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The management of several types of shoulder fractures is presented. These infrequently occurring fractures are seen in a sports medicine practice. Basic principles of fracture care apply and are used in their treatment. Other fractures not discussed would be treated similarly.
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Fractures about the shoulder in children rarely require operative treatment. Exceptions include open fractures and those associated with neurovascular compromise. Fractures of the proximal humerus in older children that cannot be adequately reduced and maintained should be treated with open reduction and internal fixation. Interposition of periosteum and biceps tendon can lead to difficulty in fracture reduction. Irreducible displaced fractures of the clavicular shaft, fractures that develop nonunion, and congenital pseudarthrosis of the clavicle can be treated by an intramedullary pin technique with bone grafting. Posterior displacement of fractures of the medical clavicle sometimes become an orthopedic emergency. Reduction by closed or open means should be accomplished to relieve compression of mediastinal structures. This injury does not require internal fixation. Types IV, V, and VI distal clavicle injuries require open reduction and reefing of the periosteal tube with occasional need for temporary lag-screw fixation. There is some debate about the type III injury. Large glenoid fractures involving the anterior rim that are associated with instability of the glenohumeral joint are best treated by open reduction and internal fixation.
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The combination of an ipsilateral clavicule and scapula fracture causes a double instability of the shoulder. In opposite to an isolated clavicule or scapula fracture this injury should be treated operatively. Diagnosis of the scapula fracture in polytrauma can be difficult. If there is a clinical or radiologic suspicion, the indication for a CT scan is given. Osteosynthesis with plates from separated approaches, first the scapula from dorsal then the calvicule from ventral has proven good. The nervus suprascapularis must be treated carefully and, if necessary, liberated from the fracture. The optimal treatment of this injury is not always possible in polytraumatised patient.
Three cases of dislocation of the shoulder and ipsilateral fracture of the shaft of the humerus are reported. The literature is reviewed. It is suggested that X-ray films should be taken of the shoulder and elbow in all patients with fractures of the shaft of the humerus.
Fracture complications of convulsions are reported occasionally, e.g.: mono- or bilateral posterior shoulder luxations and luxation fractures, central dislocations of the hip as well as fractures of the femoral neck or compression fractures of vertebrae. A case is reported where the patient sustained four such lesions simultaneously. The epileptic seizure occurred following the sudden interruption of a neurotropic therapy with Carbamazepin (Tegretal). A general osteodystrophy was not found. The simultaneous presence of four such lesions following one convulsion has never before been reported and appears to be very uncommon. The frequency and problems of post-epileptic fractures are discussed and the operative treatment of the lesions briefly described.
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Posterior fracture-dislocation of the shoulder is rare. Comprehensive treatment guidelines for posterior fracture-dislocation of the shoulder with fracture of the humeral head have not been previously published. Although open reduction and internal fixation of the proximal humerus for posterior fracture-dislocation has been reported in several series, the successful reconstruction of the articular surface by rigid internal fixation of a large osteochondral fragment has not been reported. This paper describes two cases of posterior fracture-dislocation of the shoulder with a substantial defect of the anteromedial humeral head resulting from the cleavage of a large osteochondral fragment. Preoperative computed axial tomographic (CAT) scanning of the injured shoulders helped in operative planning by precisely defining the extent of the articular injury. Accurate reconstruction of the articular surface restored joint stability and gave excellent clinical results. Large humeral head osteochondral fracture fragments require accurate reduction and internal fixation.
The authors share their experience with treatment of injuries of the humeral articulation and their consequences. Main diseases of the articulation such as scapulohumeral periarthritis, habitual dislocation of the shoulder, fractures of the proximal end of the humeral bone are described. Original methods of conservative and operative treatment are proposed.
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Roentgenoradiological control of a reparative process after diaphysial comminuted shoulder fractures was exercised at all stages of the treatment after G. A. Ilizarov's method. Osteoscanning permitted the assessment of the viability of bone splinters on the first days after trauma and quantitative assessment of the activity of osteogenesis. A study of the optical density of radiograms provided an opportunity for evaluation of mineral content in regenerating bones, their structure only at late stages of treatment when it was rather high.
Operative treatment of proximal humeral fractures is performed with a variety of fixation techniques. Selection of the optimum device for fixation is dependent on anatomic considerations, fracture characteristics, surgical exposure, and biomechanical features of fixation devices. Fixation objectives are evaluated in light of Neer's four segment classification. An extended deltopectoral approach with release of anterior deltoid distal insertion as well as the proximal pectoralis major raphe provides a wide exposure. The approach heals rapidly and allows rapid rehabilitation. The shoulder fracture fragments are adaptable to tension band wiring. With loss of bone stock, tension band wiring becomes increasingly important because compression or shearing forces can be expended in the tendinous insertion of the fragments. Fixation principles are applied according to specific fracture patterns. Whatever the choice of fixation method, a protracted and vigorous rehabilitation program is essential to achieve maximal functional recovery.
Shoulder dislocations associated with a displaced fracture of the humeral head or glenoid require different treatment than shoulder dislocations without fracture. If the humeral head is fractured, two possible complications must be considered:impairment of the subacromial gliding mechanism and insufficient blood supply to the humeral head. In glenoid fractures, instability may be induced. The degree of instability depends on the size of the fragment. In fractures of the humeral head, in particular of the greater tuberosity, we differentiate between the so-called en bloc fracture and the so-called supra-spinatus avulsion fracture. In "en bloc" fractures, one has to be aware that displacement of the fragment can occur not only in the superior direction but in the posterior direction as well. Posterior displacement is displayed radiologically by the "tangential" view. Both the duration of pain and range of motion depend on the amount of displacement of the fragment. Displacement exceeding 3 min in one direction should be reduced surgically in the active patient. For operative treatment of a displaced "en bloc" fracture, we recommend closed reduction and percutaneous screw fixation performed under regional anesthesia. "Supraspinatus avulsion fractures" ought to be treated like rotator cuff tears because there is no possibility of the small fragments healing due to their placement on the joint cartilage. In fracture dislocations, the blood supply of the humeral head is seriously jeopardized if the fracture is situated in the anatomical neck, whereas this is not the case in a fracture of the surgical neck. The number of displaced fragments allows a prediction concerning the survival of the articular segment of the humeral head.(ABSTRACT TRUNCATED AT 250 WORDS)