FRACTURES AND DISLOCATIONS OF THE SHOULDER GIRDLE AND HUMERUS

The scapula is almost completely covered by muscle on both its anterior and posterior surfaces (Fig. 15.1).
The muscles keep the scapula relatively protected from injury and help
explain why most fractures occur only after high-energy impact and why
fractures of the scapular body frequently can be treated
nonoperatively. The lateral aspect of the scapula has three bony
processes, each related to important soft tissue structures that can
influence surgical decision making:

One other feature of the bony anatomy of the scapula has
relevance for surgical decision making. The thin bone that makes up a
large portion of the scapular body is not well suited for internal
fixation. There are, however, regions that have bone stock adequate to
accommodate screw or wire fixation, including the coracoid process, the
acromial process, the base of the scapular spine, the glenoid process,
and the lateral scapular border (44).

Finally, the concept of the superior shoulder suspensory complex (SSSC), popularized by Goss (45),
should be understood because it provides a useful framework for
considering shoulder injuries and their treatment. The SSSC is a bony
and soft tissue ring composed of the glenoid process, the coracoid
process, the acromial process, the

coracoclavicular
(CC) ligaments, the acromioclavicular (AC) joint, and the distal end of
the clavicle. This ring is supported by two bony struts: the clavicle
superiorly and the lateral border of the scapula inferiorly (Fig. 15.4).

Isolated injuries to the components of the SSSC such as
AC separations or isolated distal clavicle fractures are typically
stable injuries and respond well to nonoperative treatment. When the
SSSC is injured in two places, however, a so-called double disruption (Fig. 15.5),
one or both of the injuries may become significantly displaced because
the ring is left unstable. Double disruptions often lead to delayed
union, malunion, or nonunion and secondarily to decreased strength and
muscle fatigue and, possibly, neurovascular compromise. Osteoarthrosis
may result when one of the disruptions involves a joint surface.
Examples of double disruptions of the SSSC include a clavicle fracture
together with an AC joint disruption, a glenoid

neck
fracture with either an AC joint disruption or clavicle fracture, and
unusual combinations such as ipsilateral fractures of the acromion and
coracoid process (45).
The most common sequela is anterior, medial, and inferior displacement
of the scapula secondary to the weight of the arm and the combined pull
of the pectoralis major, pectoralis minor, and latissimus dorsi muscles.

A high index of suspicion is necessary to make the
diagnosis of a scapular fracture in an acutely injured patient. In one
large series, one third of the scapular body fractures were not
diagnosed or recorded at the time of the patients’ admission to the
hospital (138). Scapular fractures may be
evident on the chest x-ray obtained as part of the initial evaluation
of a multiply injured patient. More often, special-view
radiographs—including scapular anteroposterior, scapular lateral, and
axillary views—are necessary to better define the fracture pattern.
Computed tomography (CT) scans are useful for detailed assessment and
preoperative planning of intraarticular and glenoid neck fractures.
Frequently they can be obtained when the patient goes to the CT scanner
for evaluation of other injuries.

Scapular fractures are best characterized by anatomic
regions because the criteria for operative and nonoperative treatment
and the expected outcomes vary accordingly. The regions and the
approximate incidence of scapular fractures that occur in each are
scapular body (35%), glenoid neck (27%), acromion (12%), scapular spine
(11%), glenoid fossa (10%), and coracoid process (5%) (Fig. 15.6) (2). Diagnosis and treatment of these fractures are discussed by anatomic region.

The body of the scapula is covered with dense muscular attachments (Fig. 15.1);
therefore, extreme force usually is necessary to produce scapular body
fractures. Because of the rich blood supply to this region and the
stabilizing effect of the surrounding muscular envelope, healing
usually occurs uneventfully, and nonunion is rare. Focus treatment on
symptomatic relief. Prescribe ice to the local area and sling
immobilization of the arm for comfort. Within a week of injury, begin
pendulum exercises and advance to the use of overhead pulleys and
active-assisted range-of-motion exercises as soon as the patient’s
symptoms allow. Malunion with significant displacement may produce a
snapping or grating sensation with scapulothoracic motion, but patients
rarely complain of restricted motion or pain that limits function (2).

Fractures of the glenoid neck occur in three basic patterns (Fig. 15.7):
(a) fracture of the anatomic neck; (b) fracture of the surgical neck;
and (c) fracture of the inferior neck coursing inferior to the scapular
spine to exit along the medial scapula border, leaving the superior
portion of the glenoid intact (Fig. 15.8) (46).
These fracture patterns can be identified on the standard shoulder
trauma x-ray series, but CT scans are helpful in clearly defining the
fracture anatomy and assessing associated injuries to the shoulder
girdle.

In addition to fracture pattern, fracture displacement
is important for deciding treatment. Excessive translation and
angulation can lead to shoulder dysfunction from altered rotator cuff
mechanics and pain. Therefore, we consider glenoid neck fractures as
one of two types, as suggested by Goss (46).
Type I fractures are undisplaced or insignificantly displaced; type II
fractures are displaced at least 1 cm or angulated at least 40° (Table 15.2).
Any fracture pattern (A, B, or C) may be either type I or type II. Type
I fractures are usually stable and heal satisfactorily because the
superior shoulder suspensory complex is disrupted in only one place.
Therefore, treatment is nonoperative and aimed at symptom relief.
Provide an arm sling for patient comfort and ice the injured region.
Instruct the patient to begin gentle pendulum exercises within 1 week
and progressively increase use of the arm and shoulder as pain allows.
The goal is to promote healing without developing debilitating shoulder
stiffness, which often follows prolonged immobilization.

Type II fractures require operative treatment for optimum results (2,141).
If the displaced glenoid neck fracture is an isolated injury without a
secondary disruption of the SSSC, then treat the fracture via open
reduction and internal fixation (ORIF) through a posterior approach.

Use interfragmentary fixation and/or a buttress plate as the fracture pattern dictates.

Frequently, in the setting of a type II glenoid neck
fracture, there is an associated disruption in the SSSC, rendering the
shoulder complex unstable. Most often the clavicle is fractured also;
less commonly, the acromioclavicular joint is disrupted. Several
authors have described this combination of injuries and the need for
ORIF of one or both of them. Herscovici (55), Rikli (117), and Goss (46)
suggest that ORIF of the associated injury—a clavicle fracture, for
example—would indirectly reduce the glenoid neck fracture and is
sufficient to restore stability to the shoulder complex. Leung et al. (81)
recommended ORIF of both injuries, suggesting that more rigid fixation
would allow more vigorous rehabilitation and better final results.

