Upper extremity - Cambridge University Press

Part I

Upper extremity

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Cambridge University Press978-0-521-67859-9 - Practical Procedures in Orthopaedic Trauma Surgery: A Trainee’s CompanionEdited by Peter V. Giannoudis and Hans-Christoph PapeExcerptMore information

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1

Fractures of the claviclePeter V. Giannoudis

1.1 OPEN REDUCT ION AND INTERNALF IXAT ION (OR I F ) OF MIDSHAFTFRACTURES

Indications

(a) Open fractures.(b) Painful non-union.(c) Associated injury to the brachial plexus and/or sub-

clavian artery.(d) Floating shoulder.(e) Bilateral fractures.(f) Multiple-injured patient.(g) Soft tissue interposition between the fragments.(h) Impending skin necrosis or penetration from a

prominent fragment.

Pre–operative planning

Clinical assessment

� Mechanism of injury: motor vehicle accident, sportsinjury, fall on outstretched hand, direct trauma.

� Deformity, ecchymosis, swelling, tenderness, crepita-tion.

� Look for pneumothorax or haemothorax, especially inpresence of associated injuries.

� Assess and document vascular status of the upper armand any difference in peripheral pulses between theinjured and contralateral extremity.

� Assess neurological status (usually brachial plexusinjury presents as an upper roots traction injury).

Radiological assessment

� Anteroposterior view of the clavicle, including stern-oclavicular and acromioclavicular joints (Fig. 1.1).

� Oblique views.� Lordotic view (usually after surgery for ORIF evalua-

tion).

Operative treatment

Anaesthesia

� General anaesthesia at induction.� Administration of prophylactic antibiotics as per

local hospital protocol (usually second generation ofcephalosporin is administered).

Table and equipment

� AO small fragment (3.5 mm) set.� Ensure availability of the pre-planned plate length. A

3.5 DCP plate or a reconstruction plate can be used(Fig. 1.2a,b).

� Standard osteosynthesis set as per local hospitalprotocol.

Table set up

� The instrumentation is set up on the side of the oper-ation.

� Image intensifier is from the ipsilateral side.� Position the table diagonally across the operating room

so that the operating area lies in the clean air field.

Practical Procedures in Orthopaedic Trauma Surgery: A Trainee’s Companion, ed. Peter V. Giannoudis and Hans-Christoph Pape.

Published by Cambridge University Press. C© Cambridge University Press 2006.






4 Practical Procedures in Orthopaedic Trauma Surgery

Fig. 1.1 Anteroposterior view of the clavicle, including

sternoclavicular and acromioclavicular joints.

Draping and surgical approach

� Skin preparation is carried out using usual antisepticsolutions (aqueous/alcoholic povidone-iodine).

� Prepare the skin of the chest to the medial border of thescapula. Clean up to the anterior and lateral surface ofthe neck and down to below the level of the nipple.

� Use single U-drapes (Fig. 1.3 a,b).� Make an incision over the clavicle (Fig. 1.4 a,b).� Using the cutting diathermy bring down the incision

through the skin to the periosteum (Fig. 1.5).� Identify the clavicle and the fracture fragments.� Perform a subperiosteal dissection on the clavicular

edge and circumferentially only at the fracture site(Fig. 1.6).

� Drill a hole to the bone through a plate hole above thedistal fragment and affix the plate to the distal fragment(Fig. 1.7).

� Then reduce the proximal fragment and secure theplate positioning over the bone by using a clamp.

� Place one screw at the proximal fragment and ensurereduction maintenance with fluoroscopic control(Fig. 1.8).

� Place the rest of the screws in the same manner(Fig. 1.9).

� Cancellous bone grafting is performed for bone defectsor devitalized bone.

� Ensure fracture reduction, adequate screw length withfluoroscopic Lordotic views.

Closure

� Closure is performed as a full-thickness layer over theplate using 2/0 Vicryl and 3/0 subcuticular sutures forthe skin (Fig. 1.10 a,b).

(a)

(b)

Fig. 1.2 a,b A 3.5 DCP plate or a reconstruction plate can be used.

Post-operative treatment

� Assess and document the neurovascular status of theextremity.

� Obtain post-operative radiographs (Fig. 1.11).� Use a sling for the initial 10 post-operative days (Fig.

1.12).






1.1 ORIF: midshaft fractures 5

(a) (b)

Fig. 1.3 a,b Positioning and draping of the patient.

(a) (b)

Fig. 1.4 a,b Make an incision over the clavicle.

Fig. 1.5 Using the cutting diathermy bring down the incision

through the skin to the periosteum.

Fig. 1.6 Perform a subperiosteal dissection on the clavicular edge

and circumferentially only at the fracture site.







Fig. 1.7 Drill a hole to the bone through a plate hole above the

distal fragment and affix the plate to the distal fragment.

Fig. 1.8 Place one screw at the proximal fragment and ensure

reduction maintenance with fluoroscopic control.

Fig. 1.9 Place the rest of the screws in the same manner.

