Peifu Tang

Hua Chen
Editors

Orthopaedic Trauma
Surgery
Volume 1: Upper Extremity Fractures and
Dislocations

123
Orthopaedic Trauma Surgery
Peifu Tang • Hua Chen
Editors

Orthopaedic Trauma Surgery

Volume 1: Upper Extremity Fractures
and Dislocations
Editors
Peifu Tang Hua Chen
Department of Orthopaedics Department of Orthopaedics
Chinese PLA General Hospital Chinese PLA General Hospital
Beijing, China Beijing, China

ISBN 978-981-16-0207-8    ISBN 978-981-16-0208-5 (eBook)

https://doi.org/10.1007/978-981-16-0208-5
Jointly published with Military Science Publishing House
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Foreword

In the last 50 years, the methodology of treating fractures has undergone a series of changes.
The Association for the Study of Internal Fixation (AO), shortly after its establishment in
1980, proposed the treatment principle emphasizing mechanical stability and focusing on ana-
tomical reduction, rigid internal fixation, surrounding soft tissue protection, and early func-
tional exercise. Gradually, this concept evolved into one emphasizing a biological internal
fixation that better protects the blood supply of bone and soft tissues at the fracture site. The
change has prompted the invention of new types of implants, including locking compression
plates and interlocking intramedullary nails, and the development of new technologies, includ-
ing minimally invasive plate osteosynthesis. These advances, in combination with high-quality
intraoperative imaging technologies, such as X-ray and CT, have raised fracture care to a new
level.
The Chinese PLA General Hospital is a top-tier comprehensive hospital. Its Department of
Orthopaedics has been established in 1953. In 1977, the Orthopaedic Trauma Center was
formed. It has obtained prominent medical and scientific achievements in the field of orthopae-
dic trauma treatment. Great thanks to the contributions of our respected seniors, such as Prof.
Shibi Lu, Prof. Shengxiu Zhu, Prof. Boxun Zhang, and Prof. Yan Wang. Prof. Peifu Tang, as
the editor-in-chief of this book, chairman of the department of orthopaedic surgery, director of
the Orthopaedic Trauma Group of the Orthopaedics Division of the Chinese Medical
Association, has been a good friend of mine for many years. Under his leadership, the
Department of Orthopaedic Trauma of the Chinese PLA General Hospital has made brilliant
achievements in clinical and scientific research. I am delighted to see that the books have sum-
marized years of experience at the 301 Orthopaedic Hospital of the Chinese PLA General
Hospital in fracture care in a book, which will surely benefit the development of orthopaedic
trauma care in China.
The following distinguishing features of this book stand out to me.
First, this book is a valuable guide for clinicians. By introducing the conceptual evolution
of internal fracture fixation approaches in recent years, the book increases the awareness and
willingness of readers to utilize new technologies. Considering that orthopaedic trauma medi-
cine covers a wide range of injuries with diverse mechanisms and complex conditions, the
book emphasizes the importance of treatment timing and individualized optimal treatment
strategies in clinical decision-making and presents practicable approaches for reference.
Second, the book has a well-organized, easy-to-read structure with concise, bulleted text,
full-colour illustrations, and intraoperative photographs. Each chapter follows a similar for-
mat, starting with applied anatomy and then combining it with the biomechanics and func-
tional characteristics of the fractured body part to describe the anatomical structure and clinical
issues such as injury mechanisms, treatments, and healing. This unique format is an attractive
feature of the book. In addition, the book maintains a focus on clear, step-by-step depictions
and descriptions of surgical procedures for each surgical technique, consistent with the work-
ing habits of clinicians. Another feature of the book is the combination of illustrations/photo-
graphs and text. On many occasions, intraoperative photographs, schematic diagram(s), and
intraoperative X-ray or CT images are jointly used. The schematic diagrams help readers
understand the mechanisms underlying the surgical approach and fracture reduction and

v
vi Foreword

­ xation, the intraoperative photographs supply readers with an intuitive visual impression of
fi
the intraoperative scene, and the intraoperative radiographs and CT images offer a reference
for reduction and fixation.
Third, this book provides tips and cautions based on the experience obtained over the years
by the Department of Orthopaedic Trauma of the Chinese PLA General Hospital. In the sec-
tions introducing the surgical procedures in particular, the experience and lessons, which have
not been easy to explain clearly in previous books, are unreservedly presented in detail through
illustrations and text, which offers a surgeon’s-eye view of the relevant scenarios and helps
readers grasp the “gold content” of the book.
I have known Professor Peifu Tang for more than 15 years. He is a rising star in the young
generation of orthopaedic traumatologists in China. With his intelligence and diligence, he has
become a good model for the young generation of orthopaedic trauma surgeons. Hard work
will certainly yield fruitful results. I sincerely applaud the publication of this book and hope
that Prof. Peifu Tang will continue to publish more work in orthopaedic trauma.

The Third Hospital of Hebei Medical University Ying-ze Zhang

Shijiazhuang, Hebei, China
Preface

In recent years, with the economic growth and subsequent rapid development of construction
and transportation industry, the incidence of orthopaedic trauma has shown a prominent
increasing trend. Moreover, with the advancement of medicine, the expectations of patients
regarding treatment outcomes have also increased. Surgery is an important treatment method
for orthopaedic trauma, which is attracting an increasing amount of attention.
In response to these trends, the Department of Orthopaedics of the Chinese PLA General
Hospital was established in 1953, upgraded to a Grade one Orthopaedic Trauma Center in
1977. The Department has been developed along the path initiated by a group of well-known
researchers, including Prof. Jingyun Chen, Prof. Zhikang Wu, Academician Shibi Lu, Prof.
Shengxiu Zhu, Prof. Boxun Zhang, Prof. Jifang Wang, and Prof. Yan Wang. They emphasize
clinical and scientific research and has earned five first-class and two second-class awards of
the National Science and Technology Progress Award. This book, Orthopaedic Trauma
Surgery, is a summary of our valuable experience in fracture treatment gained over the previ-
ous 60 years.
We systematically searched for relevant information in China and other countries and com-
piled case reports and imaging data from the Department of Orthopaedics of the PLA General
Hospital accumulated over the years, writing this book, which has three volumes and 29 chap-
ters that, respectively, introduce upper extremity fractures and dislocations, lower extremity
fractures and dislocations, axial skeleton fractures, and nonunion.
The book adopts the principle of guiding surgery by anatomy, fixation by biomechanics,
and clinical procedures by functional recovery. In each chapter, the applied anatomy of the
fracture site is first introduced. This section confers prominence to the relationship between the
anatomical structure and surgery and emphasizes the structure that must be protected and
repaired during surgery. In addition, the biomechanical characteristics of the fracture site are
described, so that the appropriate fixation method can be selected according to the characteris-
tics of the mechanical environment. In most chapters on periarticular fractures, the book also
describes in detail how the joints fulfil their function, which is often the core of clinical
decision-­making, with the hope that the reader can understand the how and the why.
The book adopts the outline-style format instead of the traditional paragraph-by-paragraph
discussion to supply readers with the extracted essence in a more succinct manner, which
improves the logical flow and concision and thereby improves the readability of the book. In
addition, using more than 3,000 illustrations and photos, many of which were obtained from
our clinical practice, the book discusses injury mechanisms and the classification and assess-
ment of extremity and axial skeleton fractures, with a focus on typical and new surgical meth-
ods developed in recent years. These illustrations and photos provide the reader with a good
reference for learning surgical techniques and skills. Hopefully, this design will make the book
useful for orthopaedic surgeons at all levels in China.
Many professors and associate professors with rich clinical experience in the Department of
Orthopaedic Trauma of the PLA General Hospital have contributed to this book. We would
like to thank Dr. Zhe Zhao for his painstaking efforts in the preparation of this book. He has
contributed a tremendous amount of work in the structural design, content compilation, case
selection, and figure design. Thanks are extended to Dr. Hua Chen for his work in the structural

vii
viii Preface

design of this book, which laid the foundation for this book. We also thank Professor Boxun
Zhang and Professor Yutian Liang for their meticulous review of the manuscript.
During the preparation of this book, we have done our best to keep abreast of the latest
surgical advances in fracture treatment and striven to deliver accurate and informative content.
However, due to the rapid development of new concepts and instruments for the treatment of
orthopaedic trauma, time and knowledge source limitations, inevitably there might be defi-
ciencies in this book, and we welcome the reader to point them out and help us to improve the
content of the book.

