Upper Extremity Trauma – Miller

Trauma – Upper Extremity Brachial plexus injury - Preganglionic o Motor def o Horner’s sx o Winged scapula o Nonfx rhomboids o Diaphragmatic paralysis o Intact sensation (DRG attached to axon) o Cervical paraspinal M denervation on EMG - Postganglionic o Flail arm o Both sensory/motor absent o Cervical paraspinal M ok on EMG - Acute exploration o Only for sharp penetrating trauma (not GSW) o Open fx o Progressive neuro deficit (hematoma) o Upper plexus injuries better outcome (hand fx preserved) - Reconstructive priorities o Elbow flexion o Shoulder abduction o Hand sensibility o Wrist extension, finger flexion o Wrist flexion, finger extension Clavicle Fx o Medial aspect – last long bone to ossify 20 yo o Last epiphysis to close 25 yo o Imp to distinguish SC dislocations from physeal fx o Medial third fx  Principal deformity in malunions is ant angulation o Middle third fx  Lateral shaft consistently displaced posteriorly to medial shaft fragment o Lateral third fx  Type I b/w intact CC lig Type II medial CC lig w/ unstable medial fragment  A – conoid/trapezoid intact  B – conoid torn  Type III fx into AC jt, med lig intact  Type IV periosteal sleeve w/ intact CC lig  Type V comminuted fx  Type I, III, IV nonoperative  Type II, V operative – 90% good results  Distal clavicle fx more commonly have nonunions  Primary ORIF w/ complication rate 10%  Nonunion rate 30-45%  Some studies say most type II distal clavicle can be tx nonsurg o Outcomes  31% pt report shoulder weakness, fatigability, parasthesias of hand, forearm  fx w/ > 2 cm of shortening ass w/ poor outcome o Malunion  RF: open fx, comminution, initial shortening > 2 cm SC jt only 50% contact, fibrocartilage o Capsular ligament  Anterior portion strongest – restraint to superior displacement o Costoclavicular ligament  Superior/inferior rotation o Intra-articular disk ligament  Checkrein vs. medial displacement o Anterior dislocation – palpable bump increased by arm abduction  Tx general anesthesia  Abduction, extension arm  Direct pressure over medial clavicle  Trauma – Upper Extremity o Posterior dislocation – dyspnea, paresthesias (BP), limited shoulder ROM, relief of pain toward affected side  Abduction, extension arm  Manipulate medial clavicle w/ towel clip o Serendipity view  40 deg cephalic tilt o Medial clavicle excision  Indications – chronic/recurrent dislocations, pers pain  Must have costoclavicular lig intact  Do not resect more than 1.5 cm  If they are torn at surgery, then should repair them o Medial clavicle physeal fx  Age < 25  Most injuries will remodel  Anterior displacement –  Attempt closed reduction  Figure of 8 harness  Posterior displaced physeal fx should be reduced  If irreducible o Asx, < 23, then observe o Sx, > 23, open reduction AC injuries o Type I – sprain o II AC tear, CC intact o III AC and CC out w/ 25-200% subluxation o IV – post clavicle displacement through trapezius o V – III w/ > 100% displacement o VI – II w/ inferior displacement o IV-VI ORIF o III controversial – if elite athlete, laborer then surgery Scapula fx o 50% involve body/spine o high energy trauma o union @ 6 wks o surgery  involvement > 25% glenoid, humeral subluxation  step-off > 5mm or gap  > 40 deg angulation, 1 cm translation of neck fx  Floating shoulder – pt in sling had equal or superior outcome to pt treated surgically  Glenoid: 5mm displ, any subluxation of humeral head  Neck: 2cm displ, 40 deg ang o Floating shoulder  Functional scores equal surg or nonsurg  Surg results in better FF, but weaker ER (surg approach) ST disassociation o Intrathoracic – inf edge of scapula wedged b/w 2 ribs  Tx w/ arm abduction, manipulation o Lateral  Vascular injury common – subclavian  Arteriography, immediate repair  BP injury Shoulder dislocation o Westpoint view: anterior glenoid margin o Stryker notch view – Hill-Sachs defect o RTC tear w/ GT fx – beware in > 40 yo o Axillary neuropraxia 10%, follow w/ EMG’s o Open better than arthroscopic repair o Inferior dislocation – luxatio erecta  Greater incidence of NV injury  May resolve after reduction  Late thrombosis Trauma – Upper Extremity o Posterior dislocation  < 5% of all dislocations  associated w/ lesser tuberosity fx (esp isolated)  unable to externally rotate shoulder  common w/ seizures, electrocutions  50% have associated impaction fx b/w articular margin, LT of humeral head  20-40% defect, transpose LT w/ subscap