Fig. 1.10 (a)

Fig. 1.10 (b)

Fig. 1.10 a,b Closure is performed as a full-thickness layer over

the plate using 2/0 Vicryl and 3/0 subcuticular sutures for the skin

Fig. 1.11 Post-operative radiograph.






1.1 ORIF: midshaft fractures 7

Fig. 1.12 Use a sling for the initial 10 post-operative days.

� Initiate active flexion and abduction 6 weeks afterinjury.

� Return to prior activities is possible 3 months afteroperative treatment.

Outpatient follow up� Review at clinic in 3, 6 and 12 months with X-rays on

arrival to consider plate removal.� Beware of late vascular complications (thrombosis,

pseudoaneurysm).

Implant removal� Plate can be removed after 12 months.






2

Section I: Fractures ofthe proximal humerusDavid Limb

2.1 GENERAL CONS IDERAT IONS

The practicalities of surgical management of proximalhumeral fractures are common to the various injuriestreated. A generic description of the investigationsrequired and practical set-up of the operating room willtherefore be presented before discussing specific injuries.


� It is essential that all shoulder fractures be assessedwith a minimum of two shoulder views – the antero-posterior (AP) and axial views.

� A scapular lateral completes the trauma series but isnot always essential.

� The axial view can be obtained successfully in mostcases – in the rare instances where the patient will notpermit sufficient movement of the injured limb awayfrom the side, angled views (modified axial) shouldbe obtained. Never miss a dislocation (too many aremissed, and most of these have not had an axial viewtaken).

� In complex cases a CT scan might assist, particularly inassessing whether the humeral head is intact and hasany tuberosity attachments remaining. A humeral headfragment with an attached tuberosity is much less likelyto suffer avascular necrosis than one with no remainingtuberosity attachments. Three-dimensional CT is par-ticularly useful for assessing glenoid fossa fractures.

Anaesthesia

� General anaesthesia or scalene blocks can be used.Even if general anaesthesia is selected, a scalene blockcan add useful analgesia.

� The risk of phrenic nerve palsy and pneumothoraxshould be considered if a scalene block is to be used,particularly if there is already chest trauma (which notinfrequently accompanies shoulder trauma).

� Great care has to be taken to avoid interference withanaesthetic tubes and pipes by the surgeon or assistantin general anaesthetic cases.

Table and positioning

� The table should allow the patient to be sat up at thehips into the beach chair position (Fig. 2.1). Usuallythe torso is raised 30 to 45◦ from the horizontal, but ifaccess is needed to the front and back of the shoulderthen a more upright position is necessary, supportingthe spine and head but allowing access to the wholeshoulder girdle.

� To avoid the patient sliding down the table, the tableis tilted ‘feet up’ below the hips. The knees are flexedby lowering the end of the table or by placing a pillowbehind the knees.

� Any part of the table that could intervene between theends of a C-arm during X-ray screening of the shouldershould be radiolucent.

� Shoulder table attachments are available that convertnormal operating tables to permit patient positioningas described above (e.g. Schlein table attachment).

Operating room set up

� Shoulder surgery requires the surgeon to stand in theaxilla of the patient on the side of the injury. Eitherthe C-arm is positioned, or an assistant stands, abovethe patient’s shoulder.

Practical Procedures in Orthopaedic Trauma Surgery: A Trainee’s Companion, ed. Peter V. Giannoudis and Hans-Christoph Pape.

Published by Cambridge University Press. C© Cambridge University Press 2006.






2.1 General considerations 9

Fig. 2.1 The beach chair position.

� The hand and forearm are draped and rested on a smalltable. The height of the table should be adjustable.

� It is preferable for the head of the table to be furthestaway from the anaesthetic machine. The anaesthetistshould be aware of this, as extension tubes may beneeded for the gas lines.

� Alternatively the anaesthetist can work from the sideof the patient opposite to the operated shoulder, witha suitable exclusion drape.

� An experienced radiographer is required to obtain goodX-ray views of the shoulder during surgery.

� If the anaesthetist is working at the foot end of thepatient, the scrub nurse can work across the patient’schest, provided great care is taken with anaestheticpipes beneath the drapes. Alternatively the nurse canstand adjacent to the small table upon which thepatient’s arm rests.

� If no X-ray screening is necessary the scrub nurse canwork from above the head end of the table or on thesame side as the surgeon. If X-ray screening is used,the nurse works across the chest (see above) or fromthe same side as the surgeon.

Draping and approach

� Skin preparation is carried out using locally approvedantiseptics. Prepare the forequarter from the midlineof the chest to the medial border of the scapula. Cleanup to the root of the neck and down to below thelevel of the nipple. The arm is prepared down to wristlevel.

� A U-drape is used to shut off the forequarter and aseparate impervious stocking is rolled up the arm to

Fig. 2.2 C-arm draping and positioning for X-ray control during

surgical fixation of shoulder fractures.

above the level of the elbow. This leaves the drapedarm free for manipulation during surgery. It is restedon the arm table and raising this relaxes the deltoid byabduction of the arm. This facilitates exposure of thehumeral head.

� A deltopectoral approach is preferred for manage-ment of all proximal humerus fractures. It is possi-ble to reduce and stabilize a greater tuberosity fracturethrough a deltoid split. If unexpected comminution isdiscovered or later surgery is required for complica-tions, a deltoid split cannot be safely extended withoutrisking injury to the axillary nerve.

