Case reports
57
and one can only speculate whether the screw migrated further into the pelvis during this period. Certainly, at operation it could not be visualized, and no force was used in trying to locate it with the coupling screw, though the possibility does exist that it may have been pushed in unknowingly by the operating surgeon. The ease with which thrs may have occurred indicates that the screw may have tracked into the retroperifoneal region during some of the patient’s falls, a fact not fully appreciated from the preoperative radiograph (Figure I). The failure to use the compression screw during internal fixation made it impossible to extract the implant in one piece, as is usually possible when the fixation in the femoral head is poor. There is a feeling that compression should not be used in porotic bones for fear of the threads cutting oui, and that its use does not affect the outcome of a femoral neck fracture in terms of union (Fransden et al., 1984). Whereas these are logical assumptions, in view of the difficulty encountered in removing this screw, and the potential risks of penetrating acetabular screws (Keating et al., 1990). it is recommended that the compression screw be used in all fixations, but tightened only if the bone quality is judged to be adequate.
Traction-suspension neck fracture P. A. J. Van Wellen, P. P. Casteleyn University
Hospital, Free University
References Keating E. 34.. Ritter M. A. and Faris P. M. (1990) Structures at risk from medially placed acetabular screws. 1. Bone ]oint Surg. 72A, 509
Fransden P. A, Andersen P. E. Jr. Chrlstoffersen H et al. (1984) Osteosynthesis of femoral neck fracture: sliding screw plate with or without compression. Acta Orthop. Stand 55, 620. Kyle R. F., Wright T. M. and Burstein A. H. (1980) Biomechanical analysis of the sliding characteristics of compression hip screws. ]. Bone joint Furg. 62A, 1308. Wolfgang G. L.. Bryant M. H. and O’Neiil J. P. ( f982) Treatment of intertrochanteric fracture of the femur usmg sliding screw plate fixation. C/in. 0rthap. 163, 148.
Paper accepted 8 April 1991
Keqrt~stsfor repnnk should be addresseil to: Sudhir 8. Rae. Registrar 111 Orthopaedics, Ysbyty Gwynedd. Bangor, Gwynedd LL.57 2PW. UK.
therapy for unstable glenoid
and P. Opdecam
of Brussels, Belgium
Introduction Scapular neck fractures following a blow on the shoulder are considered unstable if the clavicle or the coracoclavicular ligament is disrupted. Further displacement cart occur if the adductors pull the glenohumeral complex anteromedially. The weight of the arm, the triceps, the coracobrachialis and the short head of the biceps muscle also act by pulling longitudinally. If reduction is not obtained, the biomechanics of the shoulder joint can be altered; pain and loss of motion can be the final outcome. Some authors believe that this lesion has to be treated operatively in an attempt to restore the anatomical relationship. This case report illustrates an attempt to obtain anatomical, or at least biomechanically sound reduction, by non-operative means.
Case report A 36.year-old busmessman was admitted to the emergency room after a car accident in which he sustamed a direct blow to the left hemithorax. He was in severe pain, with tenderness over the left shoulder, left hemithorax and dorsal spine, Active shoulder motion was reduced. During passive mobilization. crepitus was observed at the glenohumeral joint. NO neurovascular symptomatology was noted. Radiographic examination revealed a comminuted fracture of the left scapula iFrgure I) at the level of the surgical neck, and a ($1. 1992 Butterworth-Heinemann ooze-1383/92/010057-02
Ltd
Figure I. Unstable fracture of the glen&
neck
58
Injury: the British Journal of Accident Surgery (1992)Vol. 23/No.