into defect  > 40% defect – hemiarthroplasty o Anatomy  Primary supply from anterolateral branch of anterior humeral circumflex artery  Runs in intertubercular groove (medial to GT)  Interosseus anastomosis Proximal humerus fx  Osteoporosis just as much a RF as fall risk is  Nerve injury in 67% of pt (by EMG)  2 part surg neck  shaft anterior and medially by pec  head and attached tuberosities neutral  2 part GT  SS/IS/TM retract fragment superiorly and posteriorly  45% incidence of nerve injury (axillary MC)  musculocutaneous – ends in lateral antebrachial cutaneous N.  anatomic neck fx – 1 part  ORIF in young  Hemi in old  2 part LT  posterior dislocation  ORIF if large fragment   Excise w/ small w/ RTC repair 2 part GT  blocks ER and ABD  accept minimal displacement  tension band  > 5mm displ – surgery 2 part surgical neck  anterior/varus most poorly tolerated deformity  > 45 deg angulation  posterior better tolerated  orif o PP o Plate fixation o Enders rods o IM device 3 part  trend away from ORIF  prosthetic replacement w/ tuberosity reconstruction is tx of choice in elderly  in young, PP may be best or blade plate  plates lateral to bicipital groove to avoid ant hum circum artery 4 part  hemi better than TSA  ORIF in young pt  Hemiarthroplasty in older pt vs. nonop Tx (sling immob) o Restore head height o Reattach tuberosities to shaft  Most pt develop ON, but results good Locking compression plate more elastic than spiral blade, T-plate, nail (better in osteo bone) Valgus impacted 4 part fx  Excellent results w/ ORIF  Low rate of AVN Arthroscopy  2-part fx w/ 31% inc of complete labral tear       Trauma – Upper Extremity  3- & 4-part fx w/ 10% complete labral tear  Fx-dislocations w/ 56% labral tear  20% fx have full-thickness RTC tear, 30% w/ partial Hemiarthroplasty  Late arthroplasty inf to acute replacement  Fx type, gender, type of prosthesis irrelevant w/ outcome  Inc age, inc preoperative delay (> 2 wks), poor tuberosity reduction – poorer outcome  Prosthesis too high, too retroverted, w/ low GT – poor outcome  MC mistake – excessive retroversion  Average offset in pt w/ good outcome sign higher than offset in bad outcomes  > 23mm offset, head height < 14mm – good outcome  head-to-tuberosity distance is 8 mm  GT should be placed 10mm below art surf of hum head  Severe tuberosity nonunions – reverse prosthesis Complications  Hemiarthroplasty o Tuberosity pull-off and nonunion MC causes of failure o Active assisted ROM exercises delayed until healing of tuberosities at 6-8 wks  TSA o Excessive anteversion of humeral/glenoid components results in anterior instability  MC – missed dislocations    Adhesive capsulitis Malunion AVN – usu req TSA   Humeral Shaft Fx - Function brace 8-12 wks - 50-80% nonunion rate w/ 8 degrees varus - acceptable deformity o 20 deg anterior angulation o 30 v/v o 3 cm shortening - indications for operative indication – absolute o open fx o vascular injury o floating elbow o intra-articular injuries - relative indications o IMN in polytrauma pt o Nerve injury after reduction o Pathologic fx (IMN w/ cementation) - ORIF o 4.5 mm DCP o minimum of 6 cortices above and below - IMN o Higher nonunion rates o Higher incidence shoulder problems  16-37% pt o Consider in path fx, segm fx, osteopenic bone o Adv: preserve fx hematoma, blood supply o Insert 2 cm distal to surg neck, 3 cm prox to olecranon fossa o Must explore radial nerve before IMN distal 1/3 fx - Nonunions o Defined as p 24 wks o ORIF w/ 4.5 DCP, bone graft o 6 cortices o vasc free fibular bone graft for failed conventional technique  heals similar to acute fx, in contrast to creeping subst (allograft) Trauma – Upper Extremity Neuropraxia of radial nerve o Highest in mid to distal 1/3 fx o Transverse fx MC associated o Spiral fx MC ass w/ laceration/entrapment o > 70% recovery over 3 mo o for palsies  EMG/NCV @ 6 wks  Fasiculations – continued observation  Fibrillations – then exploration o Holstein-Lewis fx  Palsy post-reduction – should be explored o For other fx post-reduction, controversial Complications o Varus common o Transverse fx MC develop angular deformity  o HO     MC in anterior elbow approach Delayed surgery Prophylaxis w/ XRT and excision Excision early (before it matures) Higher in nonunion pt esp valgus deformity - Distal Humerus Fx - unsatisfactory in 25% of pt - BM support for parallel plates of medial, lateral aspects of columns - Avulsion fx – medial MC than lateral - Metaphyseal fx – disrupted medial/lateral columns o Dual plating – 90 deg offset posterolateral, medial greatest rigidity - Milch I: lateral trocheal ridge intact o Tx: if nondisplaced, then early ROM o SH IV - Milch II: Fx through lateral trochlear ridge o ORIF o SH II - Total elbow arthroplasty o In older pt, small fragments, osteopenic bone o more prone to infx than TKA/THA - Complications o Ulnar neuropathy  MC complication Capitellum Fx - Extends into lat trochlear lip o may also inv fx of lat epi - olecranon osteotomy for post troch fx - Can be mechanical block to flexion - Ass w/ radial head fx & post elbow dislocations - Type I: Hahn-Steinthal, fx in coronal plane - Type II: Kocher- Lorenz, Sleeve fx of art surface - Type III: comminuted - Less than 2 mm displacement – early ROM - ORIF for larger fragments - Osteochondritis of capitellum seen in gymnasts Olecranon Fx - Type I – nondisplaced o Splint w/ elbow 45-90 deg - Type II-A o Minimal communition, stable o Fx does not extend distal to coronoid o Conventional tension band wiring technique - Type II-B o Fx distal to coronoid process o Tension band often inadequate o Contoured 3.5 DCP best - Excision up to 50% olecranon fx, reattachment of triceps = ORIF results o Instability can occur if > 60% taken or if ass coronoid fx present o Integrity of ant bundle of MCL critical - Trans-olecranon fx-dislocation o Tx: early ROM o Uncommon w/ ligament injury Trauma – Upper Extremity Coronoid Fx - Important for anterior stability - Ant buttress of greater sigmoid fossa - Att site for anterior bundle of MCL - Usu seen w/ instability or fx dislocation - Ass w/ recurrent instability - Type I – shear fx of tip (not an avulsion) - Type II – up to 50% - seen w/ elbow dislocations, radial head fx - Type III – more than 50% - involve olecranon - Tx w/ screw, nonabsorbable suture - Early ROM when stable Radial head fx - Head/neck fx in 50% dislocations - MC in anterolateral portion of radial head o Area w/o art cartilage and subchondral bone weaker - unhealed fx @ 1 yr can still heal 2 yr later - Ass w/ DRUJ injury - Mason I o Minimal, nondisplaced o < 2mm disp o some loss of extension < 15 deg - Mason II o Displacement greater than 2mm of head o Motion may be mechanically blocked o ORIF - Mason III o Severe comminution of neck o Acute excision never indicated w/o replacement o Excise  If not amenable ORIF  No interosseus/DRUJ/MCL injury o Kocher approach  b/w anconeus (radial N) and ECU (PIN)  keep arm pronated to protect PIN o HDWR safe zone  110 deg area of nonarticulation Essex-Lopresti o Radial head fx w/ IM disruption, DRUJ dislocation o Blocked supination, hand w/ radial deviation o Must keep radial head 3+ frag = high rates of failure, nonunion, poor FA rotation p ORIF Resection ok only if coronoid not fx Silicone head will not prevent proximal migration Metal head improved results, modular o always use smaller head (not overstuff jt) - Elbow dislocation - Progression of inj is from lat to med - Position of FA in relation to humerus o Posterolateral > 80% of all - Ass injuries o Terrible triad: elbow dislocation, coronoid fx, radial head fx - Primary stabilizers o Ulnar trochlear articulation o Anterior band of MCL – attaches to coronoid process  Resection will cause gross instability x in extension o Ulnar portion of LCL - MCL o Resists valgus forces o Primary stabilizer of elbow (esp ant band) o More contribution in 90 deg of flexion o Resection will cause gross instability except in extension - Unstable elbow – small fx of ant-med facet of coronoid process o leads to post-med varus rot instab patterns - Tx o Early closed reduction o Check ROM after reduction o Splint in 90 deg for several days, then ROM Trauma – Upper Extremity o Immobilize > 3 wks, detrimental to elbow motion o No clear advantage to acute repair of ligaments o post olecranon fx-dislocations worse outcomes than ant Pivot shift to test stability o Recurrent instability 1-2% of simple dislocations o Reconstruction of lateral UCL 80% successful  w/ posterolateral instability o Usu anterior band MCL is torn in dislocation radial head excision even w/ stable MCL o HO 20% w/ elbow dislocation & fx o elbow contracture should be released p 6 mo Primary Degen Arthritis o pain on terminal flexion and extension  Tx: Outerbridge-Kashiwagi ulnohumeral arthroplasty Post-traumatic arthritis o total jt arthroplasty not good o