Clavicle fracture

Overview

1. Most clavicle fractures require no reduction.

2. Closed reductions cannot be maintained and should not be attempted.

Indications for Use

1. Minimally displaced clavicle shaft fractures (Figure 9-1)

2. Medial physeal clavicle fractures

Figure 9-1

Precautions

Do not attempt heroic measures to reduce clavicle fractures.

Pearls

1. Clavicle fractures with more than 1.5 cm of overlap result in long-term disability and should be treated with an open reduction and internal fixation.

2. Fractures that tent the skin can erode through the skin and are unlikely to heal without open reduction and internal fixation.

3. There is no difference in outcome between a figure-of-8 splint and a sling for closed management of clavicle fractures.

4. The sling or figure-of-8 strap should be relatively tight to support the weight of the arm.

Improvization

If no sling is available, a simple scarf or towel can be used.

Equipment

1. Sling

2. Figure-of-8 strap (alternative)

Basic/Detailed Technique

1. Sling (see Chapter 13)

2. Figure-of-8 strap (see Chapter 13)

Acromioclavicular separation

Overview

1. Most acromioclavicular (AC) separations require no reduction.

2. Closed reductions cannot be maintained and should not be attempted.

Indications for Use

1. Minimally displaced AC separations (grades 1 to 3) (Figure 9-2)

2. Severely displaced AC separations (grades 4 to 6) (Figure 9-3)

Figure 9-2

Figure 9-3

Precautions

Do not attempt heroic measures to reduce AC separations.

Pearls

1. AC separations with severe displacement or soft tissue interposition (grades 4 to 6) should be reduced surgically on an elective basis.

2. AC separations that tent the skin are unlikely to heal without fixation.

3. The sling should be relatively tight to support the weight of the arm.

Improvisation

If no sling is available, a simple scarf or towel can be used.

Equipment

Sling

Basic/Detailed Technique

Sling (see Chapter 13)

Glenohumeral dislocation

Overview

1. Most glenohumeral dislocations can be reduced in a closed manner.

2. The reduction technique varies according to the direction of dislocation.

3. An axillary or modified axillary view is an essential part of the radiographic series (Figure 9-4)!

Figure 9-4

Indications for Use

1. Anterior glenohumeral dislocation

2. Posterior glenohumeral dislocation

3. Inferior glenohumeral dislocation (luxatio erecta)

Precautions

1. Confirm that no fracture is present on diagnostic films before attempting a reduction. Standard reduction maneuvers can result in a displaced four-part fracture that requires surgical fixation/prosthetic replacement.

2. Confirm that the humeral head is not impacted onto the glenoid (known as a Hill-Sachs lesion) before attempting a reduction (see Figure 9-4). Standard reduction maneuvers can result in a head-splitting fracture.

3. When applying traction, make sure that the force is applied over a broad area; otherwise, a forearm fracture can result.

4. Be aware that some persons may voluntarily initiate a glenohumeral dislocation in an effort to gain access to drugs.

5. Reducing dislocations in persons who present more than a few days after the injury may not be possible, and attempting to do so could result in a fracture; it is preferable not to attempt a reduction and to take the patient to the operating room if simple traction does not succeed in reducing the dislocation.

6. When reducing posterior dislocations, do not externally rotate the humerus until the head is disimpacted from the glenoid or a fracture may result.

Pearls

1. Be patient; the stability of the shoulder is provided largely by a set of small but powerful muscles that must be overcome with gentle sustained traction before a reduction is possible.

2. Gentle internal and external rotation of the shoulder can coax the humerus back in place.

3. For posterior dislocations, stretching the rotator cuff muscles by maximal internal rotation of the shoulder may be necessary.

4. General anesthesia may be required if muscle spasms are not overcome with sedation.

5. External rotation is a better position for immobilization of both anterior and posterior dislocations after reduction, although a gunslinger brace may not be available immediately.

6. The sling or gunslinger brace can be applied loosely for comfort.

Improvization

When all else fails, try traction at different angles of abduction and extension.

Anterior glenohumeral dislocation

Equipment

1. Two bed sheets

2. Stretcher

3. Medications for conscious sedation

4. Sling or gunslinger brace (if available)

Detailed Technique

1. Position the patient supine on the stretcher.

2. Induce conscious sedation.

3. Prepare traction setup:

a. Make sure that guard rails are down on the ipsilateral side and up on the contralateral side.

b. Slide a rolled bed sheet around the patient’s trunk under the ipsilateral shoulder and tie it over the contralateral upper corner of the stretcher for countertraction (Figures 9-5 and 9-6).

c. Tie another rolled bed sheet around your waist, leaving about a foot of slack.

d. Place the patient’s forearm inside the sheet around your waist so that the entire proximal half of the forearm is covered by the sheet (Figure 9-7).