I
Figure 2. Diagram of the traction system. small apical pneumothorax following fractures of the third, fourth and fifth ribs. A lateral impression fracture of D8 was also recorded. All lesions were treated non-operatively. As the glenoid was severely displaced anteromedially. we feared instability resulting in future muscle imbalance and impingement if the fracture healed in this position. Therefore, a traction-suspension of the left arm was set up (Figure2). Two threaded pins with an external fixator caliper were placed in the hurneral head, and a K-wire in the olecranon. The arm was positioned in 90” flexion, and IO” to 20” of internal rotation, the elbow being flexed at 90”. Zenith traction was applied to the K-wire, and lateral traction to the fixator caliper. Our aim was to relax the powerful pectoralis major muscle so that lateral displacement would be easier. Ten kilograms of lateral pull were necessary to achieve reduction of the glenoid with respect to the acromion. The traction-suspension was removed after 3 weeks (Figure 3) and passive pendulum exercises were begun under supervision of a physiotherapist. Active mobilization was allowed 5 days later as he was pain free. A sling was used between practice periods. No residual joint stiffness was observed 8 weeks after removal of the traction and he had full range of motion. Using C. R. Rowe’s shoulder evaluation criteria (Rowe, 1988), the functional result was judged as excellent, 6 months after trauma.
Discussion Most fractures of the scapula heal readily and respond satisfactorily to non-operative measures (Depalma, 1983). Nevertheless, controversy still exists about whether to operate on unstable fractures of the scapular neck (Hardeg-
ger et al., 1984). Non-operative treatment often results in inadequate reduction, whereas operative treatment is often complicated by joint stiffness. To avoid these complications we advocate balanced traction initially for unstable fractures
Figure 3. Reduction obtained after 3 weeks’ traction-suspension.
of the glenoid neck. If reduction cannot be obtained within I week, operative treatment should be considered.
References Depalma A. F. (I 983) Fractures and Dislocations ofthe Scapula, 3rd Ed. Philadelphia: Lippincott, 362. Hardegger F. H., Simpson L. A. and Weber B. G. (1984) The operative treatment of scapular fractures. 1. Bone joint Surg. 66B, 725. Rowe C. R. (1988) 7be Shaulakr, 1st Ed. New York: Churchill Livingstone, 632. Paper accepted
8 April 1991
Rquests for reprints should be aa’dressd to: Dr P. A. J. Van Wellen, University Hospital VUB, Laarbeeklaan 101, B-1090 Brussels, Belgium.
57
and one can only speculate whether the screw migrated further into the pelvis during this period. Certainly, at operation it could not be visualized, and no force was used in trying to locate it with the coupling screw, though the possibility does exist that it may have been pushed in unknowingly by the operating surgeon. The ease with which thrs may have occurred indicates that the screw may have tracked into the retroperifoneal region during some of the patient’s falls, a fact not fully appreciated from the preoperative radiograph (Figure I). The failure to use the compression screw during internal fixation made it impossible to extract the implant in one piece, as is usually possible when the fixation in the femoral head is poor. There is a feeling that compression should not be used in porotic bones for fear of the threads cutting oui, and that its use does not affect the outcome of a femoral neck fracture in terms of union (Fransden et al., 1984). Whereas these are logical assumptions, in view of the difficulty encountered in removing this screw, and the potential risks of penetrating acetabular screws (Keating et al., 1990). it is recommended that the compression screw be used in all fixations, but tightened only if the bone quality is judged to be adequate.
Traction-suspension neck fracture P. A. J. Van Wellen, P. P. Casteleyn University
Hospital, Free University
References Keating E. 34.. Ritter M. A. and Faris P. M. (1990) Structures at risk from medially placed acetabular screws. 1. Bone ]oint Surg. 72A, 509
Fransden P. A, Andersen P. E. Jr. Chrlstoffersen H et al. (1984) Osteosynthesis of femoral neck fracture: sliding screw plate with or without compression. Acta Orthop. Stand 55, 620. Kyle R. F., Wright T. M. and Burstein A. H. (1980) Biomechanical analysis of the sliding characteristics of compression hip screws. ]. Bone joint Furg. 62A, 1308. Wolfgang G. L.. Bryant M. H. and O’Neiil J. P. ( f982) Treatment of intertrochanteric fracture of the femur usmg sliding screw plate fixation. C/in. 0rthap. 163, 148.