interposition arthroplasty tx of choice 50% loss of elbow motion results in 80% loss of fx to UE no single ideal position for arthrodesis Total elbow arthroplasty o static loading cond of elbow result in forces = 3x body weight o dynamic loading = 6x body weight o linked prosthesis may be used in pt w/ bone loss  recommended for elderly pt w/ comminuted intra-art fx of dist hum  rec for dist hum nonunions o infx rates 2-5% - - - - Elbow Reconstruction - elbow arthroscopy o rate of perm neuro inj higher in elbow than knee or shoulder o nerve inj higher in pt w/ RA or in those undergoing capsular release - instability o 3 prim static constraints  ulnohumeral articulation  ant band of MCL  LUCL o anconeus is dyn stab vs. PL rotatory instab o if coronoid fx, then radial head is primary stabilizer o Posterolateral Rotatory Dislocation  valgus moment w/ FA supination  w/ instab, sx occur during ext arc w/ FA in sup o Posteromedial Rotatory Dislocation  varus moment w/ flexion  key is ant-med coronoid fx o Recurrent valgus instab  rupture of MCL  poss radial head fx o Radial head replacement  accelerated degen process occurs at ulnohum jt after Radius and Ulna fractures - Nonoperative tx for nondisplaced isolated ulna fx o Distal 2/3 ulna fx w/ < 50% displacement, < 10 deg angulation o Functional fracture brace - Isolated radial shaft fx – nondisplaced – nonoperative only if o Radial bow must be intact o Usu ORIF best tx option - Rotational malalignment of ulna less impact on rotation than radius - Adv of longer plates, bicort screws in FA - Approaches o Radius  Volar – Henry – interval b/w BR (rad N) and PT/FCR (med N.) Trauma – Upper Extremity Dorsal – Thompson – PIN at risk in prox third  ECRB (rad N) and EDC/EPL (PIN)  Ulna  ECU and FCU (PIN and ulnar) o DCP 3.5 mm standard AO o IMN cannot maintain radial bow, higher nonunion rate Galeazzi – distal 1/3 radius fx, DRUJ injury o If DRUJ irreducible – open and remove ECU tendon  Tx w/ immobilization for 6 wks in supination or PCP 4 wks o Tx: ORIF radius, stabilize DRUJ o radial shaft fx more than 7.5 cm from jt unlikely to inj DRUJ Monteggia Fx – dislocation of rad head, ulna fx o 20% associated PIN palsy, esp w/ Type III open fx o tx ORIF ulnar shaft, reduce radial head o Post diff to tx  prox ulna w/ poor bone  fx coronoid comminuted  fx radial head – dec FA rot  ulnohum jt unstable complications o increase of re-fracture: persistent loosening, early removal of plate, use of thick plates o synostosis (radius and ulna fixed w/ one incision), bone grafting, infx, CHI, BBFX at same level  delay excision until mature (1 yr)  proximal and distal poor results (even after resection)  midshaft – better results  Ulnar styloid fx denotes higher energy fx, greater radial displacement Acceptable reduction o Change in palmar tilt < 10 deg o Radial shortening < 2 mm o Change radial angle < 5 deg Repeat reduction attempts (rtc visits) w/ 50% satisfactory results PP best in unstable extra-articular fx (stable volarly) Ex fix does not reliably restore 10 deg palmar tilt o Limit duration 7-8 wks (need to preserve digital ROM) o Avoid over-distraction (distraction > 5 mm poor prognosis) Compartment sx o Carpal tunnel pressure lowest w/ wrist in neutral position DRUJ injuries may entrap ECU, EDM TFCC primarily stabilizer of DRUJ DRUJ o Acute management much better than late recon o Requires anatomic reduction w/ PP EPL MC tendon to rupture due to attrition o Tx w/ EIP tx o Can have tenosynovitis 1st, 3rd compartments Ulnar styloid fx o High energy to wrist o Fx thru base ass w/ rupture of TFCC, DRUJ instability Ulnar impaction o Radial shortening o Positive ulnar variance o Lunate chondromalacia o Can tx w/ ulnar shortening o Wafer procedure – preserving attachments of TFCC - - - - - - - - - Distal Radius Fx - Volar tilt 11 deg - Nl radial height 12 mm, inclination 23 deg Gamekeeper’s Thumb - Proper collateral ligament o Tight in flexion - Accessory collateral ligament Trauma – Upper Extremity o Tight in extension Top ten - Clavicle fx – ORIF only medially unstable, open, skin compromise, vasc inj - Isolated LT fx – posterior shoulder dislocation, clinically unable to ext rotate - Higher incidence of humeral nonunion w/ ORIF over closed management o Need 4.5 plate, 6 cortices above and below - Radial N. deficit – EMG/NCV @ 6 wks if fasciculations present – observation - MCL torn in all elbow dislocations o + pivot shift – reconstruct LUCL