Fractures of the glenoid cavity make up approximately
10% of all scapular fractures, and only 10% of these are significantly
displaced (2,62,86).
If a glenoid fracture is suspected from physical exam (pain, swelling,
ecchymosis, crepitus) or after review of a chest radiograph, obtain a
shoulder trauma series to confirm the diagnosis, rule out a dislocation
of the glenohumeral joint, and help determine if surgery is indicated.
A CT scan is helpful for delineating the articular fracture pattern and
is recommended before operative treatment.

Treat minimally displaced glenoid fossa and rim
fractures not associated with humeral head subluxation or dislocation
nonoperatively with early progressive ROM exercises as the patient’s
pain decreases. Progressive shoulder strengthening begins when shoulder
ROM has returned to normal. The majority of patients with glenoid
cavity fractures can be treated in this fashion. Functional outcome is
usually excellent, but it can take 6 to 12 months to reach maximum
recovery.

In contrast, displaced glenoid cavity and rim fractures
can lead to decreased range of motion, painful osteoarthrosis, and
chronic instability (2,29,76).
Although the exact amount of displacement or stepoff of the articular
surface necessary to cause significant morbidity is unknown, many
authors believe that residual displacement of 5 to 8 mm should be
reduced and stabilized in accordance with the principles of displaced
intraarticular fractures in other anatomic regions (51,67).
The indications, approaches, and techniques for operative treatment of
these injuries are dependent on the degree of displacement and the
fracture pattern.

Ideberg developed a classification scheme based on his experience with 300 glenoid fractures (Table 15.3) (62).
Type I fractures represent a substantial portion of the glenoid rim and
occur when a lateral force drives the humeral head into the glenoid
rim. These should be differentiated from small capsular avulsions of
bone associated with shoulder dislocations. They are considered
unstable if they are displaced at least 1 cm or involve at least 25% of
the anterior rim or 33% of the posterior rim (6,51,76,133).

Type II fractures involve the glenoid fossa and can have
several different fracture patterns depending on the position of the
humeral head at the time of injury and the direction of the applied
force. Type II fractures that are displaced 5 mm or more or associated
with inferior subluxation of the humeral head require open reduction
and internal fixation (47,51) (Fig. 15.10).

Type III and IV fractures require open reduction and
internal fixation if there is an articular stepoff of 5 mm or more,
lateral displacement of the superior fragment, or wide separation of
the inferior and superior fragments. A posterosuperior approach is
recommended for reduction of the fragments (44)
and placement of a 3.5-mm or 4.0-mm interfragmentary lag screw from the
superior fragment into the inferior fragment. When there is an
associated injury to the SSSC, reduction and fixation of the glenoid
surface may indirectly reduce the second injury of the double SSSC
disruption. However, open reduction and fixation of the associated
injury should be performed as well if fixing the glenoid surface does
not reduce the second injury adequately. Type V fractures require open
reduction and internal fixation if there is an articular stepoff of 5
mm or more, inferior displacement of the inferior glenoid fragment with
subluxation of the humeral head, wide separation of the joint surfaces,
or an associated SSSC injury leading to a separated superior glenoid
fragment (44).

Type VI fractures are severely comminuted and rarely
amenable to open reduction and internal fixation. Several nonoperative
approaches to these difficult fractures have been advocated, including
(a) a sling and swathe followed by early ROM; (b) immobilization in a
shoulder abduction (“airplane”) splint and early ROM above the level of
the splint as the patient’s symptoms allow; and (c) traction-suspension
therapy with ROM within the ranges allowed by the traction setup (44,141).

In summary, the goal in treating fractures of the
glenoid rim and fossa is to achieve a smooth articular surface and
enough bony stability to allow full shoulder function. Frequently

that
can be achieved nonoperatively. In cases in which fracture displacement
is significant and anatomic alignment cannot be achieved by closed
manipulation, open reduction and internal fixation are indicated.
Surgical approach, fixation techniques, and postoperative
rehabilitation follow the principles outlined above for treatment of
glenoid neck fractures.

For the purposes of this discussion, the acromion is
defined as the bony continuation of the scapular spine lateral to the
spinoglenoid notch. Acromion fractures account for 8% to 12% of all
scapula fractures (2,86)
and can occur in two areas: zone 1 fractures occur in the anatomic
acromion, and zone II fractures occur more medially near the scapular
spine and descend toward the spinoglenoid notch (Fig. 15.11) (107). Zone 1 fractures have been subclassified by Kuhn et al. (75)
into three main types: Type IA fractures are avulsion injuries of the
tip; type 1B fractures are nondisplaced, true fractures of the acromion
(Fig. 15.12A); Type II fractures are displaced
but do not decrease the subacromial space; Type III fractures are
displaced such that the subacromial space is decreased (Fig. 15.12B).

The majority of acromial process fractures can be
treated nonoperatively. Although nonunion or pseudarthrosis may result
from fractures treated nonoperatively, most of these are not painful
and do not lead to functional impairment (75).
The occasional nonunion that is painful can be treated with bone
grafting and internal fixation. There are however several indications
for acute surgical treatment (Table 15.4).
Avulsion fractures can be repaired with heavy suture through drill
holes in the acromion. Zone 1 fractures are best stabilized with a
tension band construct, either with cannulated 4.0 mm partially
threaded screws or Kirschner (K-) wires and either 18-gauge wire or
heavy suture (Fig. 15.13A). Zone 2 fractures are best stabilized with a 3.5 mm reconstruction plate (Fig. 15.13B and Fig. 15.14).

Double disruptions of the SSSC involving the acromial process and the coracoid base usually are treated adequately

with fixation of the acromial process fracture alone (47).
If the second injury involves the acromioclavicular joint, however,
then temporary fixation with an additional pin across the AC joint may
be necessary. If pins are used around the shoulder girdle complex, they
must be bent to avoid migration and should be removed once the injured
structures have healed.