Paper accepted 8 April 1991
Keqrt~stsfor repnnk should be addresseil to: Sudhir 8. Rae. Registrar 111 Orthopaedics, Ysbyty Gwynedd. Bangor, Gwynedd LL.57 2PW. UK.
therapy for unstable glenoid
and P. Opdecam
of Brussels, Belgium
Introduction Scapular neck fractures following a blow on the shoulder are considered unstable if the clavicle or the coracoclavicular ligament is disrupted. Further displacement cart occur if the adductors pull the glenohumeral complex anteromedially. The weight of the arm, the triceps, the coracobrachialis and the short head of the biceps muscle also act by pulling longitudinally. If reduction is not obtained, the biomechanics of the shoulder joint can be altered; pain and loss of motion can be the final outcome. Some authors believe that this lesion has to be treated operatively in an attempt to restore the anatomical relationship. This case report illustrates an attempt to obtain anatomical, or at least biomechanically sound reduction, by non-operative means.
Case report A 36.year-old busmessman was admitted to the emergency room after a car accident in which he sustamed a direct blow to the left hemithorax. He was in severe pain, with tenderness over the left shoulder, left hemithorax and dorsal spine, Active shoulder motion was reduced. During passive mobilization. crepitus was observed at the glenohumeral joint. NO neurovascular symptomatology was noted. Radiographic examination revealed a comminuted fracture of the left scapula iFrgure I) at the level of the surgical neck, and a ($1. 1992 Butterworth-Heinemann ooze-1383/92/010057-02
Ltd
Figure I. Unstable fracture of the glen&
neck
58
Injury: the British Journal of Accident Surgery (1992)Vol. 23/No.
I
Figure 2. Diagram of the traction system. small apical pneumothorax following fractures of the third, fourth and fifth ribs. A lateral impression fracture of D8 was also recorded. All lesions were treated non-operatively. As the glenoid was severely displaced anteromedially. we feared instability resulting in future muscle imbalance and impingement if the fracture healed in this position. Therefore, a traction-suspension of the left arm was set up (Figure2). Two threaded pins with an external fixator caliper were placed in the hurneral head, and a K-wire in the olecranon. The arm was positioned in 90” flexion, and IO” to 20” of internal rotation, the elbow being flexed at 90”. Zenith traction was applied to the K-wire, and lateral traction to the fixator caliper. Our aim was to relax the powerful pectoralis major muscle so that lateral displacement would be easier. Ten kilograms of lateral pull were necessary to achieve reduction of the glenoid with respect to the acromion. The traction-suspension was removed after 3 weeks (Figure 3) and passive pendulum exercises were begun under supervision of a physiotherapist. Active mobilization was allowed 5 days later as he was pain free. A sling was used between practice periods. No residual joint stiffness was observed 8 weeks after removal of the traction and he had full range of motion. Using C. R. Rowe’s shoulder evaluation criteria (Rowe, 1988), the functional result was judged as excellent, 6 months after trauma.
Discussion Most fractures of the scapula heal readily and respond satisfactorily to non-operative measures (Depalma, 1983). Nevertheless, controversy still exists about whether to operate on unstable fractures of the scapular neck (Hardeg-
ger et al., 1984). Non-operative treatment often results in inadequate reduction, whereas operative treatment is often complicated by joint stiffness. To avoid these complications we advocate balanced traction initially for unstable fractures
Figure 3. Reduction obtained after 3 weeks’ traction-suspension.
of the glenoid neck. If reduction cannot be obtained within I week, operative treatment should be considered.
References Depalma A. F. (I 983) Fractures and Dislocations ofthe Scapula, 3rd Ed. Philadelphia: Lippincott, 362. Hardegger F. H., Simpson L. A. and Weber B. G. (1984) The operative treatment of scapular fractures. 1. Bone joint Surg. 66B, 725. Rowe C. R. (1988) 7be Shaulakr, 1st Ed. New York: Churchill Livingstone, 632. Paper accepted
8 April 1991
Rquests for reprints should be aa’dressd to: Dr P. A. J. Van Wellen, University Hospital VUB, Laarbeeklaan 101, B-1090 Brussels, Belgium.
