Fracture of Shoulder and Humerus

InjuriesInjuries
of the shoulder girdleof the shoulder girdle
and humerusand humerus

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Acromioclavicular injuriesAcromioclavicular injuries
Mechanisms of injuryMechanisms of injury
The typical mechanism of injuryThe typical mechanism of injury
is a direct blow to the tip of theis a direct blow to the tip of the
shoulder. Occasionally, anshoulder. Occasionally, an
indirectly applied force injuresindirectly applied force injures
the acromioclavicular joint.the acromioclavicular joint.

Acromioclavicular injuriesAcromioclavicular injuries
1.1. In subluxations and sprains theIn subluxations and sprains the
clavicle preserves some contactclavicle preserves some contact
with the acromion.with the acromion.
2.2. In dislocations the clavicle losesIn dislocations the clavicle loses
all connection with the scapula,all connection with the scapula,
the conoid and trapezoidthe conoid and trapezoid
ligaments tearing away from theligaments tearing away from the
inferior border of the clavicle.inferior border of the clavicle.
3.3. The displacement may beThe displacement may be
severe, and the ensuingsevere, and the ensuing
haematoma may ossify.haematoma may ossify.

Acromioclavicular dislocations:Acromioclavicular dislocations:
Diagnosis (a):Diagnosis (a):
The patient should beThe patient should be
standing and the shouldersstanding and the shoulders
compared. The outer end ofcompared. The outer end of
the clavicle will bethe clavicle will be prominentprominent,,
locallocal tendernesstenderness is alwaysis always
present.present.

Acromioclavicular dislocationsAcromioclavicular dislocations
Diagnosis (b):Diagnosis (b):
Key - signKey - sign
Confirm any subluxation byConfirm any subluxation by
supporting the elbow withsupporting the elbow with
one hand, gently pushing theone hand, gently pushing the
clavicle down with the other.clavicle down with the other.

ConservativeConservative
treatmenttreatment
 If there is no grossIf there is no gross
instability, treat by theinstability, treat by the
use of a broad armuse of a broad arm
sling under the clothessling under the clothes
for 4-6 weeks.for 4-6 weeks.
 Physiotherapy isPhysiotherapy is
seldom required and anseldom required and an
excellent result is theexcellent result is the
rule.rule.

OperativeOperative
treatmenttreatment
Ligaments restoringLigaments restoring
by means of wiringby means of wiring

Operative treatmentOperative treatment
A common method is to holdA common method is to hold
the clavicle in alignment withthe clavicle in alignment with
the acromion, using a lagthe acromion, using a lag
screw (1). Transarticularscrew (1). Transarticular
sutures (2) in the acromio-sutures (2) in the acromio-
clavicular joint..clavicular joint..

Sternoclavicular dislocationSternoclavicular dislocation
Clinical Presentation
There is asymmetry of the inner ends of the clavicles (2) due to the
clavicle on the affected side subluxating downwards and forwards.
There is local tenderness.

Sternoclavicular dislocationSternoclavicular dislocation
ConservativeConservative
treatmenttreatment
If a dislocation reducesIf a dislocation reduces
with the arm in abduction,with the arm in abduction,
a shoulder spica (for 6-8a shoulder spica (for 6-8
weeks) may be used as anweeks) may be used as an
alternative to surgery.alternative to surgery.

Dislocation of the shoulderDislocation of the shoulder
When the shoulder dislocates,theWhen the shoulder dislocates,the
head of the humerus may come (1)head of the humerus may come (1)
in front of the glenoid (in front of the glenoid (anterioranterior
dislocationdislocation), (2) behind the glenoid), (2) behind the glenoid
(posterior dislocation(posterior dislocation (3), beneath(3), beneath
the glenoid (luxatio erecta).the glenoid (luxatio erecta).
Anterior dislocation is theAnterior dislocation is the
commonest.commonest.

Anterior dislocationAnterior dislocation
of the shoulderof the shoulder
This most commonly results fromThis most commonly results from
a fall. It is rare in children,a fall. It is rare in children,
common in the 18-25 years agecommon in the 18-25 years age
group and comparativelygroup and comparatively
common in the elderly.common in the elderly.

Diagnosis (a):Diagnosis (a):
Any motion is very painful:Any motion is very painful:
the patient resents movement,the patient resents movement,
and holds the injured limband holds the injured limb
with the other hand. The armwith the other hand. The arm
does not always lie into thedoes not always lie into the
side, appearing to be in slightside, appearing to be in slight
abduction.abduction.