The scapular spine is surrounded by the muscles of the
rotator cuff, deltoid and trapezius. Fractures in this region are
commonly associated with scapular body fractures and can lead to some
degree of pain and weakness. In one series, 70% of patients with
scapular spine fractures had abduction weakness and pain at rest from 3
to 7 years after their injury and many of these patients also had night
pain (2). Nevasier (100)
referred to this phenomenon as a “pseudorupture” of the rotator cuff
caused by hemorrhage and scarring of the supra- and infraspinatus
muscles related to the fractures which are frequently comminuted and
displaced. Because patients with these injuries may develop problems
either acutely or on a delayed basis, some authors advocate that
scapular spine fractures should be reduced and surgically stabilized (2,51). To date, there are no published reports that provide definite indications for surgery.

Fractures of the coracoid process account for 5% to 7% of all scapula fractures (2,86).
The typical mechanism of injury is an avulsion fracture caused by
traction on the conjoined tendon and/or the coracoclavicular ligaments.
Occasionally a direct blow by the humeral head at the time of
glenohumeral dislocation produces the fracture (48,108). In general, coracoid process fractures can be treated nonoperatively (48,50,84),
although associated injuries may warrant surgery. Prescribe a sling for
patient comfort for the first week or two, and then begin progressive
range of motion exercises. Avoid heavy lifting and weight training for
8 to 12 weeks since the short head of the biceps brachii and the
pectoralis minor (as well as the coracobrachialis) muscles originate
from the coracoid and forceful contraction of those muscles might
displace the fracture (Fig. 15.2).

Open reduction and internal fixation may be indicated in
exceptional cases. For example, a coracoid fracture in a high
performance athlete who relies on the precise functioning of his/her
upper extremity warrants ORIF. Another indication for surgery is an
associated injury such as a type III AC disruption (see below),
acromion fracture, glenoid neck fracture, or clavicle fracture that
results in wide displacement of the associated injury or both injuries.
In most cases, fixation of the associated injury is all that is needed,
and doing so indirectly reduces the coracoid process fracture and
allows it to heal in satisfactory position. Delayed treatment of an
avulsion fracture is occasionally necessary in patients who develop
soft tissue irritation from the displaced bony fragments. In those
cases, reduce and internally fix large fragments, or, if the bony
fragments are small, excise them and suture the conjoined tendon to the
remaining coracoid process.

A standard shoulder trauma series of radiographs plus a
CT scan will delineate the presence of these injuries and assist in
choosing a treatment plan and surgical strategy. Anterior and posterior
45° oblique views may be beneficial to show fracture displacement (45).
If AC or distal clavicle injuries are suspected, AP shoulder
radiographs obtained while 10-lb weights are suspended from the
patient’s wrists can be used to accentuate the disruptions and aid in
the diagnosis.

Unacceptable displacement of one or both of the SSSC
injuries is an indication for surgery. Only recently has attention in
the literature been focused on the complex nature

of these injuries (45),
and, therefore, precise criteria for operative intervention are
unknown. The surgeon must rely on his judgment as to the likelihood
that the displacement will lead to delayed or nonunion and/or adverse
biomechanical and functional outcomes. The more widely displaced the
injured structures are, the more likely surgical intervention will be
beneficial.

The operative strategy for these combined injuries is
straightforward. Identify the injury that is easiest to approach
surgically, perform the site-appropriate reduction and stabilization
utilizing the techniques described above, and then evaluate the
secondary disruption for persistent displacement and instability. Once
the initial injury has been reduced and stabilized, it usually produces
an indirect reduction of the secondary injury and makes the whole
shoulder complex sufficiently stable so that ORIF at the second site is
not necessary. For example, ORIF of the clavicle will usually reduce
and stabilize an associated glenoid neck fracture, and K-wire fixation
or coracoclavicular ligament reconstruction in selected type III AC
separations and all type V AC separations (see below) will reestablish
the clavicle as the stable superior buttress of the shoulder girdle (Fig. 15.9).

Postoperative management is injury specific. For most of
the cases, except those with pins across the AC joint, prescribe sling
support for 1 to 3 weeks in conjunction with pendulum exercises. After
2 to 3 weeks, start active assisted ROM exercises and add gentle
strengthening exercises after 6 and 8 weeks. By 3 months, most patients
should have full shoulder motion and be using their shoulders for all
activities of daily living.

Scapulothoracic dissociation is essentially a closed
forequarter amputation caused by severe blunt trauma and traction to
the upper extremity. Beneath an intact layer of skin, there is
disruption of the scapular rotators, subclavian vessels and the
brachial plexus (22,109).
Bone and joint injuries such as AC separations, clavicle fractures, and
sternoclavicular (SC) disruptions complete the clinical picture.

Diagnosis may be delayed because of multiple other
severe injuries that necessarily divert the resuscitation efforts to
life-saving maneuvers. In addition, ipsilateral musculoskeletal
injuries may mistakenly be identified as the cause of neurovascular
deficits. However, careful attention to the mechanism of injury (thrown
motorcyclist or farming accident), critical assessment of the position
of the scapulae in relation to the spinous processes (the medial
borders should normally be equidistant from the spinous processes) (Fig. 15.15),
and a thorough physical exam (absent pulses, neurologic compromise,
severe swelling over the shoulder region) can lead the resuscitation
team to the correct diagnosis. Further workup includes upper extremity
angiography to identify the level of the arterial lesion and guide the
surgical strategy for vascular repair.

The first goal of treatment for this condition is to
restore perfusion to the affected limb. Frequently, that requires a
saphenous vein graft to repair the avulsed subclavian or axillary
arteries or a shunt. Next, explore the brachial plexus and
reapproximate any transected nerves with appropriate microsurgical
techniques. It is much easier to perform the nerve repairs acutely than
later, when they are encased in scar. Finally, establish bony stability
where needed such as by plating or pinning a clavicle fracture or
reconstructing the AC joint to restore the length and stability of the
shoulder girdle, protect the neurovascular repairs, and create a stable
environment for soft-tissue healing.

In the past, amputation or glenohumeral disarticulation
was recommended for patients who presented with complete neurologic
deficits in the affected limb (22,31).
Recent improvements in microsurgery, however, have allowed surgeons to
salvage limbs that might have been amputated previously. Partial
neurologic deficits generally have a good prognosis in terms of return
of function and sensation (31). The decision to
amputate a revascularized, viable limb because of neurologic or other
soft-tissue injuries should be delayed and made only after
multidisciplinary consultation and discussion with the patient and
family. More specific indications and a discussion of treatment options
regarding brachial plexus injuries are

beyond the scope of this chapter but are found elsewhere in this book (see Chapter 60).