Beijing, China Peifu Tang

Contents

1  racture of the Scapula �������������������������������������������������������������������������������������������    1

F
Hua Chen, Zhe Zhao, and Lin Qi
2  racture of the Clavicle �������������������������������������������������������������������������������������������   25
F
Hua Chen, Zhe Zhao, and Zuhao Chang
3  roximal Humerus Fracture�����������������������������������������������������������������������������������   49
P
Hua Chen, Zhe Zhao, and Zhengguo Zhu
4  racture of the Humeral Shaft �������������������������������������������������������������������������������   95
F
Hua Chen, Zhe Zhao, and Gaoxiang Xu
5  racture of the Distal Humerus������������������������������������������������������������������������������� 127
F
Hua Chen, Zhe Zhao, and Bin Shi
6  racture of the Proximal Ulna��������������������������������������������������������������������������������� 161
F
Hua Chen, Zhe Zhao, and Wei Zhang
7  racture of the Radial Head and Terrible Triad Injury of the Elbow����������������� 191
F
Hua Chen, Zhe Zhao, and Jiantao Li
8  ractures of the Ulnar and Radial Shaft ��������������������������������������������������������������� 221
F
Hua Chen, Zhe Zhao, and Ming Li
9  racture of the Distal Radius����������������������������������������������������������������������������������� 251
F
Hua Chen, Zhe Zhao, and Jiaqi Li
10  ractures of the Scaphoid���������������������������������������������������������������������������������������� 289
F
Yonghui Liang, Xuefeng Zhou, and Hao Guo

ix
Contributors

Zuhao Chang, MD Chinese PLA General Hospital, Beijing, China

Hua Chen Chinese PLA General Hospital, Beijing, China
Hao Guo, MD Chinese PLA General Hospital, Beijing, China
Yonghui Liang, MD Aerospace Center Hospital, Beijing, China
Jiantao Li, MD Chinese PLA General Hospital, Beijing, China
Jiaqi Li, MD Chinese PLA General Hospital, Beijing, China
Ming Li, MD Chinese PLA General Hospital, Beijing, China
Lin Qi, MD Chinese PLA General Hospital, Beijing, China
Bin Shi, MD Chinese PLA General Hospital, Beijing, China
Gaoxiang Xu, MD Chinese PLA General Hospital, Beijing, China
Wei Zhang, MD Chinese PLA General Hospital, Beijing, China
Zhe Zhao Beijing Tsinghua Changgung Hospital, Beijing, China
Xuefeng Zhou, MD Chinese PLA Strategic Support Force Characteristic Medical Center,
Beijing, China
Zhengguo Zhu, MD Chinese PLA General Hospital, Beijing, China

xi
 Fracture of the Scapula
Hua Chen, Zhe Zhao, and Lin Qi
1.1 Basic Theory and Concepts
1.1.1 Overview
• The incidence of scapular fracture is relatively low,
accounting for 3–5% of shoulder injuries and 0.4–1% of
all fractures. In descending order of incidence, scapular
fractures include fractures of the scapular body, scapular
neck, glenoid margin, glenoid, acromion, scapular spine,
and coracoid process. Approximately 65% of scapular
fractures are complicated type, that is, involving multiple
anatomical sites of the scapula (Voleti et al. 2012; Rowe
1963; Koval and Zuckerman 2006).
–– The scapula is adjacent to the thorax, and pulmonary
contusion occurs in 11–54% of the patients, resulting
in critical illness. Patients with severe pulmonary con-
tusion should be treated with tracheal intubation as
soon as possible to maintain positive pressure ventila-
tion (Fischer et al. 1985; McGinnis and Denton 1989;
Thompson et al. 1985).
–– Pneumothorax complication occurs in 11–55% of
scapular fractures and can occur at the time of injury or
a few days after injury. In particular, tension pneumo-
thorax can lead to death if not treated in a timely man-
ner, and thus, early diagnosis and appropriate treatment
should be provided. The occurrence of sudden wheez-
ing a few days after injury warrants attention to pneu-
mothorax (Armstrong and Vanderspuy 1984;
McLennen and Ungersma 1982).
–– Scapular fractures are often accompanied by injuries
in the ipsilateral upper limb and trunk, such as rib frac-
tures, clavicular fractures, sternal fractures, and frac-
tures and dislocations around the shoulder (Fig. 1.1).
H. Chen (*) · L. Qi
Chinese PLA General Hospital, Beijing, China
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_1
1
The diagnosis and treatment of complicated injuries
warrant attention to prevent missed diagnosis.
• Comolli’s sign is a rare compartment syndrome of the
scapula. If severe swelling and severe pain at the scapula
occur after scapular fracture, the occurrence of complica-
tions should be considered (Landi et al. 1992).
–– Comolli’s sign is manifested as severe pain in the scap-
ula area, with triangular or scapular swelling.
–– Due to the lack of toughness on the surface fascia of
the supraspinatus muscle and the infraspinatus muscle,
the hematoma and the swelling soft tissue around the
scapula may spread along the chest wall to the sur-
roundings and even inward into the thorax.
–– Once Comolli’s sign is clearly diagnosed, decompres-
sion by fascia incision should be performed as soon as
possible.
• Pseudo-rotator cuff tear is associated with clinical mani-
festations similar to those of rotator cuff injuries.
–– Scapular fractures cause swelling in deep tissue. Due to
bleeding and swelling of the muscle, followed by fibro-
sis, muscle contraction is limited, resulting in reduced
shoulder function or even transient loss of arm lift func-
tion. The clinical manifestations of pseudo-­rotator cuff
tear are similar to those of rotator cuff injuries, with
spontaneous recovery usually within a few weeks.
–– Compared to the rotator cuff, the degree of swelling in
pseudo tear syndrome is often more severe. MRI
examination can clearly reveal internal bleeding or
rotator cuff injury.
• The muscular bracing effect on the scapula fracture:
–– The scapula is wrapped by many muscles with abun-
dant blood supply, and thus the fracture healing rate is
very high.
–– The supraspinatus muscle and the infraspinatus mus-
cle are attached to the rear surface of the scapula body,
whereas the subscapular muscle is attached to the
front, forming a muscular splint that helps maintain the
position of the fracture fragment and plays a protective
role (Fig. 1.2).
1
2 H. Chen et al.

Fig. 1.1 Scapular fractures

with multiple rib fractures and a b
pulmonary contusion. (a) A
routine radiograph showing
scapular fractures. (b)
Computed tomography (CT)
scan with three-dimensional
reconstruction showing
multiple rib fractures (another
patient). (c) CT scan showing
right pulmonary contusion,
pneumothorax, and pleural
effusion

Fig. 1.2 Lateral view of the scapula. The lateral view allows Coracoacromial arch
visualization of a large number of muscles attached to the scapula. The
subscapular muscle is in the anterior aspect of the scapula. The Acromion Coracoacromial Coracoid
supraspinatus and infraspinatus muscles are attached to the posterior ligament process
aspect. These muscles can maintain the position of the fracture
Supraspinatus
fragment
Subacromialbursa
Subtendinous bursa
Infraspinatus of subscapularis
Glenoid cavity Tendon of biceps brachii,
Glenoid labrum long head
Joint capsule Subscapularis