Diagnosis (b)Diagnosis (b)
Palpate under the edge of thePalpate under the edge of the
acromion. The usual resis-acromion. The usual resis-
tance offered by the humeraltance offered by the humeral
head will be absent.head will be absent.
Compare the two sides. TheCompare the two sides. The
displaced humeral head maydisplaced humeral head may
be palpable lying anteriorly.be palpable lying anteriorly.

Diagnosis (c):Diagnosis (c):
In the doubtful case,In the doubtful case,
it may be helpful to tryit may be helpful to try
to assess the relativeto assess the relative
positions of the humeralpositions of the humeral
head and glenoid byhead and glenoid by
palpation in the axilla.palpation in the axilla.

Diagnosis (d):Diagnosis (d):
Axillary nerve palsyAxillary nerve palsy
is the commonest neurologicalis the commonest neurological
complication.complication.
Test for integrity of the nerveTest for integrity of the nerve
by assessing sensation to pinby assessing sensation to pin
prick (1)prick (1)
Look for other (rare) involvementLook for other (rare) involvement
of the radial portion of theof the radial portion of the
posterior cord (2) and involvementposterior cord (2) and involvement
of the axillary artery (3).of the axillary artery (3).

Radiographs:Radiographs:
The majority of anteriorThe majority of anterior
dislocations show on thedislocations show on the
standard AP radiographs ofstandard AP radiographs of
the shoulder. The importantthe shoulder. The important
diagnostic feature is thediagnostic feature is the lossloss
of congruity between theof congruity between the
humeral head and thehumeral head and the
glenoid,glenoid, as illustrated.as illustrated.

Reduction by Kocher’s method (a)Reduction by Kocher’s method (a)
Severe pain, or if the patient is ofSevere pain, or if the patient is of
muscular build, are indications formuscular build, are indications for
general anaesthesia. Apply traction (1)general anaesthesia. Apply traction (1)
and begin to rotate the arm externallyand begin to rotate the arm externally
(2).(2).

Reduction by Kocher's method (b):Reduction by Kocher's method (b):
Take plenty of time over externalTake plenty of time over external
rotation.rotation.
Excessive force must be avoidedExcessive force must be avoided inin
order to prevent fracture of theorder to prevent fracture of the
humeral shaft.humeral shaft.

Reduction by Kocher'sReduction by Kocher's
methodmethod (c):(c):
Flex the shoulder (by lifting upFlex the shoulder (by lifting up
the point of the elbow) and thenthe point of the elbow) and then
adduct it, bringing the elbowadduct it, bringing the elbow
across the chest. (These and theacross the chest. (These and the
following movements may befollowing movements may be
carried out rapidly.)carried out rapidly.)

Reduction by Kocher'sReduction by Kocher's
methodmethod (d):(d):
Now internally rotate the shoulder,Now internally rotate the shoulder,
bringing the patient's hand towardsbringing the patient's hand towards
the opposite shoulder. If reductionthe opposite shoulder. If reduction
has not occurred, repeat all stages,has not occurred, repeat all stages,
attempting to get more externalattempting to get more external
rotation in stage b.rotation in stage b.

Hippocratic method:Hippocratic method:
The principle is that traction isThe principle is that traction is
applied to the arm and the headapplied to the arm and the head
of the humerus is levered backof the humerus is levered back
into position. The stockingedinto position. The stockinged
heel is placed against the chestheel is placed against the chest
(without being pressed hard(without being pressed hard
into the axilla) to act as ainto the axilla) to act as a
fulcrum, while the arm isfulcrum, while the arm is
adducted.adducted.

Stimson's method:Stimson's method:
The patient is given a powerfulThe patient is given a powerful
analgesic (e.g. 200 mg of pethidine inanalgesic (e.g. 200 mg of pethidine in
a fit athletic male) with resuscitationa fit athletic male) with resuscitation
facilities available. The patient shouldfacilities available. The patient should
be prone, with the arm dependent, abe prone, with the arm dependent, a
sandbag under the clavicle and asandbag under the clavicle and a
weight of about 4 kg tied to the wrist.weight of about 4 kg tied to the wrist.
The joint normally reducesThe joint normally reduces
spontaneously within six minutes: ifspontaneously within six minutes: if
not, with one hand fix thenot, with one hand fix the
superomedial angle of the scapulasuperomedial angle of the scapula
(a), and with the other push the(a), and with the other push the
inferior angle medially (b).inferior angle medially (b).