There are several potential pitfalls and complications
to avoid when managing scapular fractures. The first is the failure to
recognize a double disruption of the SSSC. If one overlooks one or both
disruptions in the suspensory complex, further displacement and
instability of the shoulder complex may result when movement is
initiated. Conversely, a rehabilitation program that is not vigorous
enough can be equally problematic and result in excessive shoulder
stiffness. A well-designed and supervised exercise program is the key
to success.

Another pitfall to avoid is injury of the suprascapular
nerve when operating on the scapula. The nerve may be injured at the
spinoglenoid notch by careless medial dissection during the posterior
approach to the glenoid neck or excessive traction on the infraspinatus
muscle. Finally, avoid placing K-wires across the AC joint or into the
scapula wherever possible. In rare cases when they are used temporarily
to fix small fragments, bend the ends of K-wires to prevent pin
migration. Remove them 4 to 6 weeks postoperatively before beginning
vigorous shoulder motion to avoid pin breakage and interference with
motion.

The structural unit of the sternum and both attached
clavicles has been likened to a yoke and serves to keep the shoulder
girdle positioned laterally throughout a wide range of motion,
enhancing upper extremity function (82). The
clavicle also provides a base for muscular attachments of the shoulder
girdle, allows maximum upper extremity range of motion for better
positioning of the hand, protects vital neurovascular structures,
facilitates optimum respiration and circulation via the attached
secondary muscles of respiration, and contributes to the cosmetic
appearance of the neck region (82,90).
The clavicle is an S-shaped bone, concave arteriorly at its lateral end
and convex anteriorly at its medial end, and subcutaneous throughout
its entire length. The cross-sectional anatomy changes along its
lateral-to-medial course from flat to tubular to prismatic (Fig. 15.17).
The junction from the flat region to the tubular region is a stress
riser; that fact, coupled with the effect of the first rib acting as a
fulcrum near the same spot over which the clavicle rides as
superior-lateral load is applied to it, explains the high incidence of
fractures in that region. The medial end of the clavicle is firmly
attached to the sternum and first rib by stout ligaments, the only
articulating connection of the upper extremity to the axial skeleton.
Laterally, the clavicle is attached to the coracoid process by the
coracoclavicular ligaments (Fig. 15.2) and to the acromion by the acromioclavicular ligaments.

The relationship of the soft-tissue attachments and
neurovascular structures with the clavicle help explain some patterns
of injuries seen clinically and highlight potential complications to
avoid when treating them. For example, because of their insertions, the
sternocleidomastoid and trapezius muscles pull the medial aspect of the
clavicle superiorly after clavicle fractures (Fig. 15.18).
The subclavian artery and vein as well as the brachial plexus pass
between the junction of the middle and medial third of the clavicle and
the first rib and need to be protected during plating of clavicle
fractures. The strong tubular portion of the clavicle, clothed on its
underside by the subclavius muscle and fascia, overlies these vital
structures, which may account for the low incidence of neurovascular
injury associated with clavicle fractures.

Begin radiographic evaluation with two views of the
clavicle: an AP view on a large film that includes the upper third of
the humerus, shoulder girdle, and upper lung field and a 45° cephalad
“oblique” view (126). Together these views are
sufficient for evaluating most clavicle fractures except those in the
medial third and will show associated musculoskeletal injures, screen
for a pneumothorax, and show both the superior–inferior and
anterior–posterior displacement of the clavicle. In fractures that have
been treated with internal fixation or in cases of questionable
nonunion, an abduction lordotic view is an alternate method of getting
a second view at 90° for a more complete representation of the clavicle
(116). Distal third fractures are more
difficult to assess because of overlapping bony structures.
Anterior–posterior oblique stress films with the patient standing and
while 10-lb weights are suspended from each wrist should be sufficient
to diagnose an unstable distal clavicle fracture or acromioclavicular
separation. Computed tomographic scans are useful for evaluating medial
clavicle fractures because plain films are

usually inadequate for assessing anterior–posterior displacement.

Clavicle fractures are classified into three groups
according to location in the bone because prognosis and treatment vary
according to type. Group I (middle-third) fractures are the most
common, accounting for approximately 80% of all clavicle fractures.
Approximately 97% of fractures in this group are mild to moderately
displaced and can be treated nonoperatively, with certain exceptions,
outlined below. However, 3% of middle-third clavicle fractures are
completely displaced and shortened. This small group of fractures
accounts for 90% of nonunions in middle-third fractures and therefore
may warrant early open reduction and internal fixation (139).

Group II (distal) fractures occur in the distal third of
the bone and account for approximately 10% of clavicle fractures.
Critical to the behavior and treatment of these injuries is the
condition of the coracoclavicular ligaments. If they are both
disrupted, the shoulder girdle loses its superior strut, and the
fracture displaces because of four main forces (95) (Fig. 15.19).
If the ligaments are not disrupted, the same displacement pattern will
still occur if the ligaments are attached to an inferior butterfly
fragment (111). The displacement caused by
these forces may account for the reported 30% nonunion and 45% delayed
union of these fractures when treated nonoperatively (32).
Group II fractures can be further subdivided into five subtypes based
on fracture location because the anatomic details of the fracture play
a role in treatment options (Table 15.5; Fig. 15.20).

Group III (medial) clavicle fractures are usually stable

because of the supporting sternoclavicular ligaments (Table 15.5).

Proper evaluation of a patient with a clavicle fracture
includes a complete history, a careful neurovascular exam of the
shoulder and ipsilateral upper extremity, and appropriate imaging. The
mechanism and events surrounding the injury as well as the patient’s
preexisting medical problems provide useful information about the
amount of energy and forces which produced the fracture as well as
important clues about associated injuries. Most clavicle fractures are
closed, isolated injuries sustained in low energy falls (103);
however, they also occur in high energy accidents. Although
neurovascular injuries and open fractures are uncommon, subclavian
artery and vein injuries, severe chest trauma, and brachial plexus
injuries all have been reported. Unfortunately, associated injuries
often are missed initially (9,61,118,127); look carefully for them to avoid delays in diagnosis.