Teres minor
Axillary recess

Infraspinatus Subscapularis

Scapula, lateral border

1 Fracture of the Scapula
–– Due to the special muscular splint structure of the
scapula and the high fracture healing rate, the majority
of patients achieve satisfactory function through con-
servative treatment, and surgical indications should be
strictly controlled.
1.1.2 Applied Anatomy
1. The glenohumeral joint is the main joint of the shoulder
girdle complex, which is composed of the large humeral
head and the shallow articular glenoid. The limited cover-
age of the articular glenoid on the humeral head underlies
the inherent instability of the glenohumeral joint. From
an evolutionary perspective, although this special joint
structure reduces the stability of the joint, it increases the
maximum degree of movement of the glenohumeral joint.
2. Stable structure of the shoulder joint and its injury:
(a) The connection of the upper limb to the axial skele-
ton ensures the stability of the shoulder joint, and its
physiological function is to implement the complex
a b
1
2
2 3
Fig. 1.3 (a) The levator scapulae originates from the transverse pro-
cess of the first to the fourth cervical vertebrae and is inserted into the
superior angle of the scapula (1). The rhomboid minor muscle arises
from the spinous process of the sixth to the seventh cervical vertebrae
and is inserted into a small area of the medial border of the scapula
above the level of the scapular spine (2). The rhomboid major muscle
arises from the spinous processes of the first to the fourth thoracic ver-
tebrae and is inserted into a small area of the medial border of the scap-
3
function of the human upper limb, which is achieved
through the structure of the shoulder girdle. The
shoulder girdle is mainly composed of the scapula,
the clavicle, the glenohumeral joint, the acromiocla-
vicular joint, the sternoclavicular joint and the sur-
rounding muscles, and the ligament structure. The
connections between the scapula and the chest wall
and between the clavicle and the sternum are the ana-
tomical base, and the entire function is achieved by
the anatomy of the superior shoulder suspensory
complex (SSSC) (Lyons and Rockwood 1990).
(b) The interaction of the scapula and the chest wall and
the scapulothoracic dissociation:
• The scapula and the chest wall are connected by
three groups of muscles but no bone structure: the
first group is the anterior serratus muscle; the sec-
ond group is the rhomboideus and levator scapu-
lae muscles; and the third group is the subclavius
and pectoralis minor (Fig. 1.3).
• These three groups of muscles do not perpendicu-
larly connect the scapula and the lower chest wall.
c
2
1
ula below the level of the scapular spine (3). (b) The subclavian muscle
arises from the first rib and is inserted into the inferior surface of the
clavicle (1). The pectoralis minor muscle arises from the third to the
fifth rib and is inserted into the coracoid process (2). (c) The serratus
anterior muscle originates from the first to the ninth ribs. Its upper part
is inserted into the superior angle of the scapula (1), the middle part into
the medial edge of the scapula (2), and the inferior part into the medial
edge of the scapula and the subscapular angle (3)
4 H. Chen et al.
Instead, they stabilize the scapula on the surface
of the chest wall similar to a cable-stayed bridge.
This structure gives the scapula a certain ability of
movement and also reduces the stability of the
scapula.
• Injury of scapulothoracic dissociation due to
trauma is mostly caused by high-energy traction
injury, with a high probability of complicated inju-
ries in blood vessels and nerves that are often fatal.
(c) The clavicle and the sternum are linked depending on
the sternoclavicular joint and the muscles attached to
the clavicle (see the section on clavicular fracture for
details).
(d) Anatomy of the superior shoulder suspensory com-
plex (Goss 2004) (SSSC):
• The SSSC consists of an annular structure with the
upper and lower bony processes:
–– The annular structure consists of the coracoid
process, the coracoclavicular ligament, the dis-
tal clavicle, the acromioclavicular ligament,
the acromion, and glenoid fossa.
–– The upper bone process includes the middle
1/3 of the clavicle.
–– The lower bone process includes the connection
part of the outermost side of the scapular body
and the innermost side of the scapular neck.
• The SSSC is the link between the upper limbs and
axial skeleton, which is an important structure to
maintain the stability of the upper limbs and axial
skeleton.
• SSSC injury and floating shoulder injury.
–– Due to the annular structure in the SSSC, the
impact of a single tear or fracture on the stabil-
ity of the SSSC is minor, and treatment efficacy
is good.
–– When more than two sites of the annular struc-
ture are injured, the stability of the annular
structure will be damaged, and surgery is
needed to repair the annular structure to avoid
delayed healing of the fracture, weakened
upper limb strength, and other long-term com-
plications (Fig. 1.4).
–– The traditional definition of floating shoulder
injury is the loss of connection between the
glenohumeral joint and axial skeleton due to
fractures of the two bony struts of the SSSC;
William et al. (Williams Jr et al. 2001) defined
the floating shoulder as the loss of bone and
ligament connection between the scapula and
axial skeleton at the scapular neck with the gle-
noid cavity and glenohumeral joint.
–– Therefore, the following three cases are con-
sidered generalized floating shoulder injury
(Coleridge and Ricketts 2003; van Noort et al.
2001):
Fracture through anatomical neck of the
scapula
Fracture through the surgical neck + rup-
tured coracoclavicular ligament + ruptured
coracoacromial ligament ± ruptured acro-
mioclavicular ligament
Fracture through surgical neck of the scap-
ula + clavicular fracture + ruptured cora-
coacromial ligament + ruptured
acromioclavicular ligament
3. The areas that may be fixed in surgery for scapular frac-
ture are the coracoid process, the glenoid neck, the base
of scapular spine, and the lateral margin of scapula
(Fig. 1.5).
(a) Lateral margin of the scapula:
• The arc extending from the subscapular angle out-
ward and upward to the neck of the glenoid, which
is the thickest margin of the scapula.
• This site and the neck are the best place for
fracture reduction and fixation with plate and
screw.
• Fixing material should not be placed in the scapula
body, which is thin and translucent.
(b) Coracoid process:
• The coracoid process is the curved forwarding
protrusion of the scapular neck and is an impor-
tant anatomical landmark.
• The coracoid process is the beginning of five ana-
tomical structures, including the coracoradialis,
coracobrachialis, entopectoralis, coracoacromial
ligament, and coracoclavicular ligament.
(c) Glenoid fossa: The glenoid is a pear-shaped fossa
below the acromion with upper and lower diameters
of 39 mm and an anteroposterior diameter of 29 mm
(lower half).
4. Axillary nerve
(a) The axillary nerve travels in front of the glenoid,
bypasses from below the glenoid, and controls the
deltoid after passing through the quadrilateral
foramen
(b) For glenoid fractures, operation for fixation of the
scapular neck and scapula medial margin by the
Judet approach should be performed in the gap
between the infraspinatus and teres minor in the inner
margin of the quadrilateral hole. If the triceps is
crossed by mistake, the front axillary nerve may be
damaged, leading to deltoid weakness.
1 Fracture of the Scapula
a b
Clavicle
Osteochondral ring
c
intact Single injury
Break Torn ligament
double injury
Bone break/
Torn ligaments Double break torn ligament
e f
Fig. 1.4 (a) Anterior view of the left scapula. The superior shoulder
suspensory complex (SSSC) includes an annular structure and two
bony protrusions. The upper bony protrusion is the middle 1/3 of the
clavicle. The lower bony protrusion is the junction between the lateral
scapula and the medial scapular neck. (b) Lateral view of the left scap-
ula. The annular structure of the SSSC is composed of the coracoid
process, the coracoclavicular ligament, the distal clavicle, the acromio-
clavicular ligament, the acromion, and the glenoid fossa. (c) Annular
structure injury is associated with a variety of mechanisms, including
single- or two-site injury of the bone and ligament. Two-site injuries
can be divided into two-site injuries of the ligament, two sites of frac-
tures, and one-site injuries of the bone and the ligament. (d) Mechanisms
5
Acromion
Glenoid fossa
Triceps
d
double disruptions of bone-ligament structures
Double break Bone break/torn liganment
g
of two-site injury of the annular structure and the bony supportive struc-
ture: two fractures of the bony supportive structure and injury of a bony
supportive structure with a ligament. (e) Scapular anatomical neck frac-
ture results in a loss of the connection between the glenohumeral joint
and the axial skeleton. (f) Scapular surgical neck fracture accompanied
with coracoclavicular ligament and coracoid ligament rupture can also
lead to a loss of the connection between the glenohumeral joint and the
axial skeleton. (g) Scapular surgical neck fracture with clavicle frac-
ture, acromioclavicular ligament, and coracoacromial ligament rupture
can result in a loss of the connection between the glenohumeral joint
and the axial skeleton
6 H. Chen et al.

a 1 b c
1
1

3 2
2 3 2

4 4 4

Fig. 1.5 Designated regions for scapular fracture fixation: coracoid process (1), glenoid neck (2), base of scapular spine (3), and lateral edge of
the scapula (4). Anterior view of the scapula (a) Posterior view of the scapula (b) Lateral view of the scapula (c)

Fig. 1.6 The suprascapular clavicle

nerve travels to the posterior
aspect of the scapula via the
suprascapular notch and then supraspinatus Suprascapular artery and nerve
curves around the scapular
spine inferior to supply the scapular spine
Shouder joint capsule
infraspinatus muscles. It is
vulnerable to fractures and Teres minor
surgical operations. The
axillary nerve passes through infraspinatus teres minor
the quadrangular foramen into deltoid
the posterior humerus;
medial border axillary nerve and posterior
therefore, caution should be circumflex humeral artery
taken to avoid nerve injury
circumflex scapular quadrilateral foramen
when using the posterior artery
approach. Damage to the profunda brachii artery
axillary nerve can cause teres major and radial nerve
weakness in the deltoid
muscle
long head
trilateral foramen triceps brachii
lateral head