Other methods of reductionOther methods of reduction

Aftercare (a)Aftercare (a)
Check radiographsCheck radiographs
should be taken. Placingshould be taken. Placing
a gamgee or wool pad ina gamgee or wool pad in
the axilla (for perspira-the axilla (for perspira-
tion) (1) and apply ation) (1) and apply a
broad arm sling (2).broad arm sling (2).

Aftercare (b)Aftercare (b)
External rotation should beExternal rotation should be
prevented by a body bandageprevented by a body bandage
(1), stretchable net (2) or, less(1), stretchable net (2) or, less
securely, by the outside clothessecurely, by the outside clothes
(3).. If there is some residual(3).. If there is some residual
pain, an outside sling may bepain, an outside sling may be
worn for a further week.worn for a further week.
Mobilisation is usually rapidMobilisation is usually rapid
without physiotherapy beingwithout physiotherapy being
required.required.

Fractures of the clavicleFractures of the clavicle
Mechanism of injury:
Most (94%) clavicular injuries
result from a direct blow on
the point of the shoulder,
generally from a fall on the
side (A). Less commonly,
force may be transmitted up
the arm from a fall on the
outstretched hand (B).
Under the age of 30 road
traffic and sporting injuries are
the commonest causes.

(in children)(in children)
Greenstick fractures are
common, particularly at the
junction between the middle
and outer thirds. Fractures may
not be particularly obvious on
the radiographs and it is often
helpful in children to have both
shoulders included for
comparison..

In the adult, undisplaced
fractures are also common,
and are comparatively stable
injuries. Late slipping is rare.
Symptoms settle rapidly
and minimal treatment
is required.

With greater violence, thereWith greater violence, there
is separation of the boneis separation of the bone
ends. The proximal end,ends. The proximal end,
under the pull ofunder the pull of
sternomastoid, oftensternomastoid, often
becomes elevated (1). Thebecomes elevated (1). The
shoulder loses the prop-likeshoulder loses the prop-like
effect of the clavicle, so thateffect of the clavicle, so that
it tends to sag downwardsit tends to sag downwards
and forwards (2). Note (3)and forwards (2). Note (3)
the glenoid, (4) the coracoid,the glenoid, (4) the coracoid,
(5) the acromion.(5) the acromion.

Diagnosis:
Clinically there is tenderness
at the fracture site; sometimes
there is obvious deformity with
local swelling, and the patient
may support the injured limb
with the other nand. In cases
seen some days after injury,
local bruising is often a
striking feature. Diagnosis is
confirmed by appropriate
radiographs.

Treatment
The most important aspect
of treatment is to provide
support for the weight of the
arm which has lost its clavicular tie.
As a rule this is best achieved
with a broad arm sling (1).
Additional fixation may be
obtained by wearing the sling
under the clothes (2). No other
treatment is needed in greenstick
or undisplaced fractures.

Ring or Quoit method (a):Ring or Quoit method (a):
Narrow gauge stockinet is cutNarrow gauge stockinet is cut
into two lengths of about ainto two lengths of about a
metre each (1). The centralmetre each (1). The central
portions are stuffed with cottonportions are stuffed with cotton
wool (2). One of the strips iswool (2). One of the strips is
taken and the padded areataken and the padded area
positioned over the front of thepositioned over the front of the
shoulder and tied firmly behindshoulder and tied firmly behind
(3).(3).

Ring or Quoit method (b):Ring or Quoit method (b):
The second strip is appliedThe second strip is applied
in a similar manner to thein a similar manner to the
other shoulder (4). Theother shoulder (4). The
patient is then advised topatient is then advised to
brace the shoulders backbrace the shoulders back
and the free ends of the ringand the free ends of the ring
pads are tied together (5). Apads are tied together (5). A
pad of gamgee (sandwichpad of gamgee (sandwich
gauze/cotton wool) may begauze/cotton wool) may be
placed as a cushionplaced as a cushion
beneath the knotsbeneath the knots (6).(6).

Figure-of- eightbandage:Figure-of- eightbandage:
Pads of gamgee or cotton woolPads of gamgee or cotton wool
alone are carefully positioned roundalone are carefully positioned round
both shoulders (1). The patient, whoboth shoulders (1). The patient, who
should be sitting on a stool, is askedshould be sitting on a stool, is asked
to brace back the shoulders; a woolto brace back the shoulders; a wool
roll bandage is then applied in aroll bandage is then applied in a
figure-of-eight fashion (2). Forfigure-of-eight fashion (2). For
added security the layers may beadded security the layers may be
lightly stitched together at thelightly stitched together at the
crossover (3).crossover (3).