More than 200 methods have been described to treat fractures of the clavicle (26).
Group I, middle one-third, clavicle fractures can generally be treated
nonoperatively. A figure-of-eight bandage with or without plaster
reinforcement has long been recommended and is one very good treatment
option (Fig. 15.21) (3,26,119,127). See Chapter 10
for a description of the use of a plaster bolero. The goal of this
method is to reoppose the bone ends as much as possible by
simultaneously raising the lateral fragment upward and backward while
depressing the medial fragment. The advantage of a figure-of-eight
brace is that it leaves the ipsilateral hand free for use while
splinting the fracture helps keep the patient’s shoulders back and the
clavicle out to length, minimizing the chance of the bone healing in a
shortened position. The disadvantages of this method include the
difficulty many patients have keeping the brace adjusted properly and
the potential skin problems caused by the brace, as well as impairment
of patients’ agility, personal hygiene needs, and comfort while
sleeping (5).

Alternatively, middle-third clavicle fractures may be treated with an arm sling (5,118).
Although a sling does nothing to correct shortening or displacement at
the fracture site, it is often more comfortable and convenient for
patients than a figure-or-eight brace and yet leads to the same rate of
union and excellent function as can be achieved with more restrictive
treatment methods (5,105).

Treated nonoperatively, the vast majority of
middle-third clavicle fractures heal uneventfully and with little or no
functional limitations. The nonunion rate for middle-third clavicle
fractures ranges from 0.1% in Neer’s series of 2,235 patients to 15% in
Hill’s series of 242 consecutive patients (57,94).
Higher rates of nonunion in middle-third clavicle fractures have been
associated with high-energy fractures, wide displacement (1–2 cm),
refracture, soft tissue interposition by the trapezius muscle, and
operative treatment (57,65,83,94,127,139,145).

Operative treatment of middle-third clavicle fractures is indicated in some situations (Table 15.6).
The most commonly encountered indication is an open fracture, which
should be treated with thorough wound irrigation, debridement, and
stable internal fixation (49). The exception
may be an isolated clavicle fracture with a small (grade I) inside-out
puncture wound, which could be treated by irrigating and debriding the
wound and treating the fracture with sling immobilization. If the wound
requires surgical treatment anyway, however, then rigid internal
fixation of the fracture at the same time is indicated,

as the wounds heal much better when the clavicle is stabilized because the fractured ends tend to displace into the wound.

Other indications for surgical treatment of group I
fractures are less common. Associated neurovascular injuries that do
not improve with attempted reduction warrant surgery to decompress and
prevent further damage to the underlying structures (9).
Fractures that are displaced upward to the point of tenting and
threatening the integrity of the skin may need reduction and fixation
if closed maneuvers fail to reduce the clavicle. As outlined above,
double disruptions of the SSSC that include a clavicle fracture require
reduction and stabilization of at least one of the injuries. Surgical
treatment of the clavicle fracture is logical in this setting because
it is usually the most accessible and simplest disruption to fix.

Widely displaced fractures may benefit from early
operative intervention. It has been shown that middle-third clavicle
fractures with more than 2 cm of displacement or 15 mm of shortening
are at increased risk for nonunion (34,57,83).
Thompson reviewed more than 100 middle-third clavicular nonunions
reported in the literature and found that 90% of the original fractures
had displacement greater than 100%, overriding more than 1 cm, or had
severe comminution (139). Although fractures
with this much displacement are uncommon, accounting for 3% of all
middle-third clavicle fractures, they warrant open reduction and
internal fixation.

Clavicle fractures in the multiply injured patient may
need operative management. If a patient has associated ipsilateral
upper extremity fractures treated surgically and would benefit from
early mobilization of the affected limb, then ORIF of the clavicle
fracture is indicated. Patients with bilateral upper extremity injuries
including a clavicle fracture benefit from immediate clavicle fixation
because it frees up one upper extremity so the patient may perform
independent activities of daily living, and patients with lower
extremity fractures and a clavicle fracture benefit from fixation of
the latter because it facilitates the use of crutches or a walker for
early mobilization. Finally, stabilization of clavicle fractures is
indicated for patients with multiple ipsilateral rib fractures because
it helps stabilize the hemithorax, resulting in less pain and better
pulmonary hygiene (102). Other relative indications for the surgical treatment of clavicle fractures are listed in Table 15.6.

We treat the vast majority of middle-third clavicle
fractures nonoperatively. Our preference is to support the ipsilateral
extremity with a sling for comfort. As the fracture begins to heal and
becomes less painful, we instruct the patient to begin active-assisted
ROM exercises. Once the fracture is clinically stable, discontinue the
sling and begin overhead exercises and gentle strengthening. Healing
takes 4 to 8 weeks in most patients. Symptoms dictate the return to
desired activities. Avoid contact sports for at least 6 weeks, and then
the shoulder must be carefully padded when the athlete returns to play.

Have patients wear a sling for the first 1 to 2 weeks
for comfort but remove it twice a day to perform pendulum exercises and
active-assisted ROM exercises below shoulder level. We encourage
patients to use the affected extremity for routine activities of daily
living below shoulder level as their pain allows. After 3 to 4 weeks,
when the wound is completely healed and the patient is comfortable,
institute active-assisted ROM exercises above shoulder level and full
return to activities of daily living. Most patients resume all normal
activities 8 to 12 weeks postoperatively. If the plate is prominent and
bothersome to the patient, it can be removed after the fracture heals,
but this is not routine.

Most authors agree that poor technique and soft-tissue
handling were significant factors in the rates of nonunion and other
complications reported in the earlier literature. Therefore, whatever
approach is chosen, take great care to avoid excessive soft-tissue
stripping, work to achieve solid fixation, and plan on acute bone
grafting for fractures that are highly comminuted or where there is
bone loss. When exposing middle-third clavicle fractures, be cognizant
of the small supraclavicular nerves that cross through the operative
field and try to preserve them.

Other reported complications from the operative
treatment of distal clavicle fractures include pin migration, coracoid
fracture (89), lysis of drill holes in the clavicle when dacron tape is used (89), wound-healing problems (56), K-wire failure (32), and infection (72).
To prevent pin migration, always bend the ends of the pins. Although
coracoid fracture and lysis of drill holes have been reported after use
of synthetic tapes to stabilize chronic AC separations, this may not be
a problem when they are used to help stabilize distal clavicle
fractures if bony union occurs and relieves stress on the implants (43).
Minimize wound-healing problems and infection by not undermining skin
flaps, by handling soft tissues carefully, and by waiting for acutely
damaged skin to improve before operating. Use stout K-wires, such as
two 2-mm pins as opposed to smaller pins, to decrease the chance for
hardware failure. Never use threaded wires. If distal clavicle
resection is done acutely, carefully assess the stability of the
remaining clavicle after the resection. If it is unstable, repair or
reconstruct the coracoclavicular ligaments.