5. Suprascapular nerve: i­ nnervation in the infraspinatus, causing weakness in

(a) The suprascapular nerve travels from the suprascapu-
lar notch to the suprascapular fossa to control the
supraspinatus and passes the glenoid trace to control
the infraspinatus (Fig. 1.6).
(b) In the process of repairing the rear margin and lateral
margin of the glenoid through the Judet approach,
excessive inward separation to damage the nerve
should be avoided and may result in the loss of
the abduction movement of the arm.
6. The mechanism of shoulder abduction movement: The
shoulder joint is the joint with the largest range of move-
ment and has a complex anatomy. Shoulder movement is
the joint movement of multiple joints. A full understand-
ing of the complex biomechanics of the shoulder is neces-
sary for effective treatment of shoulder diseases (Kapandji
2007).
1 Fracture of the Scapula
(a) The shoulder can be considered a complex lever
mechanism in which movement not only relies on the
glenohumeral joint but also involves the acromiocla-
vicular joint, sternoclavicular articulation, and scapu-
lothoracic joint.
(b) In terms of abduction movement, the lever mecha-
nism requires not only torque but also fulcrums to
ensure that the positions of the related structures do
not change in the movement of the shoulder joint.
(c) The abduction movement of the shoulder joint can be
divided into three stages The first stage is 0–60°
abduction: At this stage, the abduction movement is
basically accomplished by the movement of the gle-
nohumeral joint, and the clavicle plays the role of the
arm. Figure 1.7a, b:
• Fulcrum: The humeral head and lower part of the
glenoid in the shoulder joint form the fulcrum,
and shrinkage of the rotator can stabilize the ful-
crum. Both are indispensable.
–– Glenoid: The glenoid is located in the lateral
scapula and appears as a pear-like structure.
The lower lip is more prominent and larger
than the upper lip, playing the role of the ful-
crum in the abduction movement of the
shoulder.
–– Rotator cuff: The humeral head is larger than
the glenoid, and thus, the glenoid cannot wrap
around the humeral head. Consequently, an
additional stabilization device is needed to
realize its fulcrum function. The rotator cuff
includes the supraspinatus, infraspinatus, teres
minor, and subscapularis muscle. The long
head tendon of the brachial bicep wraps the
glenohumeral joint to maintain the stability of
the fulcrum through a “concave-compression”
mechanism; that is, the medial component of
the muscle contraction force pushes the
humeral head toward the glenoid, playing a
role in preventing dislocation (Fig. 1.7c).
–– In fracture by the glenoid, the lower half of the
glenoid is often an isolated bone, in association
with humeral head subluxation. In this case,
the fulcrum function is lost, and surgical treat-
ment should be provided.
–– In fracture of the scapular neck, once the dis-
placement is more than 10 mm or the angle
change is more than 45°, the movement of the
rotator cuff will be abnormal, which will also
affect the stability of the fulcrum.
• Torque: The contraction of the deltoid can gener-
ate power, and the shoulder can complete the
abduction movement with the fulcrum as the axis.
The horizontal component of the contraction of
7
the supraspinatus plays a supporting role in abduc-
tion movement of the shoulder.
(d) The second stage is 60–120° abduction: Before the
glenohumeral joint reaches 90°, movement of the
scapula can be observed. In the synergistic move-
ment, the angular ratio of the two joints is approxi-
mately 2:1, which is called the scapulohumeral
rhythm. When the movement of the glenohumeral
joint reaches 90°, the greater tubercle meets the upper
edge of the glenoid, causing a buckle lock of the gle-
nohumeral joint. Subsequent abduction movement is
completed mainly by the auxiliary movements of the
sternoclavicular joint, the acromioclavicular joint,
and the scapulothoracic joint. Figure 1.7d, e, f.
• Fulcrum: In this case, the scapula and the humerus
can be considered as a single entity.
–– In front of the body, this lever mechanism con-
tains two fulcrums, the acromioclavicular joint
and the sternoclavicular joint. At this stage, the
clavicle plays the role of a support rod to pre-
vent inward collapse of the shoulder joint.
–– In the rear of the body, the scapulothoracic
joint stabilizes the scapula during the contrac-
tion of the surrounding muscles.
• Torque: The abduction movement of the shoulder
is completed by the muscle power produced by
the contraction of the trapezius and the serratus
anterior muscle.
• In the case of clavicular fracture, the fulcrum of
abduction is not available, and appropriate treat-
ment is needed. In the case of paralysis in the tra-
pezius or serratus anterior muscle, the scapula
cannot be attached to the chest wall, resulting in
“wing-like scapula,” which can also cause abduc-
tion movement dysfunction.
(e) The third stage is 120–180° abduction: The coordina-
tion movement of the glenohumeral joint, acromiocla-
vicular joint, and sternoclavicular joint can provide an
abduction angle of 150°, and the remaining 30°
requires bending of the spine as compensation. In the
actual movement, before upper arm abduction to
150°, movement of the spine can be observed. For
simultaneous abduction of 180° of both sides, back-
ward extension compensation of the spine is needed.
1.1.3 Mechanisms of Injury
• Direct violence: High-energy injury is usually caused by
direct hitting or falling with direct impact on the shoulder,
resulting in fracture of the scapular body, acromion, and
coracoid process (Wilber and Evans 1977; Zdravkovic
and Damholt 1974).
8 H. Chen et al.

a b
glenohumeral joint
90°

sternoclavicular joint

30°
30°
humerus scapuloclavicular sternoclavicular
humerus joints joint

c d

e f

clavicle

sternoclavicular joint 60°

neutral position
90°

30°

Fig. 1.7 (a) The shoulder joint has 2 fulcrums: the sternoclavicular
joint and the glenohumeral joint, resembling a boom arm of a crane, as
shown in the diagram. The green lines represent the force from the del-
toid muscles. In the first stage of shoulder abduction, the movement of
the glenohumeral joint is responsible for initiating the abduction as the
clavicle remains in place and functions as a boom arm. (b) In the second
stage of shoulder abduction, the sternoclavicular and scapuloclavicular
joints complete the movement together, with each joint providing a 30°
movement range. (c) The glenohumeral joint is the fulcrum of the first
stage of abduction. (d–f) The glenohumeral, sternoclavicular, and
scapuloclavicular joints are involved in shoulder abduction
1 Fracture of the Scapula 9

• Indirect violence: The axial component of the load on the
abducting upper limb transfers along the upper limb,
causing shoulder injury, such as the scapular neck, joint
glenoid, intra-articular fracture, or avulsion fracture.
1.1.4 Classification of Fractures
1.1.5 Assessment of Scapular Fractures
1.1.5.1 Clinical Assessment
1. Typical manifestations: The hand on the healthy side sup-
ports the affected limb at the inner recipient position, the
movement of the shoulder joint is limited, and pain is sig-
nificantly aggravated during abduction movement.

• Classification of scapular fractures: The morphology of

the scapula is very irregular. The significance and treat-
7 5
ment indications of the fracture differ in different parts. It
is difficult to establish a comprehensive classification
covering all fractures, and thus most scholars tend to use
a classification that follows the anatomy (Zdravkovic–
6
Damholt classification (Kuhn et al. 1994), as shown in
Table 1.1 and Fig. 1.8).
4 3
• Classification of glenoid fractures (Ideberg classification):
According to the direction of the fracture and the displace- 2
ment, glenoid fractures are divided into five types, with the
type VI supplemented by Goss (Goss 2004; Ideberg et al. 1
1995), as shown in Table 1.2 and Fig. 1.9.
• Classification of acromion fractures (Kuhn classifica-
tion): This classification indirectly determines the degree
of displacement of the acromion fracture based on
changes in the gap below the acromion. After fracture, the
acromion shifts downward due to traction of the deltoid
muscle, reflected by a smaller acromial gap in imaging
study (Kuhn et al. 1994) (Table 1.3 and Fig. 1.10).
• Classification of coracoid process fractures (Ogawa clas-
sification): This classification is based on fractures that
occur at the proximal end of the coracoclavicular liga-
ment, usually associated with acromioclavicular disloca-
tion, clavicular fractures, and injury in other SSSC
components (Ogawa and Naniwa 1997; Ogawa et al.
1997) (Table 1.4 and Fig. 1.11). Fig. 1.8 Zdravkovic–Damholt classification. (1) Scapular body. (2 and
• Classification of scapular neck fractures: Scapular neck 3) Glenoid fossa. (4) Scapular neck. (5) Acromion.(6) Scapular spine.
fractures are extra-articular fractures and are divided into (7) Coracoid process. (Source: Kenneth A. Egol, et al. Handbook of
two types (Goss 1995). fractures. th ed. Philadelphia: Lippincott Williams & Wilkins, 2009)
–– Type I: Fracture with no displacement.
Table 1.2 Ideberg classification
–– Type II: Fracture with displacement >1 cm or angle
>45°.

Table 1.1 Zdravkovic–Damholt classification

10 H. Chen et al.

type I

type II
type III type IA type IB
transverse

type II
type IV
oblique

type II

type V

type VI
comminuted

Fig. 1.9 Ideberg classification of glenoid fractures. Type I: avulsion
fracture of the anterior glenoid rim. Type II: transverse or oblique frac-
ture through the inferior glenoid fossa. Type III: oblique fracture
through the superior glenoid fossa, accompanied by scapuloclavicular
joint injury. Type IV: horizontal fracture of the medial scapula rim.
Type V: type IV fracture accompanied by inferior glenoid fracture. Type
VI: comminuted fracture of the glenoid fossa. (Source: BucholzRW,
Heckman JD, Court-Brown C, et al. Rockwood and Green’s Fractures
in Adults.Thed. Philadelphia: Lippincott Williams & Wilkins, 2006)
Table 1.3 Kuhn classification
type III type IV
Fig. 1.10 Classification of acromion fractures. Type I: fracture without
acromion displacement or no change in the subacromial space. Type II:
fractures are displaced and do not reduce the subacromial space. Type
III: fractures with acromion displacement reduce the subacromial
space, accompanied by acromioclavicular joint dislocation or involving
the glenoid fossa
Table 1.4 Ogawa classification

• Pneumothorax can occur at the time of injury or a

2. Comprehensive assessment of airway, lung, vascular, and
neurological functions.
(a) Assessment of pulmonary function: very important.
• Life-threatening lung contusion occurs in 11–54%
of scapular fractures and requires tracheal
­intubation and positive ventilation at the end of
expiration (Fischer et al. 1985; McGinnis and
Denton 1989).
few days after injury.
(b) Blood vessels: In case of upper limb circulation prob-
lems, ultrasound or angiography should be immedi-
ately performed, and consultation with vascular
surgeons should be carried out.
(c) Nerves:
• Brachial plexus nerve injury occurs in 5–10% of
scapular fractures (Ebraheim et al. 1988; Nunley
and Bedini 1960; Tomaszek 1984).
1 Fracture of the Scapula 11

attachment of • For most patients, exercise assessment cannot be

the coracoclavicular ligaments
performed because of pain. Only assessment of
whether the innervation area is normal is possible
(Fig. 1.12).
• Sensation in the axillary innervation area must be
accurately recorded.
3. Scapulothoracic dissociation injury: When the connec-
type I tion between the scapula and the chest wall is broken,
nerve damage occurs in 94% of cases, and 88% are asso-
type II ciated with vascular injury. Because prognosis is
extremely poor or even life-threatening, missed diagnosis
should be carefully avoided (Damschen et al. 1997;
Lahoda et al. 1998).
(a) Such injuries are often caused by violent pulling and
retraction of the affected limb.
(b) Even if the patient’s local skin is intact, when the
shoulder is extremely swollen, with no pulsation in
the upper limb and complete or partial nerve injury,
careful diagnosis is required, and the lateral displace-
ment in the ipsilateral scapula should be further
Fig. 1.11 Classification of coracoid process fractures. Type I: fracture
assessed by X-ray.
proximal to the coracoclavicular ligament. Type II: fracture distal to the 4. Assessment of skin integrity: Fractures caused by a direct
coracoclavicular ligament hit on the shoulder with sticks often show ecchymosis in
the local skin.