Operative treatmentOperative treatment
Internal fixation of fractures of the clavicle in the acuteInternal fixation of fractures of the clavicle in the acute
situation may be considered in cases of so-called 'floatingsituation may be considered in cases of so-called 'floating
shoulder', where there is a fracture of the clavicle associatedshoulder', where there is a fracture of the clavicle associated
with a fracture of the proximal humerus or of the glenoid.with a fracture of the proximal humerus or of the glenoid.
Good fixation reduces pain, improves patient mobility, andGood fixation reduces pain, improves patient mobility, and
may facilitate union at each site.may facilitate union at each site.

Scapular fracturesScapular fractures
 Fractures of theFractures of the bladeblade of theof the
scapula are usually caused byscapula are usually caused by
direct violence. Even whendirect violence. Even when
comminuted and angled healingcomminuted and angled healing
is usually extremely rapid and anis usually extremely rapid and an
excellent outcome is the rule.excellent outcome is the rule.
 Treatment is by use of a broadTreatment is by use of a broad
arm sling and analgesics.arm sling and analgesics.
 Mobilisation is commenced asMobilisation is commenced as
soon as acute symptoms havesoon as acute symptoms have
settled, and is usually possiblesettled, and is usually possible
after 2 weeks.after 2 weeks.

Scapular fracturesScapular fractures
 Fractures of theFractures of the scapular neckscapular neck
lead to much bruising andlead to much bruising and
swelling. Comminution isswelling. Comminution is
common. In spite of frequentlycommon. In spite of frequently
daunting radiographs, a gooddaunting radiographs, a good
outcome usually followsoutcome usually follows
conservative management withconservative management with
early mobilisation.early mobilisation.
 Fractures of theFractures of the scapular spinescapular spine
or coracoidor coracoid may usually bemay usually be
treated conservatively.treated conservatively.

Fractures of the proximal humerusFractures of the proximal humerus
Mechanism of injury:
These fractures may be
caused by a fall on the side
(often leading to impacted,
minimally displaced
fractures) (1), by direct
violence or by a fall on the
outstretched hand.

Fractures in this region may
involve the anatomical neck (rare)
(1), the surgical neck (2), the
greater tuberosity (3) or the lesser
tuberosity (4). Combinations of
these injuries are common, and it
is customary to describe fractures
in this region by the number of
fragments involved, e.g. two-part
(5), three-part (6) and four-part
fractures (7).

Diagnosis:Diagnosis:
The patient tends to support theThe patient tends to support the
arm with the other hand (1).arm with the other hand (1).
There is tenderness over theThere is tenderness over the
proximal humerus (2) and inproximal humerus (2) and in
severely angled or displacedseverely angled or displaced
fractures there may be obviousfractures there may be obvious
deformity. Later, gross bruisingdeformity. Later, gross bruising
gravitating down the arm is angravitating down the arm is an
outstanding feature (3). (Thisoutstanding feature (3). (This
may worry the patient unlessmay worry the patient unless
this possibility has beenthis possibility has been
previously mentioned to him bypreviously mentioned to him by
the surgeon.)the surgeon.)

Radiographs (a):Radiographs (a):
The diagnosis isThe diagnosis is
established firmly by theestablished firmly by the
radiographs. Two featuresradiographs. Two features
may be clear: namely thatmay be clear: namely that
the fracture involves thethe fracture involves the
cancellous bone of thecancellous bone of the
head and neck and thathead and neck and that
there is impaction of thethere is impaction of the
fragments.fragments.

Treatment:Treatment:
Slightly displaced andSlightly displaced and
moderately angled humeralmoderately angled humeral
neck fractures may be treatedneck fractures may be treated
satisfactorily by externalsatisfactorily by external
support alone. Firstly, the armsupport alone. Firstly, the arm
should be supported in a slingshould be supported in a sling
(1) or a collar and cuff sling (2).(1) or a collar and cuff sling (2).

TreatmentTreatment
In addition, the arm should beIn addition, the arm should be
protected from rotationalprotected from rotational
stresses by a body bandage (e.g.stresses by a body bandage (e.g.
of crepe bandages) (1) under theof crepe bandages) (1) under the
clothes (2). Alternatively, anclothes (2). Alternatively, an
expanding net support may beexpanding net support may be
used and this is certainly moreused and this is certainly more
comfortable in hot weather. Paincomfortable in hot weather. Pain
is often severe, and analgesicsis often severe, and analgesics
will be required in the first 1-2will be required in the first 1-2
weeks.weeks.