� If X-ray screening is to be used, both ends of theimage intensifier C-arm are covered with sterile drapes.The intensifier is positioned above the affected shoul-der and angled in towards the midline by 20–30◦.This will correct for the angulation of the scapulaon the chest wall and give good views of the jointline.

� The C-arm passes over the shoulder, with the sourceanterior and the collimator behind the shoulder (Fig.2.2). This gives good AP views during surgery and per-mits the C-arm to be rolled into a vertical position foraxial views.

Surgical approach

� The incision for a deltopectoral approach extends fromthe clavicle across the lateral edge of the palpated cora-coid process and down to the arm into the interval pal-pable between the anterior edge of the deltoid muscle







Fig. 2.3 The deltopectoral incision.

and the adjacent biceps muscle (Fig. 2.3). The lengthof the incision is determined by the extent of exposurerequired.

� The deltoid and pectoralis major are separated dig-itally, retracting the cephalic vein (which marks theinterval) laterally – cutting muscle fibres is notnecessary. The interval can often be located by a fatstripe if the cephalic vein is not immediately apparent.

� Once fascia is exposed deep in the deltopectoral inter-val it is opened vertically, adjacent to the lateral borderof the conjoint tendon as far up as the tip of the cora-coid process.

� Sweep a finger under the conjoint tendon to ensurethe axillary nerve is not in close proximity. Sweep afinger under the deltoid to ensure the subdeltoid bursais opened – these two spaces are placements for thetwo blades of a self-retaining retractor (Fig. 2.4).

� The proximal humerus is now as visible as it is everis – clothed in the thick rotator cuff tendons. Thelong head of biceps tendon can be identified at thelower part of the incision and followed in to the inter-val between subscapularis medially and the greater

Fig. 2.4 Retraction to expose the subscapularis and proximal

humerus.

tuberosity with supraspinatus attachment laterally andabove.

2.2 TENS ION BAND WIR ING (TBW)FOR DISPLACED GREATER TUBEROS I TYFRACTURES

Indications

Fractures of the greater tuberosity displaced by 5 mm ormore.

Note

� Many consider this recommendation, commonlyquoted in the literature, to be excessively conservativeand would offer surgery for fractures displaced by aslittle as 2 mm.

� Displacement cannot always be judged on an antero-posterior (AP) film, as the infraspinatus and teresmuscles will displace the tuberosity posteriorly andmedially behind the humeral head. It is essential thatat least an axial view of the shoulder is also taken toproperly assess displacement.






2.2 TBW: displaced greater tuberosity fractures 11

Pre-operative planning

Clinical assessment

� Shoulder pain is often felt in the region of the deltoidinsertion, on the lateral aspect of the arm.

� Look for any history suggestive of dislocation – greatertuberosity fractures are not uncommonly associatedwith anterior shoulder dislocation. Often repair ofthe tuberosity fracture (if displaced after reduction)will stabilise the shoulder, but be aware that soft tis-sue procedures such as labral repair could be nec-essary either at the time of tuberosity repair, orlater.

� Assess and document the neurovascular status of thearm. It is particularly important to examine the axillarynerve. Since deltoid function can be severely compro-mised by pain, skin sensation in the ‘regimental badge’area should be carefully recorded.


� Anteroposterior (Fig. 2.5) and axillary views are essen-tial. A scapular lateral view completes the traumaseries, though is not essential in the assessment of iso-lated greater tuberosity fractures.

� Pre-operative X-ray screening should be available, par-ticularly in multifragmentary greater tuberosity frac-tures. The fragments can be impossible to see atsurgery, being hidden from view by the thick rotatorcuff tendons.

Operative treatment

Anaesthesia

� General anaesthesia with prophylactic antibioticsaccording to local protocols.

� Scalene block according to anaesthetic skills avai-lable.

Table and equipment

� The table must allow the patient to be sat up in the‘beach chair’ position and allow access to the shoulderby a C-arm.

� A table attachment allowing the same position, sup-porting the torso and head, is equally acceptable (e. g.Schlein table attachment).

� A small Mayo table, suitably padded and covered, canbe used to support the arm.

Fig. 2.5 Displacement of the greater tuberosity into the

subacromial space.

� Drill with 2–2.5 mm bit.� Heavy non-absorbable suture material (e. g. No. 5

Ethibond®) – stainless steel wire can be used, butbecause it is used around a tendon insertion itwill fragment and migrate once shoulder function isrestored.

Table set up and patient positioning

� The patient is sat up approximately 45◦ (beach chairposition).

� Arrange the table in theatre so that the surgical teamhave access to the head and affected side of thebody.

� The affected arm is draped free and rested on a paddedMayo table. The height of the table is adjusted to holdthe arm in 30–45◦ of abduction, thus relaxing the del-toid muscle and facilitating access to the proximalhumerus.

� Image intensifier access is in line with the body, fromthe head end of the table. Both ends of the C-arm arecovered in sterile drapes.






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Upper extremity - Cambridge University Press