Fractures Lecture Notes

FRACTURES The five bones of the shoulder girdle, as well as the upper part of the humerus, can be injured. The risk factor, however, appears very different depending on the bone considered (high for the clavicle and humerus, very low for the scapula and sternum). ➢ Metaphyseal fracture of the humerus These are frequent fractures in athletes due to lateral falls or direct trauma. The fracture may involve the metaphyseal region or the epiphyseal cartilage causing a fracture separation. ❉ Diagnosis - Physical examination The young athlete presents himself in the position of those injured in the upper limb, with his arm supported by the other hand. On examination, the anatomical landmarks of the shoulder may be in place (separation fracture), or modified by fracture displacement (subtrochanteric ax blow, anterior swelling, etc.). The shoulder cannot be moved due to pain. At an early stage there is no hematoma. - Radiographic examination The diagnosis is confirmed by radiography which visualizes the fracture line and the varus displacement. A contralateral examination is essential to clearly visualize the growth plate. ❉ Treatment - Slightly displaced metaphyseal fracture: Immobilization with a Dujarrier ( days). - Displaced metaphyseal fracture or fracture separation: Reduction under general anesthesia, then immobilization (1 month). Resumption of activity will take place after monitoring radiological consolidation between 6 weeks and weeks. ➢ Greater tuberosity fracture The greater tuberosity fracture is an injury in young people (older people fracture the surgical neck of the humerus). ❉ Etiology Greater tuberosity fracture is relatively common in sports. It responds to direct trauma to the shoulder stump secondary to a lateral fall (poor landing after a shot or direct trauma with the gym wall). ❉ Diagnosis - Physical examination The athlete presents himself in the position of those with upper limb trauma. The pain is very easily demonstrated, under the deltoid, at the level of the insertion of the supraspinatus. There is very often a local hematoma. The edema is masked by the muscular masses of the deltoid, it is only observable in children and subjects with very little muscle. Abduction of the arm is impossible. It is also not desirable during the initial examination to attempt this maneuver, so as not to risk moving the fractured fragment. - Radiological examination It is practiced from the front, in profile and in 3/4 view. In children, comparative study is essential. The x-ray reveals either simple cracking (oblique line) or tearing. In the latter case the bone fragment is attracted upwards and medially by the supraspinatus. ❉ Treatment In the presence of a simple crack without displacement, the patient's arm is immobilized at 0° of abduction (forearm in pronation and at 0° of flexion) using a resin system that is relatively bulky but which limits the risk of secondary displacement of the fragment. In the event of displacement, surgical reduction is performed and the fragment is fixed. In both cases, active and then passive rehabilitation will aim to regain the normal range of motion of the shoulder girdle. Remusculation of the deltoid, supraspinatus and rotators of the shoulder will complete this rehabilitation. ➢ Scapula fracture The scapula is a bone that is spontaneously protected due to its great mobility. Its fracture damage will therefore respond to a violent trauma, more likely postero-anterior. ❉ Etiology Fractures of the scapula are encountered during violent direct posterior impacts. More rarely it may be a fall on the shoulder stump. In the first case the horizontal or vertical fracture line involves the body of the scapula or the acromion, while in the second mechanism it is the neck which is most often injured. In both, we will ensure the integrity of the coracoid process. ❉ Diagnosis . Physical examination The athlete presents himself in the position of trauma victims of the upper limb, the arm glued to the body. The examination reveals posterior pain, often poorly systematized in the event of a corporeal fracture, lower anterior pain which may suggest damage to the glenoid during cervical fractures, or upper anterior pain precisely located on the coracoid when this bone is fractured. Inspection almost never shows deformation. If the patient is examined late, a hematoma can sometimes be highlighted next to the lesion. The examination will be carried out very gently by palpation of the spine, the acromion, the coracoid and the neck of the scapula. Mobility is often limited in internal and external rotation during posterior involvement . X-ray examination X-rays must be requested specifically. The frontal and profile images of the shoulder are insufficient to confirm the diagnosis. - Corporal fracture: The fracture line may be horizontal, visible on the sole strict profile image of the scapula, or vertical, including or not the two spinous fossae (the frontal image is more readable). - Cervical fracture: It is often visible on the frontal image of the shoulder. It is more frequently an inferior, interlocking fracture, tending to orient the glenoid cavity downwards. The standard radiographic examination can be supplemented in this case by an MRI to clarify whether there is an extension of the lesions to the glenoid labrum. - Coracoid fracture: X-rays of the coracoid will be taken obliquely, perpendicular to the horizontal and vertical axes of this process. The most common lesion concerns the horizontal branch of the coracoid. ❉ Treatment In the absence of displacement (corporeal fracture) simple immobilization is often sufficient. Otherwise, bloody reduction and fixation may be justified, particularly for fractures of the neck and coracoid process, the fragments of which may be unstable simply due to muscular contraction. ➢ Clavicle fracture The clavicle is the most commonly broken bone of the shoulder girdle. Its anterior position, unprotected by muscular masses, exposes it to direct trauma during forward falls. ❉ Etiology A very common injury to handball players, this fracture is secondary to a fall on the shoulder stump or a direct impact. ❉ Diagnosis . Physical examination The injured person sometimes heard the crack. It presents itself in the position of trauma victims of the upper limb. Violent pain causes total functional incapacity of the upper limb. The examination may show deformation of the clavicle and a more or less extensive hematoma. We will refrain from any painful maneuver or manipulation. Nervous or vascular damage will be ruled out. Exceptionally, this is an open fracture. . X-ray examination Standard radiography (frontal and oblique) allows the fracture level to be visualized, the existence of one or more fragments and a possible displacement. ❉ Treatment . Orthopedic: The reduction is carried out during the installation of the rings. Forty-eight hours afterwards we will check the absence of venous or nerve compression. The tension of the rings will be checked daily by a relative to whom the maneuver has been explained. The removal of the rings will be carried out one month after the accident and radiographic verification of the correct evolution of the callus. . Surgical: This fracture only exceptionally requires surgical intervention. This technique will be reserved for injuries including a third fragment, fractures of the external quarter (unstable) and open fractures. Jogging can be resumed one month after the fracture, handball can only be resumed approximately eight weeks later. This fracture does not require rehabilitation after removal of the rings or surgical intervention. ➢ Fracture of the sternum The sternum is the only odd bone participating in the structure of the shoulder girdle. Only very violent impacts are likely to break it. Its mechanical role as a point of support for the shoulder girdle is essential for the development of the strength of the different muscles inserting on the mobile bony parts. ❉ Etiology Sternal fractures are only encountered during violent frontal impacts. ❉ Diagnosis . Physical examination The subject complains of poorly systematized anterior chest pain, increased by breathing and coughing. Palpation follows the different bony parts of the sternum, from the manubrium to the xiphoid process. Simple finger pressure can reveal the fractured area. The presence of an early hematoma is exceptional. The differential diagnosis arises with sprains, sternoclavicular dislocation and costal dislocations. . Radiological examination It is practiced from the front and in profile. From the front, the fracture line is often poorly visible despite the indications given by the clinical examination. In profile, a notch can be seen, with or without antero-posterior displacement of a bone fragment. In certain cases the fracture line can be accompanied by a manubrio-corporeal subluxation. The scanner is of little use. It will only be carried out in case of doubt whether or not to authorize the return to sport. ❉ Treatment Given the generally benign nature of this fracture, rest and painkillers are enough to wait for consolidation five to six weeks later. Significant dislocations will need to be reduced and fixed.