Codman (23) was one of the first
surgeons to recognize that fractures of the proximal humerus occur
along the lines of the physeal scar, potentially creating four separate
fragments (Fig. 15.23). Neer (97,98)
later incorporated this concept into his widely known classification
system for proximal humeral fractures. Muscular attachments to these
fragments create the various patterns of displacement seen on the
initial x-rays (Table 15.8). The vascular

supply to the proximal humerus has been well studied and described by Gerber et al. (42) and Laing (78) (Fig. 15.24). Utilizing injection techniques, Gerber et al. (42)
found that the anterolateral branch of the anterior humeral circumflex
artery ascends within the intertubercular groove lateral to the biceps
tendon and enters the humeral head where the groove meets the greater
tuberosity. Once the anterolateral branch becomes intraosseous, it
becomes the arcuate artery, which supplies the entire epiphysis and all
but small portions of the proximal humerus. The posterior circumflex
artery supplies only a small portion of the posteroinferior head and
the posterior portion of the greater tuberosity. There are abundant
anastamoses between arteries, but they occur proximal to the point
where the anterolateral branch becomes intraosseous. If there is
arterial damage close to this point, the humeral head is at risk for
osteonecrosis. If the blood supply is disrupted more proximally, then
the humeral head will more likely remain viable and perfused through
anastamoses to the anterolateral branch.

Patients with injuries to the shoulder girdle often have
associated injuries. The mechanism of injury is important. A fracture
sustained in a high-energy accident in a young person is more likely to
be associated with other injuries than is a low-energy fall in an
elderly person. Follow Advanced Cardiac Life Support (ACLS) principles
when prioritizing the evaluation of a patient with a shoulder injury
(see Chapter 14). During the physical
examination, always note the appearance of the injured shoulder
compared to the opposite side. An anterior fracture-dislocation will
cause a fullness or bulging in the anterior aspect of the shoulder,
whereas a posterior fracture-dislocation may leave a hollow impression
in the anterior aspect of the shoulder. Assess the radial and ulnar
artery pulses and perform a distal sensory and motor neurologic exam.

Nerve injuries occur in association with proximal humeral fractures and dislocations in up to 45% of cases (28);
they are more common in elderly patients and in the presence of a
hematoma. Careful written documentation of the neurologic exam may seem
tedious at the time of the initial evaluation but is essential for
comparison later in the patient’s treatment course. Sensory loss does
not always correlate with motor dysfunction (28), and this should be noted. If pulses are absent, then a vascular consultation may be indicated.

Adequate radiographs are essential for the proper
classification and treatment of proximal humeral fractures. A standard
trauma series should include a true AP radiograph of the scapula, a
lateral scapular view, obtained with the patient in a 60° anterior
oblique position, and an axillary view. Computed tomography scans
provide the most reliable information and are helpful in several
circumstances including the evaluation of intraarticular fractures to
assess the degree and nature of damage to the joint surface and the
evaluation of fracture displacement, particularly the greater and/or
lesser tuberosities (Fig. 15.25).

Based on Codman’s description of the four parts of the proximal humerus (23)—anatomic
head, greater tuberosity, lesser tuberosity, humeral shaft—Neer, in
1970, devised his classic four-part classification of proximal humerus
fractures (Fig. 15.26) (97,98).
To be considered displaced, one or any combination of the four bone
fragments must be separated by 1 cm or more and/or angulated more than
45°. Fractures that do not fulfill these criteria are considered non-
or minimally displaced and referred to as a “one part fracture.” Neer
emphasized the relationship between displacement and the vascular
supply to the head of the humerus. The greater the number of displaced
fragments, the higher the risk of osteonecrosis. For example, a
two-part fracture of the greater tuberosity is much less likely to
develop osteonecrosis than a four-part fracture.

The AO group expanded Neer’s classification to include
other fracture patterns that do not fit neatly into Neer’s scheme (AO
classification). One such addition is the so-called four-part valgus
impacted fracture (64), which seems to have a lower risk of osteonecrosis (26%) than the four-part fractures Neer described (90%) (Fig. 15.27) (97).
Head-splitting and impression fractures are special fractures that do
not fit the four-part scheme. Head impression fractures are graded by
the percent of head involvement: less than 20%; between 20% and 45%;
and greater than 45% (12). The AO
classification is more detailed but also more cumbersome and is used
mostly as a research tool. The Neer classification has been shown to
have poor intra- and interobserver correlation (11), but

it is still the most widely used and commonly accepted classification scheme for proximal humeral fractures in North America.

We treat nondisplaced (“one-part”) fractures
nonoperatively, and two-part fractures as well if they can be reduced
and held in good position. We recommend an attempt at closed reduction
in the emergency room with conscious sedation. To reduce these
fractures, apply longitudinal traction while the arm is gently flexed.
Adduction of the distal shaft will help improve medial translation as
the shoulder is flexed. Counterpressure within the axilla may be
helpful to stabilize the humeral head during reduction. Position the
proximal shaft under the humeral head and impact it. We do not
recommend more than one or two attempts at closed reduction in the
emergency department. Further attempts at closed reduction should be
done under general anesthesia in the operating room.

We use percutaneous pinning for fractures that are
easily reduced but unstable. Insert two pins from the proximal lateral
and proximal anterior shaft directed into the humeral head, and add a
third pin from the greater tuberosity into the proximal shaft. For
fractures that can not be reduced, we perform an open reduction and fix
the fracture internally. We use a blade plate for young patients with
good bone quality and Ender’s rods with tension band nonabsorbable
sutures in patients with osteopenic bone.

We surgically treat greater tuberosity fractures that
are displaced more than 5 mm. We use a deltoid-splitting approach,
being careful not to split the deltoid more than 5 cm from the lateral
edge of the acromion to avoid axillary nerve injury. If the fragment is
large enough, we use a 4.5-mm or 6.5-mm interfragmentary lag screw with
a washer to compress the fragment. We add a figure-of-eight tension
band suture through the rotator cuff insertion for additional fixation.
Avoid placing the screw high in the tuberosity fragment where it would
impinge on the acromion.

