Brachial plexus

Designation of the anatomic-functional unit consisting of the clavicle, scapula, prox. humerus and adjacent chest wall with surrounding ligaments and joints.  We distinguish the following articular connections: sternoclavicular, acromioclavicular, glenohumeral.

Source: Netter’s Surgical Anatomy; 2010

Sternoclavicular luxation

Rare because of the fixed stabilizing sternoclavicular ligaments.  Its occurrence is therefore a sign of high-energy trauma, typically occurring in motor vehicle accidents or sports activities.  The mechanism of injury is most often indirect, with force applied transiently across the shoulder, and less frequently by the effect of direct force upon the clavicle.  Classification: presternal, suprasternal, retrosternal

   Source: Rockwood and Green's Fractures in Adults, 8th Edition,  2015

·       Diagnostics: clinical examination with swelling, pain and defiguration of the sternoclavicular joint, pathological mobility occurs sometimes, X-ray (AP, lateral - may not be visible on X-rays of this type, so a special projection (40° from the feet) is added in case of doubts),  event. CT, or MRI.

·       Treatment: Closed reduction, then immobilization with clavicle bandage (Delbet) for 4-6 weeks.  Surgical stabilization in young, physically active persons, and in unstable or non-reductible retrosternal luxations (wire cerclage, resorbable suture, splint).

 Source: Rockwood and Green's Fractures in Adults, 8th Edition,  2015

Acromioclavicular luxation

Luxation at the acromioclavicular joint, caused by an indirect mechanism of falling on the limb in adduction.  Tossa and Rockwood classification systems are used.

Source: Rockwood classification, Source: Rockwood and Green's Fractures in Adults, 8th Edition,  2015

·       Diagnostics: clinical examination - defiguration, pain, spring resistance, limited shoulder mobility, X-ray - AP projection, both AC joints on one image, X-ray of both shoulders with 10 kg load, axillary projection (for Rockwood type IV)

 Source: authors’ database

·       Treatment: depends on the luxation type and on the individual assessment of the patient's arms and patient’s condition - generally divided into conservative and surgical. 

○      Type I and II - conservative (sling for 2-3w, no heavy loads and contact sports for 8-12w)

○      Type III - controversial - both conservative and surgical treatment provide similar results

○      Type IV and V - surgeries (types:  ligament suture + tension band wiring, hookplate, knobs, Bosworth screw)

Source: authors’ database

Fractures of the clavicle

These are relatively common fractures, occurring by both direct and indirect mechanisms (fall on abducted arm - typical fractures in cyclists).  75 % of clavicle fractures are located in the middle third of the bone (Allman type I).  Cranial dislocation of med. fragment (by pulling of m. sternocleidomastoideus) is typical, lateral fragment descends caudally by the weight of limb and contraction of fragments occurs (m. pectoralis major).

FIG.: Allman classification, source https://sogacot.org/midshaft-clavicle-fractures-a-critical-review/

·       Diagnostics: Clinical examination - pain, deformity, haematoma, crepitations, limitation of mobility. Examination of blood supply and innervation of the respective upper limb is necessary (close topographic relationship to a. subclavia, plexus brachialis), signs of vascular or nerve injury are an absolute indication for surgical treatment.  Standard examination includes an X-ray examination in AP projection and another image from bottom view at 30° angle which provides more information about the dislocation.

FIG.: AP and inclined projection, Source: authors' database 

·       Treatment: Conservative treatment- is indicated for non-dislocated or minimally dislocated stable fractures.  Immobilization using a clavicle bandage (Delbet) (stella dorsi) with closed reduction followed by X-ray check-up of the effect, fixation time 3-6 weeks                          

                           Surgical treatment - Definitive indications for surgical treatment: open fractures, blood supply disorder or interposition, threatening perforation of the skin with a bone fragment. Further, the type and position of the fracture are the decisive factor - dislocation ad latus > 2cm, shortening > 2cm, comminuity (> 3 fragments), segmental fracture.  Anatomically preshaped splints are used, intramedullary stabilization is a less preferred option. 