4. Apply traction:

a. Position yourself along the ipsilateral side of the stretcher so that the shoulder is slightly abducted.

b. Lean back slowly and gently to apply traction while providing countertraction on the distal half of the forearm with both palms.

(1) Apply traction over the broadest surface area possible to prevent a forearm fracture.

(2) Be patient; slow, steady traction is necessary to achieve reduction (5 to 30 minutes of traction may be required depending on the level of sedation).

5. Gently externally rotate the shoulder (Figure 9-8).

a. If reduction not achieved, alternate internal rotation (Figure 9-9) and external rotation.

b. Vary the degree of abduction if necessary (Figure 9-10).

6. Await a clunk or sudden palpable shift.

7. Gently release traction.

8. Place the arm in a sling (see Chapter 13) in internal rotation or in a gunslinger brace in external rotation.

9. Obtain postreduction radiographs, including an axillary view, before terminating sedation.

Figure 9-5

Figure 9-6

Figure 9-7

Figure 9-8

Figure 9-9

Figure 9-10

Posterior glenohumeral dislocation

Equipment

1. Two bed sheets

2. Stretcher

3. Medications for conscious sedation

4. Sling or gunslinger brace (if available)

Basic Technique

1. Patient positioning:

a. The patient is supine on a stretcher.

b. The patient’s elbow is bent 90 degrees and the shoulder is internally rotated.

c. The patient’s shoulder is abducted 30 to 60 degrees.

d. A bed sheet is tied around the patient’s trunk and to the opposite side of the stretcher.

e. A bed sheet is tied around your waist and to the patient’s forearm.

Detailed Technique

1. Position the patient supine on the stretcher.

2. Induce conscious sedation.

3. Prepare traction setup:

a. Make sure guard rails are down on the ipsilateral side and up on the contralateral side.

b. Slide a rolled bed sheet around the patient’s trunk under the ipsilateral shoulder and tie it over the contralateral upper corner of the stretcher for countertraction.

c. Tie another rolled bed sheet around your waist, leaving about a foot of slack.

d. Place the patient’s forearm inside the sheet around your waist so that the entire proximal half of the forearm is covered by the sheet.

4. Apply traction:

a. Position yourself along the ipsilateral side of the stretcher so that the shoulder is slightly abducted.

b. Lean back slowly and gently to apply traction while providing countertraction on the distal half of the forearm with both palms.

(1) Apply traction over the broadest surface area possible to prevent a forearm fracture.

(2) Be patient; slow, steady traction is necessary to achieve reduction (5 to 30 minutes of traction may be required depending on the level of sedation).

5. Once the humeral head is disimpacted, translate the humerus anteriorly (Figure 9-11).

6. Gently externally rotate the shoulder.

a. If reduction is not achieved, alternate internal and external rotation.

b. Vary the degree of abduction if necessary.

7. Await a clunk or sudden palpable shift.

8. Gently release traction.

9. Place the arm in a sling (see Chapter 13) in internal rotation or in a gunslinger brace in external rotation.

10. Obtain postreduction radiographs, including an axillary view, before terminating sedation.

Figure 9-11

Proximal humerus fractures

Overview

1. Most proximal humerus fractures require no reduction.

2. Closed reductions of the tuberosities cannot be maintained and should not be attempted (Figure 9-12).

3. Reducing a fracture/dislocation in a closed manner requires a high level of expertise and should only be attempted with caution.

4. Children have a very high remodeling potential at the proximal humerus, and physeal arrest is unlikely.

Figure 9-12

Indications for Use

Reduction may be indicated for minimally displaced or angulated one- or two-part proximal humerus fractures.

Precautions

Do not attempt heroic measures to reduce proximal humerus fractures.

Pearls

1. Always obtain an axillary view radiograph to rule out a fracture dislocation and to better visualize the humeral head (Figure 9-13).

2. The majority of patients are either older and have low demand because of osteoporosis or are children with high remodeling potential.

3. Use of a sling and swath or a shoulder immobilizer is often definitive treatment.

Figure 9-13

Improvization

If no sling and swath or shoulder immobilizer are available, a simple scarf or towel can be used and secured to the body with a loose elastic bandage.

Equipment

1. Sling

2. 6-inch elastic bandages

3. ABD pad with talcum powder (if available)

4. Alternative: shoulder immobilizer

Basic/Detailed Technique

Sling and swath (see Chapter 13).

Humeral shaft fractures

Overview

1. Most humeral shaft fractures can be treated with closed reduction and splinting/bracing.

2. The radial nerve is closely associated with the humerus and can be injured both from the injury itself and from the reduction attempt.

Indications for Use

Reduction is indicated in all humeral shaft fractures.

