and function usually recovers. The anterior interosseous branch to the deep muscles is more likely to be affected than the superficial branch, which continues as the median nerve into the hand.

Malunion. Unless a good position is achieved, an unsightly malunion is likely, with the medial epicondyle pushed backwards and medially. The result is, at best, a slight loss of carrying angle, and at worst a ‘gunstock’ deformity (see Fig. 2.16). Corrective osteotomy may be required when growth is complete.

Myositis ossificans can follow any fracture in the region of the elbow, including a supracondylar fracture.

Undisplaced fractures can be treated in a backslab with the elbow flexed for 3 weeks. Unstable fractures are more difficult. The fractured surfaces are small and do not ‘fit’ together neatly. The distal fragment has many powerful muscle groups attached to it, which can displace the fragments after reduction.

Reduction is achieved by a gentle longitudinal pull with the forearm in the midprone position. Once reduced, the elbow is flexed beyond a right angle, a plaster backslab applied and the arm supported in a collar and cuff. This position can usually be maintained but if flexing the elbow beyond 90° interferes with the blood supply it must be extended until the pulse returns. If this loses reduction, the arm should be suspended and Dunlop traction (Fig. 12.34) applied.

Percutaneous ‘K’ wiring or open fixation with wires may be needed, not only to reduce difficult fragments but also to hold them in the reduced position. These wires can be removed after 3–4 weeks.

Ulnar nerve palsy. The valgus strain that causes the fracture can also stretch the ulnar nerve.

Growth arrest. If the growth of the epicondyle is impaired or the fracture is not reduced, a varus deformity at the elbow (cubitus varum) follows.

The fragment should be accurately reduced, openly if necessary, and secured with a Kirschner wire for extra stability. The wire must be removed later.

If the fragment does not unite, or there is growth arrest from damage to the epiphyseal plate or malunion, a valgus deformity of the lower end of the humerus follows. This stretches the ulnar nerve and causes a tardy ulnar palsy (p. 387). Non-union can occur, even if the fragment is undisplaced, and the injury must always be taken seriously.

The fragment should be accurately reduced, by manipulation if possible, but open reduction may be necessary to replace the fragment and hold it with a Kirschner wire.

The subluxation can be reduced by longitudinal pressure of the radius against the humerus with the elbow flexed. The forearm can then be alternately pronated and supinated and the radial head will pop back into position with dramatic relief of pain.

Like any fracture involving a joint, this injury is followed by loss of joint movement and late osteoarthritis.

Exact anatomical restitution is not required unless there is gross displacement of the fragments. Conservative management with early mobilization may produce a better result than open reduction and internal fixation.

If there is gross displacement of the fragments with complete disintegration of the elbow it may be necessary to reassemble the bones and fix them internally (Fig. 12.36). The operation is difficult and the results are not always good.

Joint stiffness. Full restoration of movement is unusual and a permanent loss of 15–20° of extension is almost inevitable.

The fragment can be removed and some movement restored, but the operation is technically difficult and the bone can reappear.

Recurrent dislocation can occur but is very rare.

The dislocation can be reduced by a longitudinal pull in slight flexion and the reduction is usually stable. The arm should be rested in a collar and cuff for 2 weeks and mobilized gently.

Unless the fragments are undisplaced, which is unusual, internal fixation is needed, using either a screw or tension band wiring (Fig. 12.40). Rigid splintage is unnecessary if the fixation is secure.

Comminuted fractures in which the fragments cannot be reassembled and fixed can be treated by excision of the olecranon, especially in the elderly.

Treatment varies according to the type of fracture.

Undisplaced fractures and those with little displacement need blood aspirating from the joint, a soft supporting bandage and early mobilization.

Displaced fractures through the radial neck with more than 30° of angulation cause a painful restriction of pronation and supination if left untreated. The displacement should be corrected, by open reduction if necessary.

Comminuted fractures. Grossly displaced or comminuted fractures of the radial head are best treated by radial head excision and early mobilization. Prosthetic replacement of the radial head has been tried but excision is usually preferred.

The ulnar fracture is so unstable that it must be internally fixed. Conservative treatment may succeed in children but the position must be checked frequently to be certain that the fragments have not slipped.

Complications are common after fractures of the radius and ulna.

Malunion. Unless the rotational deformity is corrected, a malunion will follow and the patient will be unable to supinate the forearm, which makes it difficult to wash the face or collect change when shopping.

Compartment syndromes and vascular damage are common.

Non-union is common, particularly if rotation has not been controlled.

Cross-union. Some fractures unite with cross-union between the two bones, which makes pronation and supination impossible.

These fractures are so unstable that conservative treatment is seldom successful in adults, and internal fixation may even be required in children to achieve stability.

Conservative. A well applied cast can sometimes correct and hold the rotational deformity by bringing the distal fragment round to meet the proximal, which is held in unopposed supination. The cast must include both the upper arm and the hand, which is held in supination, but in this position the longitudinal position may slip and open reduction is then required.

Operative. Open reduction and internal fixation is the treatment of choice for most of these fractures (Fig. 12.45) but external fixation is needed if the wounds are contaminated. Plates and screws or intramedullary nails are generally used.

Treatment varies according to the amount of displacement.

Undisplaced fractures. Although these fractures look deceptively straightforward on the radiograph, they should be treated with great suspicion and immobilized in a full arm cast with the elbow flexed. If this is not done the fracture will be exposed to rotational stresses and non-union can follow.

Displaced fractures. The rotational element makes displaced fractures almost impossible to immobilize and they are best treated by internal fixation with a plate.

Treatment varies according to the amount of displacement.

Undisplaced fractures. Although these fractures look deceptively straightforward on the radiograph, like isolated fractures of the ulna, they should be treated with great suspicion and immobilized in a full arm cast with the elbow flexed.