After 2 weeks the body bandageAfter 2 weeks the body bandage
may be discarded unless pain ismay be discarded unless pain is
commanding. The sling shouldcommanding. The sling should
be worn under the outer clothes.be worn under the outer clothes.
The patient is advised to com-The patient is advised to com-
mence rocking movements of themence rocking movements of the
shoulder (abduction, flexion (1)shoulder (abduction, flexion (1)
and to remove the arm from theand to remove the arm from the
sling three or four times per daysling three or four times per day
to flex and extend the elbow (2).to flex and extend the elbow (2).

At 4 weeks the sling can beAt 4 weeks the sling can be
placed outside the clothes.placed outside the clothes.
Gentle active movementsGentle active movements
should be practisedshould be practised
throughout the day. Over thethroughout the day. Over the
next 2 weeks the patientnext 2 weeks the patient
should be encouraged toshould be encouraged to
discard the use of the sling indiscard the use of the sling in
gradual stages.gradual stages.

At 6 weeks the patient shouldAt 6 weeks the patient should
be referred for physiotherapy if,be referred for physiotherapy if,
as is usual, there isas is usual, there is
considerable restriction ofconsiderable restriction of
movement.movement.

Displaced fractures of theDisplaced fractures of the
anatomical neck:anatomical neck:
Severely displaced or angled
fractures of the surgical neck):
These fractures are often complicated byThese fractures are often complicated by
avascular necrosis of the humeral head.avascular necrosis of the humeral head.

Closed reduction of the fractureClosed reduction of the fracture
After reduction of the fracture, the limb should beAfter reduction of the fracture, the limb should be
supported in a broad arm sling and body bandage.supported in a broad arm sling and body bandage.

SurgerySurgery
If closed methods fail,If closed methods fail,
consider open reductionconsider open reduction
and internal fixation,and internal fixation,
using for example anusing for example an
intramedullary nailintramedullary nail withwith
proximal and distalproximal and distal
cross-bolting.cross-bolting.

Surgery (platting)Surgery (platting)
The fracture may be heldThe fracture may be held
with a plate and screws.with a plate and screws.

SurgerySurgery
Good results mayGood results may
also be obtained inalso be obtained in
this class of fracturethis class of fracture
using anusing an externalexternal
fixator systemfixator system..

SurgerySurgery in the elderly:in the elderly:
A jointA joint replacementreplacement
procedure may offer theprocedure may offer the
best chances of a goodbest chances of a good
functional result.functional result.

Fractures of the humeral shaftFractures of the humeral shaft
Fractures of the humeral shaft
may result from indirect violence
(e.g. a fall on the outstretched
hand) or from direct violence (e.g.
a fall on the side or blow on the
arm).
In fractures involving the upper
third the proximal fragment tends
to be pulled into adduction by the
unopposed action of pectoralis
major.

In fractures involving the mid
third, the proximal fragment
tends to be abducted due to
deltoid pull.
Radial nerve palsy, and non-
union are commonest in middle
third fractures, and open
fractures of the humerus are
seen most often at this level.

Diagnosis (a):
The arm is flail and the patient
usually supports it with the other
hand. Obvious mobility at the
fracture site leaves little doubt
regarding the diagnosis.
Confirmation is obtained by
radiographs, which seldom
give difficulty in interpretation.

Diagnosis (b):
In all cases, look for evidence
of radial nerve palsy –
drop wrist (1) and sensory
impairment on the dorsum of
hand (2).

Treatment (a):Treatment (a):
Simple, single fractures maySimple, single fractures may
be treated by thebe treated by the application of a U-application of a U-
plasterplaster. If angulation is slight, no. If angulation is slight, no
anaesthetic is required. The patientanaesthetic is required. The patient
should be seated (1) andshould be seated (1) and
a plaster slab prepared of about eighta plaster slab prepared of about eight
thicknesses of 15 cm (6") plasterthicknesses of 15 cm (6") plaster
bandage (2). The length should bebandage (2). The length should be
such as to allow it to stretch from thesuch as to allow it to stretch from the
inside of the arm round the elbow andinside of the arm round the elbow and
over the point of the shoulder (3).over the point of the shoulder (3).

Treatment (b):Treatment (b):
Wool roll is then appliedWool roll is then applied
to the arm (4). Particularto the arm (4). Particular
attention is paid to theattention is paid to the
elbow. The paddingelbow. The padding
should extend from theshould extend from the
shoulder to a third of theshoulder to a third of the
way down the forearm.way down the forearm.