Pearls

1. Most humeral fractures fall into varus with apex volar deformity (Figure 9-16).

a. The splint must be applied with a valgus mold to prevent displacement (Figure 9-17).

b. A pyramidal bump can be placed under the splint to maintain valgus correction (Figures 9-18, 9-19, and 9-20).

2. Distraction is rarely needed and is often counterproductive.

3. Often it is best to perform the reduction after a coaptation splint is applied but before it sets.

4. Cooperative patients can assist in the reduction by relaxing their shoulder and passively holding their elbow in a flexed position by supporting the injured hand with the uninjured hand.

5. Fractures in the distal third of the diaphysis require immobilization of the elbow in a posterior splint in addition to a coaptation splint.

6. A posterior slab also can be applied because humeral shaft fractures have a tendency to fall into apex anterior angulation (Figures 9-21 and 9-22).

Figure 9-16

Figure 9-17

Figure 9-18

Figure 9-19

Figure 9-20

Figure 9-21

Figure 9-22

Improvization

If supplies are limited, the arm can be sandwiched between two stiff boards or supported by a sling until definitive management can be arranged.

Equipment

1. Stockinette: 4 inches wide and 6 feet long

2. Cast padding: 4 inches wide

3. Plaster: 4 inches wide

4. Elastic or self-adherent bandage: 4 inches wide

5. Tape: 2-inch silk tape (optional)

6. Bucket of tepid water

Detailed Technique

1. Apply a coaptation splint (see Chapter 13).

2. Perform a reduction maneuver based on radiographic evidence of displacement. Most fractures require a two-point mold with one hand anterolateral at the fracture site and the other posteromedial at the elbow (Figure 9-23).

3. Bring the excess stockinette material behind the neck and down to and around the wrist and tie it back to itself to create a sling.

4. Create an abduction bump by covering a pyramid of three 4-inch-wide rolls of cast padding in more cast padding.

5. Place the abduction bump between the elbow and the body and secure it to the elbow with elastic or a self-adhesive bandage (see Figure 9-20).

6. A posterior slab may be added to control elbow motion for more distal fractures (see Figure 9-22).

7. Obtain postreduction radiographs.

Figure 9-23

Periarticular elbow fractures

Overview

1. Most intra-articular elbow fractures require operative treatment.

2. The anterior interosseous nerve (AIN), radial nerve, and ulnar nerves are closely associated with the elbow and are at risk from the injury and the reduction.

Indications for Use

1. Supracondylar humerus fractures

2. Intercondylar humerus fractures (Figure 9-24)

3. Olecranon fractures

4. Radial head/neck fractures

Figure 9-24

Precautions

Evaluate and document radial nerve, median nerve, ulnar nerve, posterior interosseous nerve (PIN), and AIN function both before and after reduction.

Pearls

1. Reduction techniques should be tailored to the individual fracture pattern.

2. Because distal humeral fractures tend to displace in apex volar angulation, the elbow should be splinted in greater than 90 degrees of flexion.

3. Because proximal ulnar fractures tend to displace in apex dorsal angulation, the elbow should be splinted in less than 90 degrees of flexion in an attempt to reapproximate the fracture fragments.

4. Because radial head/neck fractures tend to displace posteriorly, a reduction maneuver should be attempted before application of a splint.

5. Fractures of the radial head require immobilization of the wrist in a neutral position to prevent pronation and supination.

6. Sometimes it is best to perform the reduction after the splint is applied but before it sets.

7. In the cooperative patient, it is easier to perform the reduction maneuver and apply the splint while the patient is upright.

Improvization

If supplies are limited, a sling will suffice in an emergency until definitive management can be arranged.

Equipment

Equipment for posterior splint (see Chapter 13)

Detailed Technique

1. Position the patient standing or sitting upright or supine on a stretcher.

2. Have the patient or an assistant support the arm by holding the wrist if upright.

3. Apply a posterior splint with side struts (see Chapter 13).

4. Perform a reduction maneuver, if warranted, according to the displacement of the fracture (Figure 9-25).

5. Obtain postreduction films.

Figure 9-25

Elbow dislocations

Overview

1. Elbow dislocations can occur in any direction, but most commonly the ulna dislocates posteriorly (Figure 9-26).

2. The AIN, radial nerve, and ulnar nerve are closely associated with the elbow and are at risk from the injury and the reduction.

3. Most simple elbow dislocations (i.e., those without a fracture) can be treated with a brief period of splinting (1 to 2 weeks) followed by early range of motion.

Figure 9-26

Indications for Use

1. Elbow dislocations

2. Terrible triad injuries

Precautions

Evaluate and document radial nerve, median nerve, ulnar nerve, PIN, and AIN function both before and after reduction.

Pearls

1. Reduction techniques should be tailored to the direction of the dislocation, with consideration of associated fractures.