Displaced fractures. The rotational element makes displaced fractures difficult to immobilize and they are best treated by internal fixation.

Malunion is common. Because the distal fragment has no longitudinal stability, the fracture is unstable and is notorious for slipping in plaster after an initial good position.

The fracture is best treated by internal fixation of the radius (Fig. 12.47). It must not be treated in a short forearm cast as if it were a Colles’ fracture, for which it may be mistaken.

The arm must be elevated, the circulation watched carefully and any loss of extension of the wrist and fingers treated seriously. If in any doubt, a wide fasciotomy of the fascial compartment of the forearm is needed to prevent the complications of a compartment syndrome.

Complications are regrettably frequent after such a common and apparently straightforward injury. Most complications occur not from neglect, but simply because there is no treatment that is truly effective.

Sudeck’s atrophy. The hand becomes stiff, blue and cold in this variety of reflex sympathetic dystrophy, caused by a disturbance of the sensory and the autonomic supply of bone and blood vessels. The condition is particularly common if the patient is allowed to rest the hand without moving the fingers and can be prevented by ensuring that the patient keeps the fingers moving. Sometimes the condition involves the shoulder as well and is then called the ‘shoulder–hand syndrome’.

Treatment is difficult and requires much patience, physiotherapy and reassurance. Because of this fearful complication, it is vitally important to ensure that the patients really do keep their fingers and shoulder moving after a Colles’ fracture.

Median nerve damage. The median nerve runs right across the site of a Colles’ fracture and may be compressed by the bruising and bleeding around it. Median nerve symptoms usually settle by the time the fracture is united but decompression is sometimes required.

Rupture of the extensor pollicis longus tendon. The extensor pollicis longus tendon runs across the fracture site at the dorsum of the wrist and may be worn through by movement across the sharp edge of the broken bone, producing an ‘attrition rupture’.

The problem is also seen in fractures with very slight displacement and may be due to ischaemia rather than attrition. If a patient reports that the thumb has dropped following a Colles’ fracture, the tendon has ruptured and must be repaired.

Malunion. Because the fracture is unstable and the bone is crushed, malunion is common (Fig. 12.50). The disability from a malunion is unpredictable and many patients manage well despite a marked and unsightly deformity.

Left untreated, the fracture will unite with backward angulation, a loss of supination, weakness of grip and loss of ulnar deviation. The functional result is often surprisingly good.

Displaced fractures. The fracture can be manipulated into good position by pulling the hand distally to disimpact the fracture, flexing the wrist and pulling the hand round into ulnar deviation. Reducing the fracture in this way is easy but holding the position is not. Because the fragment is impacted, the bone on the dorsum of the radius is crushed and a hole is left in the dorsum of the radius when the fracture is reduced. This leaves the distal fragment unsupported dorsally and the deformity recurs as the swelling subsides.

Once reduced, a plaster is applied from the elbow to the metacarpophalangeal joints, which lie in the line of the proximal skin crease in the palm and not at the base of the fingers. The fingers and the thumb must be left free so that they can move freely.

The fracture should be inspected the next day to be sure that there is no undue swelling and that the patient is moving the fingers, arm and shoulder.

The patient is then seen between 7 and 10 days later and a radiograph taken to check the position. If the fragments have slipped, a further manipulation may be required. If the patient is not using the hand and shoulder at this stage, physiotherapy should be instituted at once.

The cast is retained for a total of 4 weeks, by which time there should be full movement in the fingers, thumb, elbow and shoulder. Physiotherapy or occupational therapy may be needed if the patient is reluctant to use the hand.

Impacted fractures in good position. A fracture will sometimes impact in acceptable position with little backward angulation. Such fractures need not be manipulated, but it is wise to apply a cast for 2 weeks to prevent accidental displacement.

Operation is sometimes needed to restore supination, or to relieve pain. Three procedures are available:

The majority of these fractures need no reduction and a cast for 4 weeks is enough. Large displaced fragments must be reduced and internally fixed if manipulation is unsuccessful.

Manipulative reduction is usually easy and a cast for 4 weeks is sufficient. If the fracture is impacted with minimal displacement, 2 weeks immobilization is sufficient, provided that the patient is careful to avoid stressing the fracture for a further 4 weeks.

Both these fractures must be distinguished carefully from a Colles’ fracture and treated in a forearm cast with the hand supinated and the wrist in full extension. If a good position cannot be achieved and maintained, the fracture must be reduced openly and secured with a small buttress plate attached to the volar aspect of the radius (Fig. 12.55).

If this is not done, a disabling malunion and flexion deformity follows and arthrodesis may be needed.

Epiphyseal arrest is the principal complication of epiphyseal injuries but aseptic necrosis of the epiphysis is also seen.

Accurate reduction and great gentleness are required. Closed reduction is usually successful but, if the epiphysis is fractured as well as dislocated, open reduction may be needed.

The appearance of a greenstick fracture after removal from the cast can be alarming to the parents. The arm is not entirely straight and the parents need firm reassurance that this is normal and that the limb will remodel. Angular deformities of up to 30° in the plane of the nearest joint usually remodel perfectly but rotational deformities do not.

If both cortices are buckled but intact, a light protective plaster for 2–3 weeks is all that is needed. These fractures cannot be manipulated into perfect position and some imperfection must be accepted.

It is impossible to overcorrect a greenstick fracture, even with three-point pressure. Provided the child does not fall again before the fracture is solid, an excellent result will be achieved whatever is done.

If one cortex is broken, a deformity can develop and correction may be needed. The cast should be retained for 3 weeks.

Supracondylar fractures of the humerus, fractures of the medial epicondyle, lateral condyle and pulled elbow are dealt with elsewhere (pp. 200, 202 and 204).