supraclavicular supraclavicular nerve

nerve
superior lateral brachial
superior lateral brachial intercostal nerves, cutaneous nerve
cutaneous (axillary nerve) anterior cutaneous (axillary nerve)
branch
posterior brachial cutaneous nerve
(radial nerve)
inferior lateral
medial branchial inferior lateral brachial
brachial cutaneous
cutaneous nerve and cutaneous nerve (radial
(axillary nerve)
intercostobrachial nerve nerve)
medial brachial posterior antebrachial
cutaneous nerve cutaneous nerve (radial
lateral antebrachial cutaneous
nerve (musculocutaneous nerve)
nerve) medial antebrachial
lateral antebrachial
cutaneous nerve
cutaneous nerve
medial antebrachial (musculocutaneous nerve)
cutaneous nerve

radial nerve ulnar nerve palmar branch

superficial branch
median nerve palmar branch
common and proper palmar
digital nerves (median nerve)
common and proper palmar
digital nerves (ulnar nerve)
superficial branch of
ulnar nerve, radial nerve
dorsal branch
dorsal digital nerves
(ulnar nerve)
proper palmar digital
nerve (median nerve)

Fig. 1.12 Schema of innervation of the brachial plexus and branches on the skin. As shown in this schema, the purple area lateral-posterior to the
deltoid muscle is supplied by the axillary nerve
12 H. Chen et al.

5. After symptomatic treatment, if the patient suffers con- 1.1.5.2 Imaging Assessment
tinuous unrelievable or gradually increasing pain, com- • AP (anteroposterior) view:
partment syndrome of the scapular fascia should be –– Shoulder orthographic image: the commonly used
highly suspected. body image in shoulder joint examination (Fig. 1.13a).

Fig. 1.13 Imaging

assessment of the shoulder a
joint. (a) Anteroposterior
(AP) view of the shoulder
joint. (b) AP view of the
scapula. The angle between
the X-ray beam and the body
sagittal plane is 35o. This
view allows observation of
the lateral aspect of the
glenohumeral joint. (c)
Lateral view of the scapula (Y
view). The humerus forms the
base of the “Y”; the coracoid
process and the scapular spine
form the upper arms of the
“Y”; the humeral head is b
superimposed at the center of
the “Y”. (d) Axillary view.
This view obtained in the
position of mild abduction of 35°
the upper arm. A neutral
position of the forearm allows
observation of fractures in the
margins of the acromion and
glenoid fossa

d
1 Fracture of the Scapula 13

–– Scapula orthodontic image: the projection at an angle
of 35° with the sagittal plane (Fig. 1.13b).
• Scapular Y view: the 90° projection of the scapular AP
view (Fig. 1.13c).
• Axillary view: the projection with mild abduction in the
upper limb and neutral position of the forearm. The frac-
ture in the acromion and glenoid margin can be observed
(Fig. 1.13d).
• Stryker notch view: the anteroposterior view of the cora-
coid process. The image is captured with the elbow in
flexion, vertically up, and the hand behind the head. The
bulb is aligned with the coracoid process and is tilted to
10° to the head side for the projection to clearly observe
the fracture in the coracoid process (Fig. 1.14).
• In the anteroposterior X-ray, differences in the distances
of the bilateral scapula and the spinous process suggest
scapulothoracic dissociation. If complicated with vascu-
lar injury, arterial angiography of the upper limb should
be performed to check other injuries such as the subcla-
vian artery and axillary artery fracture, and MRI can be
performed to check the brachial plexus injury in the
advanced stage (Fig. 1.15).
• CT scan with 3D reconstruction (McAdams et al. 2002)
(Fig. 1.16):
–– It is very helpful for the diagnosis of fractures in the
glenoid or coracoid process and judgment of the reduc-
tion of the humeral head.
–– CT can reveal complicated injury, especially intra-­
articular fracture of the glenoid; this type of fracture
usually cannot be diagnosed by X-ray.
• Chest orthostatic imaging must be performed to exclude
pneumothorax.

Fig. 1.14 Stryker notch

view, i.e., anteroposterior a b
view of the coracoid process.
(a) This image is captured
with the bilateral elbow in
flexion, vertically up, and the
hand behind the head. (b) The
X-ray tube is tilted 10° to the 10°
head side for the projection to
clearly observe the avulsion
fracture at the tip of the
coracoid process

Fig. 1.15 Right clavicle

a b
fracture with scapulothoracic
dissociation. In this case, the
patient lost sensation and
motion of the right arm below
the level of the shoulder joint.
(a) Anteroposterior view
X-ray radiography reveals a
right clavicle fracture and
significantly increased
distance from the right
scapula to the midline
compared with the left side.
(b) Magnetic resonance
imaging (MRI) shows nerve
root avulsion of the right
brachial plexus
14
a c
Fig. 1.16 Special effects of a CT scan with 3D reconstruction. A CT
scan with 3D reconstruction can clearly show a glenoid fracture, which
cannot be found on an X-ray radiograph. (a) Anteroposterior view
X-ray radiography of the scapula shows no signs of fractures. (b) A CT
1.2 Surgical Treatment
1.2.1 Surgical Indications and Purpose
1.2.1.1 Surgical Indications
After conservative treatment and functional exercise, most
scapular fractures can be cured with good function, and thus
surgical indications should be strictly controlled.
• Scapulothoracic dissociation injury: For fracture cases
showing emergency surgical indications, emergency
repair of blood vessels, exploration of the nerve injury,
and surgical stabilization for the shoulder to allow the use
of a strap should be performed (Protass et al. 1975;
Houghton 1980).
H. Chen et al.
scan reveals the glenoid fracture. (c) 3D reconstruction of the scapula
(CT) shows the location, size, and degree of displacement of the frac-
ture fragment
• Glenoid fracture involving the glenohumeral joint as the
intra-articular fracture.
–– Articular surface step >4 mm
–– Articular surface separation >10 mm
–– The fracture fragment in the front is greater than the
1/4 of the glenoid, or the fracture fragment in the rear
is greater than 1/3 of the glenoid
–– Accompanied by displacement or subluxation of the
humeral head
• Scapular neck fracture
–– When the shift is >10 mm and the angle is >45°, surgi-
cal treatment should be provided, with placement of a
steel plate for reconstruction in the lateral edge of the
scapula and/or under the mesoscapula to fix the
fracture.
1 Fracture of the Scapula
–– The treatment of floating shoulder injury remains con-
troversial. Due to the use of small sample sizes and
other factors, the treatment strategies of conservative
treatment (Edwards et al. 2000), fixation of clavicular
fracture only (Hersovici Jr et al. 1992), or fixation of
both the clavicle and scapular neck (Leung et al. 1993)
have all achieved good results in different studies.
Based on our experience, fixation of both the clavicle
and scapular neck is recommended to restore the struc-
ture of the SSSC, allow early functional exercise, and
facilitate limb function recovery.
• Fractures of the bony process in the scapula: Conservative
treatment is often applied for fractures of the bony pro-
cess in the scapula.
–– Fractures in the coracoid process: Conservative treat-
ment is often applied unless the fracture hinders the
reduction of the humeral head or clinical symptoms
occur due to stimulation of the surrounding tissue
(Protass et al. 1975; Montgomery and Loyd 1977).
–– Fractures in the acromion: According to the Kuhn clas-
sification, conservative treatment can be applied to
type I and type II. For type III, the narrowed gap under
the acromion may cause acromial impingement, and
surgical treatment is needed (Houghton 1980; De
Villiers et al. 2005).
1.2.1.2 Purpose of Surgery
• Intra-articular fractures:
–– To restore the smooth articular surface of the glenoid
–– To restore the biomechanical stability of the shoulder
joint
–– To restore the stability of the superior ligament in the
upper part of the shoulder
• Extra-articular fractures:
–– To restore the morphology of the scapular neck and the
mesoscapula lateral margin to maintain the stability of
the scapular body
–– To recover the natural morphology of the scapular
body as much as possible
1.2.2 Surgical Techniques
• Deltopectoral approach: Suitable for fractures in the cora-
coid process at the front margin of the glenoid and involv-
ing the upper glenoid and for type III glenoid fracture
(Gross 1993).
• Judet approach: Suitable for fracture in the rear margin of
the glenoid, the glenoid neck, and other parts of the gle-
noid (Judet 1964).
• Anterior-posterior approach: Suitable for fracture in the
front margin of the glenoid associated with fractures in
the scapular neck and scapular body.
15
1.2.2.1 Open Reduction and Fixation
for Fractures of the Front Margin
of the Glenoid and Coracoid Process
Through the Deltopectoral Intercostal
Approach
1. Position and preoperative preparation
(a) General anesthesia: The patient is placed in the
beach-chair position, with a pillow under the affected
shoulder to push the shoulder forward; intraoperative
C-arm fluoroscopy assisted operation is performed.
2. Operative incision according to the projection on the
body surface
(a) On the body surface, the positions of the distal clavi-
cle, acromion, and coracoid process are labeled. The
deltoid and the pectoralis major groove are palpated
to draw the marking line for the skin incision, and the
incision is made along this line, with the center in the
glenohumeral joint (Fig. 1.17).
3. Surgical procedures
(a) Surgical approach (Fig. 1.18):
• The skin and the subcutaneous tissue are cut, with
separation to the deltopectoral interval.
• After finding the head vein in the intermuscular
septum, the medial chest fascia is cut to retract the
head vein and the deltoid muscle outward, which
are protected by the musculocutaneous flap.
• The deltoid muscle and the pectoralis major mus-
cle septum are further separated to the clavipec-
toral fascia, which covers the coracobrachialis and
the subscapular tendon.
• The fascia is cut to place the retractor up and
down, the humerus is rotated outward to generate
subscapular muscle tension, and the subscapular
muscle attachment point is identified (lesser tuber-
osity of humerus).
• The subscapular muscle tendon is truncated at
1 cm outside the ending of the subscapularis, the
subscapularis is marked using silk, and the end
after cutting is pulled inward. The travel of the
axillary nerve under the subscapularis muscle ten-
don is noted to ensure that the axillary nerve is
away from the lower edge of the subscapularis
muscle during outward rotation of the humerus
(extreme backward rotation of the upper arm).
• The anterior humeral vessel and axillary nerve
should be carefully protected (the anterior humeral
vessel is located in the lower margin of the sub-
scapular muscle, and the axillary nerve is below
the blood vessel). The coracoid process is an
important anatomical marker. It acts as a light-
house, in which the area in the outer side of the
coracoid process is a safe area and the area inside
is a dangerous area that includes the brachial
16
Fig. 1.17 (a, b) The patient is placed in the Fowler’s position. C-arm fluoroscopy was performed during surgery. (c) The projections of the distal
clavicle, acromion, and coracoid process on the body surface are marked. The deltopectoral groove approach was used for the procedure
plexus, axillary arteries, and other important
structures. Operation inside the coracoid process
will easily damage these important structures.
• A longitudinal incision of the joint capsule in the
lateral lips outside the glenoid is conducted using
a silk marker to expose the anterior glenoid
fracture.
(b) Reduction and fixation of fractures:
• Reduction and fixation of fracture in the anterior
and inferior margins of the glenoid (Fig. 1.19):
–– After rinsing the joint cavity, reduction of the
fracture fragment is performed from the out-
side of the joint under direct vision, and the
anatomical reduction of the bone is observed.
–– Kirschner wire is applied for temporary fixa-
tion. Depending on the size of the fracture frag-
ments and the degree of crushing, the fragments
are fixed in the front margin of the glenoid with
a small supporting plate (screw diameter of
2.0–3.5 mm) or hollow screw (3.0 mm).
–– For comminuted fractures, if the fracture frag-
ments are difficult to reset, iliac autologous
H. Chen et al.
transplantation can be performed based on the
size of the missing bone after cleaning the joint
cavity, with fixation using the same screws or
micro-plate.
• Reduction and fixation of the coracoid process
(Fig. 1.20):
–– For Ogawa II fractures of the coracoid process,
the treatment depends on the size of the frac-
ture fragment. If the fracture fragment is suffi-
ciently large to apply screw internal fixation,
the bone can be fixed with a 3.5-mm lag screw;
for comminuted fractures, the bone fragments
attached to the joint tendon should be removed,
and the joint tendon end should be sutured and
fixed to the remaining coracoid.
–– For Ogawa I factures of the coracoid process,
lag screw internal fixation near the fracture
fragment can be performed.
(c) Closure of the incision:
• The joint capsule is closed, and the subscapularis
muscle is sutured using No.2 knitting line. The
subcutaneous tissue is sutured using 2-0 suture
1 Fracture of the Scapula 17