Source: authors’ database

Fractures of the scapula

Fractures of the scapula are rare; they constitute only 4-6 % of brachial plexus fractures.  These fractures are a sign of high-energy trauma and in 68-91 % they are connected to an injury of other structures (clavicle, cranial ribs, injury to lung, spleen, liver, nerve or vascular lesions), therefore a comprehensive diagnosis is necessary.  They are divided into marginal fractures (acromion 8 %, proc. coracoideus 7%), body fractures (50 %), collum fractures (25 %), fractures of the acetabular socket (10 %)

Source: Ortopédia, Josef Vojtašák, Bratislava 1998

·       Diagnostics:  Due to other associated injuries, a fracture of the scapula can often be missed, the clinical picture is often non-specific, pain is present, and, less often, an alteration of the shoulder position occurs, especially in fractures of the collum or the joint socket.  We should build on an X-ray diagnosis in AP and lateral projection of the scapula, more information is provided by CT scanning including the option of 3D reconstruction 

·       Treatment: Conservative treatment for body fractures and slightly dislocated collum fractures.  Immobilization with Dessault’s or Gilchrist bandage for 3 weeks is used. Full elevation of the limb is allowed after 6 weeks.  Surgical treatment is indicated for dislocated collum fractures, articular surface fractures, acromion fractures, and fractures with impending instability. 

Luxation of the shoulder joint

Glenohumeral luxation is the most common luxation - 80 % of all luxations.  This is caused by the relative shallowness of the joint socket compared to the large head of the proximal humerus. The mechanism of injury is indirect, a fall on an outstretched limb with abduction and external rotation of the shoulder. The direct mechanism is rarer.  Anterior luxation is by far the most common (95%), posterior (2-5%) and inferior - axillary 1% (luxatio erecta) are significantly rarer.  We distinguish: first luxation - traumatic mechanism, reluxation - second luxation with clear traumatic mechanism, recurrent luxation: luxation caused by a banal injury or normal movement of the limb.

·       Diagnostics: through palpation, clinical examination reveals an empty joint socket, limitation of mobility, spring resistance, muscle spasm. The examination of blood supply and innervation of the limb (risk of injury to the plexus brachialis, a. axillaris, n. axillaris...) before and after reduction is an integral part of the diagnostics.  In most cases, the X-ray images in the AP and oblique projection are sufficient to establish the correct diagnosis; however, in case of diagnostic uncertainty or suspicion of a posterior luxation that may be missed, a CT scan may be added.

·       Treatment: closed reduction (Hippocrates, Artl, Kocher...), immobilization with Dessault bandage for 2-3 weeks followed by gradual mobilization.  Surgery is indicated for non-reductible luxations (obsolete, soft tissue interpositus) and luxation fractures.

 Source: authors’ database

Humerus:

Fractures of the proximal humerus

Fracture of the proximal humerus is the 3rd most common type of fracture overall.  It is a typical fracture of the elderly (low-energy trauma, indirect mechanism); in younger patients, a higher energy of injury is required and the mechanism is usually direct. Neer classification is used the most often, taking into account the number of fragments and the degree of dislocation. Another option is to use the general AO classification. 

Source: Rockwood and Green's Fractures in Adults, 8th Edition,  2015

·       Diagnostics: clinical examination with pain, antalgic position of the injured limb with limited mobility, sometimes a change in shoulder configuration occurs. It is imperative to ALWAYS examine the blood supply and innervation of the affected limb.  Anteroposterior and lateral (axillary, transthoracic) X-ray usually provide sufficient information about the nature of the fracture, CT scanning helps in diagnostic uncertainties and it is useful in preoperative planning.

·       Treatment: conservative treatment predominates (85 %).  It is indicated in non-dislocated or minimally dislocated fractures in which contact between fragments is maintained, also taking into account the general condition of the patient.  Surgical treatment (LCP splints, intramedullary nails, CKP, TEP) in younger patients and in the case of dislocated fractures. 

Source: authors’ database

Fractures of the diaphysis of the humerus:

These fractures are relatively rare (1%).  They occur through direct and indirect (torsion, traction) mechanisms.  In these fractures, the risk of lesion of the n. radialis (8-10 %) or a. brachialis must always be considered. The AO classification is used.

·       Diagnostics: clinical examination including neurocirculatory parameters, complemented with X-ray in 2 projections, rarely CT.