Treatment (c):Treatment (c):
The slab is now wettedThe slab is now wetted
and applied to the arm,and applied to the arm,
starting on the medialstarting on the medial
side at the axillary foldside at the axillary fold
(5) and then bringing it(5) and then bringing it
round the elbow up toround the elbow up to
the shoulder. The slabthe shoulder. The slab
should be carefullyshould be carefully
smoothed down.smoothed down.

Treatment (d):Treatment (d):
The plaster is securedThe plaster is secured
with a wet open weavewith a wet open weave
cotton bandage (6)cotton bandage (6)

Hanging cast methodHanging cast method ofof
treatmenttreatment::
The principle of this form ofThe principle of this form of
treatment is that the weighttreatment is that the weight
of the limb plus the plasterof the limb plus the plaster
reduce the fracture andreduce the fracture and
maintain reduction (1). Amaintain reduction (1). A
long arm plaster (2) islong arm plaster (2) is
applied along with a collarapplied along with a collar
and cuff sling (3).and cuff sling (3).

 Consider internal fixation if there is aConsider internal fixation if there is a
segmental fracture, two fractures insegmental fracture, two fractures in
the same limb; multiple injuries,the same limb; multiple injuries,
fractures of both arms, a significantfractures of both arms, a significant
head injury, pathological fracture, ahead injury, pathological fracture, a
radial nerve palsy in an open andradial nerve palsy in an open and
otherwise suitable fracture, or afterotherwise suitable fracture, or after
failed manipulation.failed manipulation.
 The most reliable method is to use aThe most reliable method is to use a
plate (1) applied to the posteriorplate (1) applied to the posterior
surface with an interfragmental screwsurface with an interfragmental screw
(2).(2).
 Alternatively, an intramedullary nailAlternatively, an intramedullary nail
with interlocking screws may be used.with interlocking screws may be used.

INJURIESINJURIES
TO ELBOWTO ELBOW
AND FOREARMAND FOREARM

Supracondylar fractures
of the humerus
A supracondylar fracture
occurs in the distal third of
the bone. The fracture line
lies just proximal to the bone
masses of the trochlea (1)
and capitulum (capitellum)
(2) and often runs through
(3) olecranon fossae.

of the humerus
Occurrence:
The supracondylar
fracture is a common
fracture of childhood;
It generally results
from a fall on the
outstretched hand

of the humerus
Diagnosis:
The olecranon and medial and
lateral epicondyles preserve
their normal equilateral
triangular relationship (unlike
dislocation of the elbow, also
common in children). There is
tenderness over the distal
humerus, there may be marked
swelling and deformity, and the
child generally resists
examination. Radiography is
mandatory, but interpretation
requires care.
(in children)

of the humerus
Radiographs (a):
The interpretation of radiographs is made
difficult by the changing complexities of
the epiphyses. Typical appearances at
ages 2, 4, 6 and 9 years are shown.
Note:
 C = capitulum - present usually within the
first year of life;
R = radial head - appears 3-5 years;
 M = medial epicondyle - present by 6;
 T = trochlea - appears 7-9;
 L = lateral epicondyle - 11-14; (Olecranon
-8-11 years.)
(in children)

of the humerus
Radiographs (b):
In fractures associated with
more violence, the next
detectable sign may be a
hairline crack, visible on the
AP view only (2). With more
violence, the fracture line will
be detectable in the lateral
projection as well (3). Next,
the distal fragment is tilted in a
backward direction (4)
(in children)

of the humerus
Radiographs (c):
With still greater violence there is
backward displacement (5), often leading
to loss of bony contact. In the AP view
there is often medial or lateral shift of the
epiphyseal complex (M). The complex
may also be rotated relative to the
humeral shaft (generally lateral rotation).
Rarely, as a result of other mechanisms
the distal fragment is displaced and titled
anteriorly (A). Occult fractures may be
suggested by the posterior fat pad
becoming apparent in the lateral
projections.

of the humerus
Interpretation of radiographs (a):
Certain displacements showing in the
lateral give a clear guide to the
necessity for reduction.
(1) Displacement with accompanying
evidence of arterial obstruction. (This
absolute also applies to angled
fractures with vascular complications.)
(2) (2) Displacements with complete loss of
bony contact.
(3) Ideally, where the displacement is such
that there is less than 50% of bony
contact.
(in children)

of the humerus
Interpretation of radiographs (b):
Reduction is required if there is
significant lateral or medial tilting.
Note that the normal 'carrying angle'
of the elbow is about 10°. Cubitus
varus and cubitus valgus do not
remodel well, and may ultimately be
associated with tardy ulnar nerve
palsy. Some regard any degree of
tilting as significant and meriting
correction, and certainly a deformity of
10° and above is unacceptable.
(in children)