a b
coracoid process
cephalic vein

subscapular tendon

tricep fascia
axillary nerve

teres major
muscle
pectoralis
major fascia
latissimus dorsi

external rotation

c d

e f
deltoid

Fig. 1.18 (a) Soft tissue was dissected to expose the cephalic vein. The
clavipectoral fascia is incised medially parallel to the cephalic vein. The
cephalic vein and the deltoid muscle are retracted laterally and protected
under the musculocutaneous flap. (b) When the upper arm is in a neutral
position, the axillary nerve is located beneath the tendon of the subscapu-
laris muscle. Therefore, it easily causes damage to the axillary nerve to
incise the subscapularis muscle at a site 1 cm away from insertion of the
tendon of the subscapularis muscle. Extremely lateral rotation of the
upper arm can reduce the risk of axillary nerve injury. (c) The tendon of
the subscapular muscle is transected at a site 1 cm from its insertion and
separated toward the midline by sharp dissection; the cutting ends should
be marked by sutures for preparation of accurate tendon anastomosis dur-
ing closure. (d) Caution should be taken to protect the nerves and blood
vessels. The coracoid process is an important anatomical landmark (like
a lighthouse); surgeries are safer in the region lateral to the coracoid pro-
cess but risk damaging important structures (i.e., brachial plexus and axil-
lary artery and vein) in the region medial to the coracoid process. (e) A
longitudinal incision was made in the joint capsule to expose the articular
surface of the glenoid fossa. (f) The joint capsule and the insertion of the
subscapular muscle should be sutured in layers during closure
18 H. Chen et al.

a b

coracoid process
subscapular tendon

joint capsule
deltoid glenoid fossa
joint capsule glenoid labrum
posterior capsule
teres major
pectoralis major muslce
muscle
humeral head

c
d

dorsal

Fig. 1.19 (a) Reduction of a glenoid fracture. (b) A lag screw can be repair the glenoid fossa. (d, e) Open reduction and internal fixation of
used to fix a large fragment of a glenoid fracture. (c) A comminuted an anteroinferior glenoid fracture (radiographs before and after
fracture of the glenoid fossa is difficult to be reduced and fixed; there- surgery)
fore, an appropriately sized autologous iliac bone graft can be used to
1 Fracture of the Scapula 19

a line, and the skin is intradermally sutured using a

single strand of absorbable suture line.
4. Postoperative treatment
(a) Week 1 postoperative: Passive movement in the full
range of shoulder movement can begin.
(b) Week 4 postoperative: The goal is to regain and
maintain the level of activity before the injury; daily
activities are encouraged, but the patient is not
allowed to lift, push, pull, or take heavy objects.
(c) If the subscapularis muscle is truncated and recon-
structed, outward rotation movement exceeding the
neutral position and inward rotation of the shoulder
against resistance are avoided for 6 weeks to facili-
tate healing of the subscapular muscle.
b
(d) To prevent muscle atrophy and promote subsidence
of limb swelling, functional exercises for the ipsilat-
eral elbow, wrist, and hand are encouraged, including
carrying 1–2 kg of weight by the elbow with
support.

1.2.2.2 Open Reduction and Internal Fixation

of Fractures in the Glenoid Rear Margin
and the Lateral Margin of the Scapula by
the Simplified Judet Approach
1. Position and preoperative preparation
(a) General anesthesia.
(b) The patient is in the lateral position and tilted slightly
forward on the pad, with a pillow under the armpit to
prevent pressure sores; the upper limb is placed on
the tray in 90° flexion with slight abduction
(Fig. 1.21).
(c) With intraoperative C-arm assisted fluoroscopy, the
orthotopic and axillary positions of the scapula are
intraoperatively adjusted (Fig. 1.22).
c 2. Operative incision according to the projection on the
body surface (Obremskey and Lyman 2004)
(a) The simplified Judet approach can be used to reveal
the rear lip of the glenoid, the scapular neck, and the
outer margin of the scapula: the outline of the scapula
is marked by palpating the surface of the scapula, and
a straight incision is created along the full length of
the scapula below the length, parallel to the meso-
scapula (Fig. 1.23).
(b) If greater exposure of the mesoscapula and even the
scapular medial margin is required, the Judet
approach should be used.
3. Surgical procedures
(a) Surgical approach (Fig. 1.24):
• The skin and the subcutaneous tissue are cut, with
Fig. 1.20 (a) Ogawa type II coracoid process fractures can be fixed fascial dissection with sharp separation.
with a 3.5 mm lag screw via the fragment if the fragment is sufficiently • In the lower margin of the mesoscapula, the del-
large. (b) In terms of comminuted fractures, the fragments attached to
the joint tendon are removed, and the stump of the joint tendon is
toid muscle is truncated. Some muscle tissue
sutured and fixed to the remaining coracoid process. (c) Ogawa type I attached to the mesoscapula should be retained to
coracoid process fractures are fixed with a lag screw via the fragment
20 H. Chen et al.

a b

Fig. 1.21 Photograph showing that a patient is placed in the left lateral with 90° flexion and slight abduction (a). The C-arm of the fluoroscopic
recumbent position and titled slightly forward with surgical pads under machine is located at the patient’s head side (b)
the axilla to prevent decubitus ulcers. The upper limb is placed on a tray

a b

Fig. 1.22 During surgery, the X-ray tube of the C-arm machine can be changed to perform fluoroscopy of anteroposterior (a) and axillary views
(b) of the scapula

facilitate postoperative repair. When flipping and
pulling the deltoid muscle, the circumflex humeral
artery attached on its medial side should be care-
fully protected.
• After pulling the deltoid muscle out, the intermus-
cular septum of the infraspinatus and teres minor
is exposed, and blunt separation along the inter-
muscular septum of the infraspinatus and teres
minor is performed. The infraspinatus and teres
minor are, respectively, pulled up and down to
expose the shoulder capsule beneath.
• Downward dissection under the periosteum is con-
ducted along the scapular neck to fu lly expose the
glenoid, scapular neck, lateral margin of the scap-
ula, and most of the scapula body.
• During the dissection of the outer edge of the scap-
ular neck, the operation should be performed in the
correct intermuscular septum. Entry of the wrong
intermuscular septum may damage the axillary
nerve and the posterior circumflex humeral artery
traveling in the quadrilateral foramen.
• For fractures requiring treatment in the scapular
base or containing large fractures within the
­comminuted joint, truncation can be performed at
1 cm from the ending of the greater tubercle, with
sharp dissection of the infraspinatus tendon from
the articular surface, to fully expose the shoulder
and the scapular base.
• When turning the infraspinatus muscle to the
inside, the suprascapular nerve traveling back-
ward from the suprascapular notch and control-
1 Fracture of the Scapula 21