We recommend ORIF of three-part proximal humeral
fractures in patients with sufficient bone stock to hold the fixation.
Patients with poor bone stock are treated with hemiarthroplasty.
Similarly, young patients (second to fourth decades) with four-part
fractures may be candidates for attempts at ORIF, but all others are
treated with hemiarthroplasty or total shoulder arthroplasty if the
glenoid has arthritic changes.

Failing to make the proper diagnosis is the first pitfall to avoid. Posterior fracture-dislocations are often overlooked,

especially in patients who have been victims of electroconvulsive
therapy and grand mal seizures. Careful radiographic assessment of
patients with suspected shoulder injuries is critical. The axillary
view is frequently the most useful for diagnosing posterior
fracture-dislocations and should be obtained as part of all shoulder
trauma workups. A careful neurovascular examination of the involved
extremity should not be deferred or neglected because axillary artery
injuries and brachial plexus injuries are common in this setting, with
incidences of 5% and 6.2%, respectively (134),
especially in patients with high-energy mechanisms. A palpable pulse
may be present because of the collateral circulation around the
shoulder girdle, but look for signs of vascular injury including an
expanding hematoma, paresthesias, and pallor. More commonly, the
axillary nerve is in danger of injury with fractures of the proximal
humerus. In addition, iatrogenic axillary nerve injury is possible if
the deltoid is split too far distally (>5 cm from the lateral edge
of the acromion) to expose a greater tuberosity fracture.

Malunion of the greater tuberosity in a superior or
medial location may cause impingement syndrome with as little as 5 mm
displacement. Osteotomy and replacement of the greater tuberosity to
its anatomic position for large displacements or exostectomy and
acromioplasty for small displacements may be required. Three-part
proximal humerus malunions are much more complex and typically require
prosthetic replacement to obtain satisfactory results. Nonunion may
occur even in two-part fractures at the surgical neck and is frequently
caused by overdistraction using hanging arm casts, soft-tissue
interposition, inadequate immobilization, overly aggressive physical
therapy, an uncooperative patient, or preexisting glenohumeral
stiffness (135).

Nonunion of the tuberosity fragments following humeral
head replacement is a difficult problem and can be avoided in most
cases by not removing too much bone from the fragments and by securely
fixing the fragments to each other, the prosthesis, and the humeral
shaft. Avascular necrosis may occur in up to 90% of four-part fractures
(97), although other authors have reported lower rates (136).
Humeral head replacement usually provides satisfactory pain relief.
Postoperative stiffness is a particularly troublesome problem for many
patients. Factors important in the development of a stiff shoulder
include prolonged immobilization, development of heterotopic
ossification, significant malunion, and nonunion. It is far better to
prevent stiffness by a well-organized physiotherapy program than to
treat stiffness after it has developed. Finally, inferior subluxation
of the humeral head after closed or operatively treated proximal
humeral fractures may appear worrisome, but in most cases it is
transient and resolves within 1 to 3 weeks as the deltoid and rotator
cuff muscles regain their normal tone. If the inferior subluxation
follows hemiarthroplasty and does not resolve, the prosthesis may be
positioned incorrectly too far down the shaft after excessive bone was
removed from the proximal humerus, and this may be an indication for
revision.

The shaft of the humerus is defined as extending from
the upper border of the insertion of the pectoralis major proximally to
the supracondylar ridge distally (146). On
cross section the shaft is cylindrical proximally, and it narrows in
the AP diameter distally as it approaches the supracondylar ridges. The
deltoid muscle inserts on the deltoid tuberosity, which is on the
anterolateral surface of the proximal shaft and extends to a level
roughly halfway down the arm. The medial and lateral intermuscular
septae divide the arm into anterior and posterior compartments. The
posterior surface is covered by the triceps muscle and serves as the
origin for the lateral and medial heads of that muscle; those muscle
origins delineate the spiral groove. The radial nerve courses through
the spiral groove with the profunda brachii artery as they traverse
from the posterior arm compartment proximally to the anterior
compartment distally. The anterior compartment contains three muscles,
the coracobrachialis, biceps brachii and brachialis, and the brachial
artery and median nerve. The ulnar nerve passes from the anterior to
the posterior compartment as it travels from proximal to distal and
enters the cubital tunnel.

Key to understanding the deforming forces at work on a
humeral shaft fracture are the muscle insertions and the effect of
gravity. Displacement of the proximal fragment will depend in large
part on whether the fracture occurs proximal or distal to the
insertions of the deltoid and pectoralis major muscles as outlined
above in the section on proximal humeral fractures (Fig. 15.35).
The distal fragment is always distracted to some degree by the weight
of the limb, and this phenomenon is the key to some methods of
nonoperative fracture management.

There is no classification system for humeral shaft
fractures that is accepted universally. In principle, however, humeral
shaft fractures can be classified by their location in the bone
(relative to the muscle insertions), fracture

pattern, and associated soft-tissue injuries (Table 15.9)
because these factors influence treatment decisions. Transverse
fractures of the midshaft usually occur from low-energy trauma, but
they unite slowly and have a higher rate of nonunion. Oblique and
spiral fractures have a larger fracture surface area and usually
progress to union without surgery. Oblique fractures in the distal
third of the shaft may be difficult to immobilize nonoperatively and
are more often associated with neurologic injuries (59).
Segmental fractures are difficult to reduce and maintain in
satisfactory alignment, and nonoperative management may lead to
nonunion at one or both fracture levels. Comminuted fractures are
especially challenging because they may be difficult to align and hold
by closed methods and also are difficult to fix surgically.

Soft-tissue injuries frequently dictate the treatment
for humeral shaft fractures. Open fractures need urgent surgical
management and have a lower rate of complications when treated with
adequate debridement and stable fixation (20).
Treatment of radial nerve injuries is controversial, as outlined below,
but may be an indication for surgery. Fractures associated with
vascular injuries require surgical stabilization to help protect the
vascular repair.

Most humeral shaft fractures can be treated nonoperatively with a greater than 90% rate of union (7,130,149).
Several methods of treatment have been described and work well. Options
include a hanging arm cast, coaptation splints, Velpeau sling,
collar-and-cuff sling, abduction humeral splint or shoulder spica cast,
and functional brace. The goals of each treatment method are to keep
the patient comfortable, establish union with acceptable alignment, and
restore full function (see Chapter 10).