of the humerus
Interpretation of radiographs (c):
Reduction is required if there is any
significant rotational deformity. This
is generally most obvious in the
lateral projection. (Left above: no
rotational (torsional) deformity
present; Right: rotational deformity
present.) Rotation, like cubitus
valgus and varus, does not remodel
well. In this context 'significant' is in
effect any degree of rotation that is
obvious in the plain films.
(in children)

of the humerus
The arm should be manipulated
under general anaesthesia.
Gentle/moderate traction is
applied at about 20° of flexion
while an assistant applies
counter-traction. This leads to
disimpaction of the fracture.
Some surgeons advise that this
and the following stages should
be carried out with the arm in
supination.
(in children)

of the humerus
Now, maintaining traction
and counter-traction (1),
flex the elbow to 80° (2).
This lifts the distal
fragment, thereby reducing
any posterior displacement
and correcting any
backward tilting (anterior
angulation).
(in children)

of the humerus
Fixation:
Unfortunately further
extension of the elbow may
be required to restore the
circulation. In such cases,
apply a generous layer of
wool (1), followed by along
arm plaster slab (2) secured
with bandages and a sling
(3).
(in children)

of the humerus
Check radiographs:
Check radiographs must now
be taken in two planes. (For
interpretation of AP
radiographs, see later.) In the
lateral projection illustrated
there has been a good
reduction: note how all
posterior displacement has
been corrected and the normal
angulation of the epiphyseal
complex has been largely
restored.

of the humerus
Late development
of ischaemia:
If while under observation the
pulse disappears, and
especially if there are other
signs of ischaemia, all
encircling bandages should be
cut, and all wool in front of the
elbow teased out. If this does
not lead to improvement, the
elbow should be placed in a
more extended position (e.g.
by cracking the slab and
slackening the sling).
(in children)

of the humerus
If a good reduction has been
obtained and the pulse remains
absent (this occurs in 3% of
cases) the circulation should be
checked more critically. The
use of a pulse oximeter before
and after manipulation is often
helpful. If the hand is warm and
pink, with good capillary return
in the nails, there is no
immediate indication for further
intervention.
(in children)

of the humerus
If there are incontrovertible
signs of gross ischaemia,
either in the face of a good
reduction or a failed
reduction, exploration of the
brachial artery must now be
undertaken. (Volkmann's
ischaemic contracture
occurs in roughly once in
every thousand cases of
supracondylar fracture, and
is generally avoidable.)
Exposure of the artery is
straightforward,
(in children)

of the humerus
Exploration of brachial
artery
The skin edges are reflected
and the bicipital aponeurosis
(1) divided close to the tendon
(2). The arm is put in full
pronation and the space (5)
between brachioradialis
laterally (3) and pronator teres
medially (4) opened up with
the finger tips.
(in children)

of the humerus
Exploration of brachial artery
The brachial artery (A) is found
lying close to the biceps tendon.
The median nerve (M) lies on its
medial side. The fracture lies deep
to the brachialis (B) in the floor of
the wound. In some cases relief of
local pressure on the vessel (e.g.
from the fracture) may restore the
circulation, but other measures,
requiring experience in vascular
surgery, may be necessary.

of the humerus
Vascular complications (a):
Where there is appreciable
displacement of the fracture, the
brachial artery may be affected by the
proximal fragment. In the majority of
cases this is no more than a kinking
of the vessel, but occasionally
structural damage to the wall may
occur, with the risk of Volkmann's
ischaemic contracture. (Rarely, the
neurovascular bundle is trapped
between the fracture and the biceps
tendon, with tethering of the overlying
skin; this is an indication for
exploration.)
(in children)

of the humerus
Vascular complications (b):
In every case check and record the
circulation prior to any manipulation.
Seek the radial pulse, and note any
evidence of arterial obstruction (pallor
and coldness of the limb, pain and
paraesthesia in the forearm, and
progressive weakness of the forearm
muscles). Look for excessive swelling
and bruising round the elbow.
Neurological complications:
Note any evidence of impaired function
in the ulnar, median or radial nerves,
said to occur in 6-16% of cases.
(in children)

of the humerus
Reduction failure
Skeletal traction may be
employed: this may be achieved
with a butterfly screw or similar
device in the ulna. Traction is
applied with weights, and the
forearm supported with a sling.
Elbow flexion may be controlled
with the sling which may be
elevated or lowered as thought
necessary - this avoids any
direct pressure in the antecubital
fossa.
(In children)

of the humerus
The K-wires (a) may cross the
growth plate without causing any
obvious growth problem. They
should remain proud of the skin
(c). Single wire fixation is less
secure and is not recommended.
Additional support with a cast
and sling is recommended. The
wires may be removed as an
out-patient procedure, without
anaesthetic, after 3—4 weeks.
(in children)

of the humerus
Aftercare:
Mobilisation may be
commenced from a sling
(i.e. the arm is removed
from the sling for 10
minutes‘ active exercises
three to four times per
day). The sling is
discarded as soon as any
discomfort has settled.
(in children)