Fig. 1.23 Modified Judet scapular spine Acromion

approach. (a) Diagram a
showing the proposed straight
incision, which is made
slightly below and parallel to
the scapula spine (the length
of the incision equals the
length of the scapula spine).
(b) Photograph of the actual
incision during surgery. (c)
Diagram showing the Judet
approach: the incision starting
below the acromion is based
on the border of the scapular
spine and angled sharply at
the superomedial angle of the
scapula and follows the
medial border inferiorly to the
inferior angle b c

ling the infraspinatus should be carefully
protected.
(b) Reduction and fixation of fractures (Fig. 1.25):
• For avulsion fracture in the rear of the glenoid and
type II fracture, reduction and fixation can be per-
formed using two hollow screws or a 3.5-mm steel
reconstruction plate.
• For the fractures of type III or higher and fractures
in the scapular neck, fixation with a 3.5-mm
reconstruction plate should be performed after
reduction.
• For patients with floating shoulder injury, fixation
of the clavicle and/or the scapular neck should be
conducted based on the evaluation results.
4. Closure of the incision:
(a) The truncated infraspinatus tendon is sutured using
No.2 knitting line. Brace protection is provided for
the first 6 postoperative weeks, and outward rotation
of the shoulder against resistance is avoided.
5. Postoperative treatment:
(a) Week 1 postoperative: Passive activities in the full
range of shoulder movement can begin.
(b) Week 4 postoperative: The goal is to regain and
maintain the level of movement present before injury;
daily activities are encouraged, but the patient is not
allowed to lift, push, pull, and take heavy objects.
(c) If the infraspinatus, teres minor and deltoid muscle
are dissociated from the ending point, protection with
a triangular bandage should continue for 6 weeks; the
patient can begin to bear load after 6 weeks, starting
with 1–2 kg, which is gradually increased to the
extent bearable by the patient.
(d) To prevent muscle atrophy and promote subsidence of
limb swelling, functional exercises for the ipsilateral
elbow, wrist, and hand are encouraged, including car-
rying 1–2 kg of weight by the elbow with support.
1.2.3 Experience and Lessons
• Auxiliary methods for functional exercise of the shoulder:
During the first 48–72 h after surgery, a nerve-blocking
analgesia pump can be applied in the intermuscular area
of the scalenus for painless activity; pulling and pushing
22 H. Chen et al.

teres minor
a b
infraspinatus fascia

deltoid

c infraspinatus posterior capsule

d posterior capsule
infraspinatus
teres minor articular surface

deltoid

teres minor

deltoid

glenoid labrum
scapula

e medial border of supraspinatus

scapula spine infraspinatus
infraspinatus
articular surface
f
teres minor

deltoid

posterior labrum

joint capsule

Fig. 1.24 (a, b) Along the inferior border of the scapula spine, the
origin of the deltoid muscle is incised to expose the space between the
infraspinatus and teres minor. (c) Upward retraction of infraspinatus
muscles and downward retraction of the teres minor allow exposure of
the posterior joint capsule and the scapular neck. Caution should be
taken not to damage the suprascapular nerve, which supplies the infra-
spinatus muscles, the subcutaneous branch (medial to the suprascapular
nerve) of the circumflex scapular artery, and the posterior humeral cir-
cumflex artery (lateral to the suprascapular nerve). (d) Opening of the
joint capsule allows exposure of the glenoid fossa and the humeral
head. (e) If an enlarged operative field is needed, the insertions of the
infraspinatus muscles can be cutoff 1 cm from the greater tubercle, and
the infraspinatus muscles can be separated from the articular capsule
surface by sharp dissection. (f) Intraoperative photograph
1 Fracture of the Scapula 23

a b

Kirschner
drill wire screws

tap

c d

e f

Fig. 1.25 (a) A Kirschner wire (K-wire) is temporarily used to fix the
reduced fragment, and a hollow screw is placed over the K-wire to fix-
ate the inferior fragment. (b) A 3.5 mm reconstruction plate is used to
treat type III fractures. (c) Intraoperative photograph showing a locking
plate placed in the lateral edge of the scapula for treatment of scapular
fractures. (d) Intraoperative fluoroscopy: anteroposterior and axillary
views. (e, f) Scapular neck fracture accompanied by ipsilateral clavicle
fractures and surgical fixation of the scapular neck and the clavicle
(radiographs before and after surgery)
24
rod movement with the contralateral upper limb in the
supine position is recommended.
• If the shoulder is stiff with poor activity at 6 weeks post-
operatively, passive movements of the shoulder under
brachial plexus anesthesia or arthroscopic surgery to
release the adhesions are recommended.
• Reconstruction of the lateral margin of the scapula is con-
ducive to the precise reduction of the complex of the gle-
noid and the neck.
–– A 2.7-mm dynamic compression plate (DCP) or steel
reconstruction plate can meet the mechanical require-
ments for scapular fracture fixation. A steel plate is
easy to shape and fix with close attachment in the frac-
ture site.
–– When a 3.5-mm or 2.7-mm steel plate is used to fix the
fracture along the lateral margin of the scapula, the
position of the reduction forceps will be in conflict with
the position of the steel plate. A 2.0-mm blade plate can
be used for temporary fixation until removal of the
reduction forceps to complete the ultimate fixation.
–– A small bone plate can be used for temporary fixation
and can also be retained for auxiliary fixation.
• A long screw placed in the coracoid process can enhance
the stability of the fixation.
–– The perspective of the scapula in the “Y” position
determines the direction of the screw for the coracoid
process.
–– The position of the scapula is determined by the posi-
tion of the screw for the coracoid process.
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 Fracture of the Clavicle
Hua Chen, Zhe Zhao, and Zuhao Chang
2.1 Basic Theory and Concepts
2.1.1 Overview
• Fracture of the clavicle is one of the most common frac-
tures, accounting for 2.6–12% of all fractures (Koval and
Zuckerman 2006; Bucholz 2010a; Postacchini et al. 2002)
and 44–66% of shoulder fractures (Koval 2006; Rowe
1968).
• Fractures in the middle segment of the clavicle account
for 80% of all clavicular fractures (Craig 1990; Craig
1996; Craig 1998; Crenshaw, 199a; Moseley 1968;
Robinson 1998; Stanley et al. 1988), whereas fractures in
the inner 1/3 and outer 1/3 segments account for 5% (Seo
et al. 1999; Throckmorton and Kuhn 2007) and 15%
(Goldberg et al. 1997; Robinson and Cairns 2004;
Rockwood 1982a; Rokito et al. 2003; Webber and Haines
2000) of clavicular fractures, respectively.
• Approximately 9% of clavicular fractures are associated
with fractures in other areas (Koval and Zuckerman
2006).
• The inner 1/3 of the clavicle plays a protective role for the
vital organs, including the brachial plexus, subclavian
vein, axillary vein, and lung tip, and fractures in this area
can be associated with severe complications, such as bra-
chial plexus injury.
• Scholars are increasingly recommending surgical treat-
ment for clavicular fractures (Canadian Orthopaedic
Trauma Society 2007; Lazarides and Zafiropoulos 2006).
H. Chen (*) · Z. Chang
Chinese PLA General Hospital, Beijing, China
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_2
2
2.1.2 Applied Anatomy
• Anatomy and biomechanics of the clavicle:
–– Viewed from above, the clavicle is S-shaped, with a
backward distal end and forward proximal end; the
inner end is larger than the outer end.
–– The middle 1/3 segment is located in the transition
area of the clavicle arc, and the section shape resem-
bles a thin tube. The middle 1/3 segment is a site of
concentrated axial load and is the predominant site of
fracture (Bucholz 2012).
–– The clavicle is an important structure connecting the
shoulder strap and the axial skeleton. The clavicle
plays the role of a boom when the upper arm is sagging
and a supporting role when the upper arm is abducting
(details are shown in the section on the functional anat-
omy of scapular fractures). Thus, recovery of the boom
and support functions of the clavicle are the goals of
treatment.
• The muscles attached on the clavicle surface and the
mechanism of displacement in injury:
–– Above the clavicle, the sternocleidomastoid muscle is
attached on the medial side, and the trapezius muscle
is attached on the lateral side.
–– Below the clavicle, the pectoralis major is attached on
the medial side, the subclavian muscle is attached on
the middle, and the deltoid muscle is attached on the
lateral side (Fig. 2.1).
–– Fracture may cause an imbalance in proximal muscle
strength, resulting in fracture displacement, which is
usually manifested as upward and inward displace-
ment of the fracture proximal.
25
26 H. Chen et al.

