Fractures of Clavicle and

Humerus
Adapted from source
 Clavicle
• protector of   brachial plexus • Classification
  
• only bony connection between • Middle third 80%
upper limb and the thorax • Distal third 15%
• 1st bone to ossify •
• Medial end secondary Medial third 5%
ossification centre ossifies at
age 25
 Clavicle Fractures
• Middle 1/3 (80%); • Xrays
              - up • in any clavicular frx,
displacement of medial carefully scutinize x-rays
frag by for presence of
sternocleidomastoid scapular frx which
muscle. represents a
              - lat frag is floating shoulder
pulled down by wt of
limb     
 Clavicle
• Non Operative Treatment:
      - difficult to reduce and
maintain the reduction of clavicle
fractures;
      - despite deformity, healing
usually proceeds rapidly;
      - union usually occurs rapidly
& produces prominent callus;
      - there will also be some
degree of malunion;
            - in these patients be
attentive to medial cord nerve
symptoms (more often
ulnar nerve)
• Kids always unite
• Treat with sling supporting the
arm
 Clavicle
• Operative Treatment:
    - indications for surgery:
            - open fracture
            - gross displacement
w/ tenting of skin
            - fractures w/ overlap
(causing medialization of
the shoulder girdle);
    - surgical considerations:
            - subclavian artery
            - brachial plexus (esp
lower trunk damage (C8, T1
);
    - floating shoulder
 Clavicle
• Lateral third
• High incidence of non
union especially with
disruption of Coroco-
Clav lig
 Proximal Humerus Fractures
• 5% of all fractures
• Incidence increasing due to
↑age and ↑osteoporosis
• Factors to consider in
deciding traetment
– Type of # (Neer)
– Age/bone quality
– General health
• Surgery can be technically
difficult
• May rquire long anaesthetic
– Time from injury
 Proximal Humerus Fractures
• Neer Classification
– 2 part
– 3 part
– 4 part

• More than 1cm

displacement or
>45degree angulation
 Proximal Humerus Fractures
2 part
• Minimal displacement usually treat non-op
• Stable Frx (impacted vs non impacted) 
•  soft tissue hinges are most likely to be intact, so that AVN is
unlikley
  
• arm may be immobilized in a sling and early motion started
immediately;
  
• need for surgery is rare, except for stable frx w/ unacceptable
          displacement
• excessive angulation in a young patient;
          - greater than 45 deg angulation will affect arm motion
 Proximal Humerus Fractures
• humeral shaft is usually
• Surgical neck displaced medially &
anteriorly by pectoralis
• 2 part fractures      
• Undisplaced fragments • Can lead to delayed union =
don’t count stiffness (due to prolonged
immobilisation)
     -
 Proximal Humerus Fractures
2part
• Anatomical neck # • If displaced
• anatomic neck • ORIF vs. prosthetic
represents the old arthroplasty;
eiphyseal plate     - in young active pts,
• Blood supply to head is consider screws from
compromised if minimal the shaft into head may
displaced # some thru be
long head biceps           inserted thru an
tendon anterior approach
• AVN can result
 Proximal Humerus Fractures
2part
• Greater tuberosity # • Lesser tuberosity
• Usually following • Rare injury in
reduction of shoulder osteoporotic bone
dislocation
• If > 5mm requires ORIF
due to secondary
impingement
 Proximal Humerus Fractures
3 part
• Difficult to tell between
3 and 4 part on Xrays
– Do CT scan

• ORIF in younger
patients
• Hemiarthroplasty in
older with poor bone
quality
Proximal Humerus Fractures
4 part
 Proximal Humeral Physeal Injuries
• either Salter I or II fractures; • Treatment is almost always non
    operative – periosteal hinge
• between ages of 11 and 15 years; allows fracture healing
    • Manipulation can lead to growth
• 80% of longitudinal growth of arrest and AVN
humerus occurs in proximal
physis;
   
• large percentage of growth
allows significant remodelling
following injuryies of proximal
humeral physis
• Look for associated brachial
plexus injuries (traction)
– But all recover by 9 months
• Osteochondritis (little league
shoulder)
 Humerus shaft #
• Classified as transverse, oblique • Exclude Radial n palsy in all
and spiral
• bending force produces
transverse frx of the shaft;

• torsion force will result in a spiral

fracture;
     
• combination of bending and
torsion produce oblique frx w/ or
w/o a butterfly fragment;
     
• compression forces will frx either
proximal or distal ends of
humerus
 Humerus shaft #
• Acceptable alignment
– upper arm will
accommodate 10-20 deg
of anterior angulation &
10-30 deg of varus
– 2.5cm overlap ok
• 2-5% non union rate
with non op treatment
– Hanging cast or Uslab
– Cast brace at 2 weeks
 Humerus shaft #
• Indications for Operative
Treatment:
  
– unacceptable frx position
following closed reduction;
  
– new onset radial nerve palsy
following closed reduction;
  
– multi-trauma patients;
  
– open humeral fractures;
  
– segmental humeral fractures;
  
– loating elbow or ipsilateral
arm injuries;
  
– pathologic fractures
 Distal Humerus #
• Paediatric vs Adult
• Adult Classification
– Distal shaft
– Lateral condyle
– Medial condyle
– Intra-articular bi-condylar
• Paediatric
– Dist. Physeal separation
– Lateral condyle
– Medial epicondyle
– Supracondylar
 Growth Plates in Kids
• C.R.I.T.O.E
• Capitellum (lat condyle)
1yr
• Radial head 3yr
• Internal (med)
epicondyle 5yr
• Trochlea 7 yr
• Olecranon 9yr
• External (lateral)
Epicondyle 11 yr
 Supracondylar Fractures in Children
• Classification
• 2 types: extension type (95%) &
flexion type
• Gartland for extension fractures:
  recognizes that anterior cortex
fails first w/ resultant posterior
displacement of distal fragment;

                 - type I: non-displaced
                 - type II: displaced with
intact posterior cortex
                 - type III: displaced with
no cortical contact
• Check pulse
• Median/ant interosseus n palsy
 Supracondylar Fractures in Children
• Non-op Treatment for
undisplaced
– Collar & Cuff
– Backslab
• Gartland 2 – Flex elbow
to 90 and repeat X-ray
– If no improvement-
Kwire fixation
• If flexion type splint in
20 deg flexion
 Supracondylar Fractures in Children
• Type 3 • Need to monitor
• Usually require MUA =/- circulation with pulse
ORIF oxymeter
• attempts in the ER at • Elevate
partial reduction and • Splint
delays in reduction will • Definitive treatment in
only lead to increase OR
soft tissue swelling
which
will complicate the
definitive reduction in
the OR
 Lateral condyle # in Kids
• common (20% of pediatric elbow)
  -
• 6-10 yrs of age;
  
  -
• are unstable & tend to become displaced even when immobilized because
of pull of forearm extensors;
  
• prone to non union since the frx is intra-articular
  
• on exam only lateral sided elbow pain
• Classification
– Milch 1 (SH4)
– Milch 2 (SH2 )  Most common       
 Lateral condyle # in Kids
• Even minimal
displacement requires
ORIF
• Fragment is bigger than
it appears on Xray