2. Terrible triad injuries, which include elbow dislocation, radial head fracture, and coronoid fracture, are extremely unstable injuries, and reduction may not be able to be maintained even in elbow flexion.

3. Terrible triad injuries should be splinted in forearm pronation to tighten the lateral-sided structures.

4. Dislocations with medial epicondyle fractures, which are seen more commonly in children, are associated with ulnar nerve entrapment in the joint. Ulnar nerve dysfunction in this setting is an emergency requiring advanced imaging or exploration.

5. Lateral epicondylar fractures in children are equivalent to lateral ligament ruptures in adults.

6. An unidentified bone fragment anterior to the joint is most commonly a coronoid fracture.

7. In the cooperative patient, it is easier to perform the reduction maneuver and apply the splint while the patient is upright.

8. Immobilization for simple dislocations should be brief and rarely lasts more than 2 weeks.

Improvisation

If supplies are limited, a sling will suffice in an emergency until definitive management can be arranged.

Equipment

Equipment for posterior splint (see Chapter 13)

Detailed Technique

1. Position the patient standing or sitting upright if a hematoma block is to be used for anesthesia (in a cooperative patient).

2. Position the patient supine on a stretcher with the ipsilateral shoulder off the stretcher if conscious sedation is to be used.

3. Prepare splinting material (see Chapter 13).

4. Stand at the side of the bed, facing the elbow.

5. If any medial/lateral translation is present, stabilize the distal humerus with one hand while grasping the proximal forearm with the other hand (Figure 9-27).

6. While applying gentle traction, translate the forearm on the humerus.

7. Feel the epicondyles and the olecranon to ensure that the olecranon is between the two epicondyles.

8. Place one hand anterior on the distal humerus and the other hand grasping the wrist (Figure 9-28).

9. With the elbow held in extension, pull hard manual traction across the elbow.

10. While pushing down on the distal humerus, begin flexing the elbow while maintaining traction (Figure 9-29).

11. A clunk may be felt when the joint is reduced, but a clunk does not always occur.

12. If the elbow can be fully flexed with no crepitus, it is most likely reduced (Figure 9-30).

13. Have an assistant hold the elbow at least 90 degrees of flexion and forearm pronation.

14. Apply a posterior splint (see Chapter 13).

15. Obtain postreduction films.

Figure 9-27

Figure 9-28

Figure 9-29

Figure 9-30

Radial head dislocation

Overview

1. Radial head dislocations can occur posteriorly, laterally, and anteriorly.

2. The PIN is at risk from the injury and the reduction.

3. Most radial heads can be reduced in a closed manner without the need for surgical intervention.

4. Closed reduction failure usually results from either the radial head buttonholing through the capsule or an ulnar fracture or plastic deformation limiting reduction.

Indications for Use

1. Radial head dislocation without associated fractures

2. “Nursemaid’s elbow”

Precautions

1. Evaluate and document radial nerve, median nerve, ulnar nerve, PIN, and AIN function both before and after reduction.

2. Do not try to reduce a chronically dislocated radial head; a careful history, lack of pain, and radiographs demonstrating a convex radial head articulation will provide evidence of a long-standing dislocation.

Improvisation

No harm can come from trying other maneuvers in the search for a reduction.

Equipment

Equipment for a posterior splint (see Chapter 13)

Detailed Technique

1. Position the patient standing or sitting upright if a hematoma block is to be used for anesthesia (in a cooperative patient).

2. Position the patient supine on a stretcher with the ipsilateral shoulder off the stretcher if conscious sedation is to be used.

3. Have the patient or an assistant support the arm by holding the wrist upright.

4. Prepare splinting materials (see Chapter 13).

5. Stand at the side of the bed, facing the elbow.

6. Anterior dislocation:

a. While an assistant stabilizes the arm, flex the arm past 90 degrees to relax the biceps, then supinate the forearm while applying direct, posteriorly directed pressure to the radial head and pulling traction at the wrist (Figure 9-32).

7. Posterior dislocation:

a. While an assistant stabilizes the arm, place the biceps on tension by extending the elbow and pronating the forearm.

b. Apply traction and a slight varus movement while placing an anteriorly directed force directly on the radial head (Figure 9-33).

8. Lateral dislocation:

a. While an assistant stabilizes the arm, extend the elbow and pronate (Figure 9-34) or supinate (Figure 9-35) the forearm depending on whether a posterior or anterior movement is desired.

b. Apply traction and a slight varus movement while placing a medially directed force directly on the radial head.

9. A clunk may be felt when the joint is reduced, but not always.

10. Maintain the elbow in the forearm rotation required for reduction.

11. Apply a posterior splint with side struts if desired (see Chapter 13).

12. Obtain postreduction radiographs.

Figure 9-32

Figure 9-33

Figure 9-34

Figure 9-35

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