·       Treatment: conservative treatment is possible in rare cases of non-dislocated fractures (Dessault, plaster fixation with epolette over the shoulder, functional treatment according to Sarmiento), however, it is burdened with a high risk of complications (malunions, secondary dislocation...).  The surgical treatment predominates, the definitive indications include open fractures, neurological deficit, signs of vascular lesion, malunions, unstable and non-reducible fractures.  Splint osteosynthesis and intramedullary nailing are used, in case of damage control protocol or in open fractures, external fixator can be used.

Source: authors’ database

Fractures of the distal humerus:

These fractures are usually caused by a direct mechanism - a fall on the elbow joint from the dorsal side; less often, they are caused by an indirect mechanism - a fall on the extended forearm in varying degrees of elbow flexion. According to the type of dislocation, the fractures can be divided into extension (volar dislocation) and flexion (dorsal dislocation) fractures.  The AO classification is used according to the relationship of the fracture to the articular surface. 

●      Diagnostics - clinical examination including evaluation of vascular and nerve supply to the periphery, X-ray in two projections, event. CT

●      Treatment: conservative treatment with plaster immobilization for 4 weeks for non-dislocated or sligthly dislocated fractures, especially extra-articular fractures.  However, because of the nature of these fractures, most of which are dislocated and often intra-articular, surgical treatment predominates.  Accurate anatomical reduction and reconstruction of the articular surface of the elbow joint is our goal. LCP splints are therefore the method of choice.  Surgical treatment is not simple.  The reconstruction of the articular surface often requires a surgical approach involving peroperative debridement of the olecranon and subsequent osteosynthesis.

Elbow:

Luxation of the elbow:

Dislocation of the elbow accounts for 20 % of all luxations and it is often associated with additional traumas (fractures of radial collum, proc. coronoideus ulnae, distal humerus).  Typically, elbow luxation occurs by a fall on the extended forearm.  There is always injury to the lateral ligaments of the elbow.  We differentiate between dorsal and rare ventral luxation (with fracture of the humerus). 

·       Diagnostics: clinical examination with swelling, defiguration and pain in the elbow, limitation of mobility. It is always necessary to consider a lesion of the n. medianus and n. ulnaris.  X-ray in AP and lateral projection are used as a standard.

·       Treatment: urgent closed reduction with continuous X-ray position monitoring, immobilization (cast fixation in 90° and supination position for 1-3 weeks), followed by rehabilitation care.  Open reduction may be necessary if closed reduction fails (soft tissue interpositus). If the instability is confirmed, ligament reconstruction is indicated.

  Source: authors’ database

Pronatio Dolorosa (nursemaid’s elbow)

This is a subluxation of the annular ligament during pronation and extension.  It most commonly occurs at 2-3 years of age and it is rare above 7 years of age. 

·       Diagnostics: clinical examination with pain in the radial side of the elbow, complemented with X-ray examination

·       Treatment: closed reduction, which often occurs spontaneously through the opposite mechanism - flexion and supination.  Rarely, surgery is necessary for non-reductible luxations or chronic subluxations

Source: Rockwood and Wilkins’ fractures in children, 9th edition

Elbow fractures in children

●      86 % of elbow fractures occur on the dist.  humerus, with supracondylar fractures being the most common (55-75 %) - they represent 5 % of all pediatric fractures.  Isolated fractures of the lateral condyle or medial epicondyle of the humerus are less common.  Fractures of the olecranon, radial head and collum or the medial epicondyle and T fractures are rare.  Supracondylar fractures are open in 1 %, nerve injury (n. radialis, medianus, ulnaris) occurs in 7.7%, and vascular injury occurs in 1% of these fractures.

●      Diagnostics: clinical examination - if the mobility is not restricted, fracture is unlikely, X-ray - comparison with the healthy side - angles, axes and fat bodies

●      Treatment: closed reduction under general anaesthesia and minimally invasive stabilisation, complemeted with cast immobilisation

Risks/complications - vessel or nerve injury, compartment syndrome caused by the pressure of the fixation bandage, subsequent Volkmann ischemic contracture or joint deformity and limitation of its mobility.

Sources:

V. Pokorný et al: Traumatologie, Triton 2002

M.Zeman, Z. Krška et al: Speciální chirurgie, Galén 2014

P. Wendsche, R. Veselý et al: Traumatologie, Galén 2015

https://surgeryreference.aofoundation.org/

https://www.wheelessonline.com/