Our preferred method is to treat the patient acutely
with a U-shaped plaster coaptation splint that extends well above the
fracture line laterally. Medially, the plaster should cup the elbow but
not extend very high. If the splint is brought up toward the axilla on
the medial side, it frequently ends at the level of the fracture and
levers it into varus. A sling is also provided for patient comfort.
After 7 to 10 days, when the acute swelling subsides, we switch to a
functional brace. The humeral functional brace was first described by
Sarmiento in 1977 (130). It works by
compressing the soft tissues circumferentially to produce fracture
alignment, and it has been shown to be very effective for treating
closed humeral shaft fractures (7,130,148,149).

Several indications for surgical treatment of humeral shaft fractures are summarized in Table 15.10. Some of the specific indications deserve special comment.

A radial nerve injury may occur in association with humeral shaft fractures in up to 18% of cases (110,114). Most commonly this occurs with middle-third shaft fractures (69).
The Holstein-Lewis fracture, an oblique fracture in the distal third,
is also well known for its association with radial nerve injury (59).
Management of the radial nerve injury is controversial. Most injuries
are neurapraxias or axonotmesis, and 90% will resolve in 3 to 4 months (41,69). The problem is in diagnosing the remaining 10% that will not recover and deciding when surgical exploration is indicated.

Some authors recommend surgical exploration after 3 or 4
months following a closed injury if is there is no evidence of
neurologic recovery (4,114).
The advantages of waiting include the fact that enough time would have
passed for recovery from neurapraxia, the associated fracture will have
healed, and the results of secondary nerve repair may equal those of
primary repair. If the initial injury is open, the nerve is more
likely—64% in one series (38)—to be partially
or completely lacerated or incarcerated in the fracture site, which is
one reason to explore these injuries early.

Definitions of time to delayed union and nonunion of humeral shaft fractures have been debated. Foster et al. (37)
defined fractures ununited by 4 months as delayed unions and ununited
by 8 months as nonunions. In contrast, based on their retrospective
reviews, Mast et al. (85) and Foulk and Szabo (39)
determined that fractures of the humeral shaft that have not begun to
unite at 6 to 10 weeks probably will not unite unless the treatment is
changed. This is consistent with the literature, which states that the
average time to union of these fractures is 8 to 12 weeks (7,21,71). To optimize outcome and minimize the patient’s disability time, surgery should be performed

as soon as a delayed union or nonunion is suspected (see Chapter 27).

Intramedullary nailing of humeral shaft fractures has
not had the same rate of success as intramedullary nailing of femur and
tibia fractures. In addition, problems from subacromial impingement
have been reported in almost every series utilizing antegrade humeral
nailing. Therefore, for humeral shaft fractures treated operatively,
particularly because of failed nonoperative treatment, open fractures,
or fractures with neurovascular complications, we prefer open reduction
and internal fixation with plates and screws using an anterolateral
approach. Bone grafting is used following the principles outlined
above. We are careful to identify the radial nerve and retract it
gently out of the way to avoid injury to it, verifying that it is
intact at the conclusion of the case. We treat nonunions with plate
fixation (Fig. 15.37) also, but we prefer to
make a posterior approach to the humeral shaft and dissect out the
radial nerve to be sure it is not injured or incarcerated in the
nonunion site (see Chapter 27 for more detail on nonunions).

We reserve intramedullary nails for the multiply injured
patient who needs a load-sharing device to facilitate rehabilitation,
but only if those fractures can be reduced easily so that there is no
question about possible soft-tissue interposition at the fracture site.
Our list of indications for intramedullary nails also includes
pathologic fractures, fractures associated with osteopenic bone, and
fractures underlying burns.

The glenohumeral joint is dislocated more often than any other major joint (68),
usually as a result of a sports injury or a fall, but many other
etiologies have been reported. Effective treatment depends on making
the correct diagnosis promptly as well as recognizing and treating
associated injuries. Injury classification also helps direct treatment
appropriately.

Acromioclavicular (AC) joint dislocations and
subluxations (“shoulder separations”) account for approximately 15% of
all shoulder girdle dislocations (18,140).
The true incidence is probably much higher because patients with
low-grade injuries may not seek medical attention. The mechanism of
injury is typically a direct blow or fall on the shoulder, in which the
acromion is driven downward, tearing the AC joint capsule and
restraining ligaments. The most common mechanisms are sports related,
but they also occur in motor vehicle accidents. The same mechanism of
injury that causes acromioclavicular joint disruptions can also cause
sternoclavicular dislocations and fractures of the clavicle or acromion.

Injuries to the sternoclavicular joint represent only 3% of shoulder girdle dislocations (19).
Because they are unusual and sometimes subtle, their diagnosis is often
delayed, especially in the multiply injured patient. Anterior
dislocations are significantly more common than posterior dislocations,
but because of their potential for associated mediastinal compression,
posterior injuries are more frequently reported. The reported ratio of
anterior to posterior injuries varies from approximately 3 to 1 to 20
to 1 (99).

The sternoclavicular joint is a moderately mobile
ball-and-socket joint having approximately 30° of anterior and
posterior slide and upward elevation. It is also capable of 25° to 50°
of rotation around the long axis of the clavicle. The ligamentous
structures binding the medial clavicle to the sternum are very strong (Fig. 15.43),
and therefore traumatic dislocations are usually indicative of
significant force and often accompany rib and sternal fractures and
other chest injuries. Most dislocations result from direct trauma, but
indirect forces transferred from lateral

compression on the shoulder also may injure the sternoclavicular joint.

On physical examination, the region of the SC joint is
tender and swollen. The most striking finding is the asymmetry between
the injured and uninjured SC joints. If the joint is dislocated
anteriorly, there may be an appreciable prominence, and if the
dislocation is posterior, there may be a hollow depression. Posterior
dislocations may present with breathing or swallowing difficulties or
even cyanosis secondary to compression of the trachea, esophagus, or
underlying vascular structures (36,80).
Plain radiographs of the sternoclavicular joint are difficult to obtain
and interpret, as mentioned above with fractures of this region.
Computed tomography scans are best for evaluating suspected joint
injuries.