Medial epicondylar injuries
The medial epicondyle (1)
may be pulled off by the ulnar
collateral ligament (2) when
the elbow is forcibly abducted
(3). It may be injured by direct
violence, and possibly
avulsed by sudden
contraction of the forearm
flexors which are attached to
it (4). Suspect if there is
medial bruising (5) and
always test the integrity of the
ulnar nerve (6).
(in children)

Medial epicondylar injuries
The medial
epicondyle must be
extracted through a
small anteromedial
incision and held in
position by K-wires
(retained for 3
weeks).
(in children)

Adult fractures at the elbowAdult fractures at the elbow
Fracture of a single
condyle in the adult
Where there is
displacement (3), best
results are obtained by
open reduction and
internal fixation: this can
usually be achieved using
one or two cancellous lag
screws (4), with an
additional plate along the
supracondylar ridge if
required.

Adult fractures at the elbowAdult fractures at the elbow
Intercondylar fractures
After reduction insert a cannulated
screw (1) and compress the fragments
using a cancellous screw (2). The
articular complex may then be lined up
with the shaft, and temporarily held with
K-wires (3). Then a posterolateral 3.5
mm reconstruction plate (4), and a
medial dynamic compression or
reconstruction plate (5) may be used to
hold the articular complex in alignment
with the shaft. Additional compression
screws may be used (6) and defects
should be packed with bone grafts

Dislocation of the elbowDislocation of the elbow
The lateral shows
posterior and proximal
displacement. These
combined appearances
are those found in the
commonest dislocation
of the elbow, the
posterolateral
dislocation.

Treatment (a):
Reduction should be carried
out under general anaesthesia.
A fair amount of force is often
required, although the use of a
muscle relaxant will reduce
this. Apply strong traction in
the line of the limb, and if
necessary slightly flex the
elbow while maintaining
traction. Success is usually
accompanied with a
characteristic reduction 'clunk'.

Treatment (b):
If the last manoeuvre
is unsuccessful, clasp
the arm and push the
olecranon forwards
and medially (1), using
traction in moderate
flexion (2) and
countertraction with
the fingers (3).

Treatment (c):
 After reduction has been
achieved, take check
radiographs, and apply a
padded crepe bandage; this
may be worn with a sling for
two weeks (4).
 Alternatively, apply a plaster
back slab and sling with the
elbow in 90° flexion (5). Avoid
too early or too vigorous
mobilisation, and also passive
movements which run the risk
of myositis ossificans.

PosteriorPosterior
dislocationdislocation
This may result from a fall onThis may result from a fall on
the outstretched, internally rotatedthe outstretched, internally rotated
hand or from a direct blow on thehand or from a direct blow on the
front of the shoulder. The head offront of the shoulder. The head of
the humerus is displaced directlythe humerus is displaced directly
backwards and, because of this, abackwards and, because of this, a
single AP projection may showsingle AP projection may show
little or no abnormality aslittle or no abnormality as
illustrated here. Nevertheless,illustrated here. Nevertheless,
clinically there is pain, deformityclinically there is pain, deformity
and local tenderness.and local tenderness.

Posterior dislocationPosterior dislocation
Treatment (a):
Reduction is usually easily accomplished by applying traction toReduction is usually easily accomplished by applying traction to
the arm in a position of 90° abduction (1) and then externallythe arm in a position of 90° abduction (1) and then externally
rotating the limb (2). If the reduction appears quite stable therotating the limb (2). If the reduction appears quite stable the
arm should be rested in a sling as described for anteriorarm should be rested in a sling as described for anterior
dislocation of the shoulder.dislocation of the shoulder.

Posterior dislocationPosterior dislocation
Treatment (b):
If the reduction is unstable, it is
essential that the arm be kept in 60°
lateral rotation for 4 weeks to give the
torn capsule and labrum a reasonable
chance of healing. This can only be
reasonably achieved by the
application of a shoulder spica, with
the shoulder abducted to about 40°,
externally rotated 60° and fully
extended.

Fracture of Shoulder and Humerus

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