a b
trapezius sternocleidomastoid
trapezius muscle superior surface muscle origin
pectoralis major
acromion muscle insertion
cephalic vein ligament attachment point
posterior
deltoid sternocleidomastoid
muscle
anterior
deltoid muscle
inferior suface
pectoralis major muscle
anterior
costoclavicular
ligament

posterior
trapezoid ligament
(part of coracoclavicular subclavius muscle
ligament) conoid ligament (part of
sternohyoid muscle
coracoclavicular ligament)

Fig. 2.1 (a) Muscles attached on the clavicle surface. (b) Attachment points of muscles and ligaments on the top and bottom surfaces of the
clavicle

• Ligament anatomy of the clavicle: The ligaments of the
clavicle can be divided into two groups. The medial group
includes the articular capsule ligament (anterior sterno-
clavicular ligament, posterior sternoclavicular ligament),
interclavicular ligament, and costoclavicular ligament.
The lateral group includes the coracoclavicular ligament
and acromioclavicular ligament (Fig. 2.2). The most
important are the posterior sternoclavicular ligament and
the coracoclavicular ligament (Palastanga and Soames
2012).
–– Posterior sternoclavicular ligament:
The posterior sternoclavicular ligament is located
in the posterior part of the capsular articulatio ster-
noclavicularis. It is very hard and is an important
structure for preventing forward and backward dis-
placement of the clavicle;
Important structures such as the brachial plexus and
subclavian vein are in the rear, and thus during sur-
gery to stabilize the sternoclavicular joint, the pen-
etration of the posterior sternoclavicular ligament
and damage to the above structures should be care-
fully avoided (Rockwood 2008a).
–– Coracoclavicular ligament:
The coracoclavicular ligament consists of the
medial cone-shaped ligament and the lateral ortho-
rhombic ligament, which is essential for the stabil-
ity of the acromioclavicular joint.
It provides stability in the vertical direction for the
acromioclavicular joint, which has far greater
strength than the acromioclavicular ligament
(Fukuda et al. 1986; Rockwood and Green 2006;
Urist 1963).
If the coracoclavicular ligament ruptures in the
fracture and poor prognosis is suggested, surgical
repair or reconstruction of the coracoclavicular lig-
ament is recommended.
• Collateral relationship between the clavicle and surround-
ing organs:
The tips of the lungs are in the medial clavicle and
higher than the level of the clavicular head, and thus,
they should be protected in front-to-rear drilling for
screw placement. Excessively deep penetration may
pierce the pleural cavity and damage the lung, causing
pneumothorax.
The medial 1/3 of the clavicle has a protective effect on
the subclavian artery, vein, and brachial plexus behind
and below it. During drilling, the periosteal elevator
should be placed under the clavicle to prevent the drill
from penetrating too deep and damaging these impor-
tant structures (Fig. 2.3).
• Clavicle and sternoclavicular joint movement:
–– The sternoclavicular joint is a saddle-shaped joint with
two movement redundancies. The movement of the
clavicle is an important part of the movement of the
shoulder strap.
–– The clavicle can move up and down by 35° and front
and back by 35°. In addition, as a third type of move-
ment, the clavicle can rotate along the long axis by 30°
(Fig. 2.4). Therefore, during the surgical repair of cla-
vicular fractures, in addition to axial stability, special
attention to the stability of rotation is needed. At both
ends of the fracture, three screws are needed to control
the rotation to avoid failure of the internal fixation
(Neumann 2010).
2 Fracture of the Clavicle 27

Fig. 2.2 (a) The intrinsic articular disc of

a
ligamentous connections of anterior sternoclavicular joint
the clavicle, including the sternoclavicular costoclavicular
sternoclavicular ligament, ligament ligament
Clavicle intercalvicular
costoclavicular ligament, and ligament 1st rib
interclavicular ligament. (b)
The extrinsic ligamentous
connections of the clavicle,
including the coracoclavicular
ligament and
acromioclavicular ligament

costal cartilages
sternocostal
radiate manubrium (synovial) joint
sternocostal
ligament

b coracoclavicular
ligament
acromial end clavicle
acromioclavicular ligament trapezoid conoid
ligament ligament
acromion
sternal end
coracoacromial
coracoacro-mial arch ligament
coracoid process superior angle
humeral head superior transverse
scapular ligament
greater tuberosity
suprascapular
less tuberosity notch
intertubercular scapula, costal
groove surface

glenoid medial border

Humerus cavity

Fig. 2.3 (a) The tips of the trachea

a b
lungs are higher than the level cupula pleurae aortic arch
of the clavicle in the medial
apex pulmonis
1/3 of the clavicle, and thus, clavicle
special attention should be
paid to avoid damaging the
lungs and causing a
1st rib
pneumothorax during screw
placement into the bore hole.
(b) The subclavian artery and
vein are behind and below the
medial 1/3 of the clavicle, and
thus, special attention should
also be paid to avoid
damaging these structures
during drilling
28 H. Chen et al.

a
elevation

retraction

posterior rotation

protraction
b
depression

Fig. 2.4 The clavicle moves up by 30° when the upper arm is lifted
above the head. The clavicle moves forward and backward by 35° on
the horizontal plane during extension and flexion of the shoulder joint,
respectively. The clavicle can rotate along the long axis by 30° when the
upper arm is lifted above the head
Fig. 2.5 Common mechanisms of clavicular injury. (a) Direct falling
of the shoulder onto the ground. (b) Falling with the upper limb in the
2.1.3 Mechanisms of Injury elbow-straight position and pushing the ground using the palm results
in a clavicular fracture due to the passage of stress along the upper limb
• Direct violence: The clavicle is located in the subcutane-
ous layer and lacks protection from soft tissue. Most frac- bility of the fracture, and thus group II in the Allman
tures are caused by direct violence; 87% of fractures are classification of outer 1/3 fractures is divided into three
caused by the force of direct falling of the shoulder onto types: type I comprises fractures in the proximal or distal
the ground, and 7% are caused by direct hitting (Koval ends of the coracoclavicular ligament that show no dis-
and Zuckerman 2006). placement and integrity of the coracoclavicular ligament;
• Indirect violence: Only 6% of the fractures are due to fall- type II comprises fractures with rupture in the proximal
ing with the upper limb in a straight position and pushing conoid ligament and integrity in the distal trapezoid liga-
the ground using the palm, which results in fracture due to ment; type III comprises fractures in the acromioclavicu-
passage of stress along the upper limb (Koval and lar joint (Neer II 1984, 1968).
Zuckerman 2006) (Fig. 2.5). • Rockwood further divided Neer type II into two subtypes.
• Other causes of fractures: These cases are rare, such as Type IIa includes fractures located in the medial coraco-
fracture secondary to epilepsy with muscle spasms, non-­ clavicular ligament with integrity in the conoid ligament
traumatic pathological fracture, and stress fatigue fracture and trapezoid ligament, whereas type IIb includes frac-
(Koval and Zuckerman 2006). tures located between the conoid ligament and the trape-
zoid ligament that show rupture in the conoid ligament and
integrity in the trapezoid ligament (Rockwood 1982b).
2.1.4 Classification of Clavicular Fractures • Craig integrated the above typing methods and added some
unusual types of fractures to develop a more detailed and
• Allman divided clavicular fractures into three groups comprehensive classification method (Craig 1990, 1996):
according to location: group I includes medial 1/3 frac- –– Group I: Middle clavicular fracture (80%). This type
tures, group II includes outer 1/3 fractures, and group III of fracture can occur in children and adults. The distal
includes inner 1/3 fractures. However, this classification and proximal fractures are relatively fixed by the
does not consider the displacement and degree of crush- attached ligaments and muscles.
ing in the fracture and thus has little significance for –– Group II: Distal clavicular fracture (15%). According
determining treatment and prognosis (Allman 1967). to the location of the fracture relative to the coracocla-
• Neer believed that, in distal clavicular fractures, the cora- vicular ligament, this group can be divided into three
coclavicular ligament plays an important role in the sta- types (Fig. 2.6):
2 Fracture of the Clavicle 29

Fig. 2.6 Group II fractures

a b
(distal 1/3 of the clavicle) in
Craig’s classification. (a)
Type I (fractures without
displacement): the fractures
occur between the conoid
ligament and the trapezoid
ligament or between the
coracoclavicular ligament and
the acromioclavicular
ligament, without any
ligament tear. Type II
(fractures with displacement):
the fractures occur in the
medial side of the
coracoclavicular ligament. (b)
Type IIa: the conoid ligament
and trapezoid ligament are c d
intact. (c) Type IIb: the conoid
ligament is ruptured, and the
trapezoid ligament is intact.
(d) Type III includes the
fractures on the articular facet
of the acromioclavicular joint
without displacement and
ligament injury

Type I: Fractures without displacement. The frac- Type I: no displacement

tures occur between the conoid ligament and the
trapezoid ligament or between the coracoclavicular
ligament and the acromioclavicular ligament, with
no ligament tear
Type II: Fractures with displacement. The fractures
occur in the medial coracoclavicular ligament, with
a high incidence of nonunion
Type IIa: The conoid ligament and trapezoid liga-
ment are intact
Type IIb: The conoid ligament is ruptured, and the
trapezoid ligament is intact
Type III: Fractures on the articular surface of the
acromioclavicular joint, with no ligament injury.
These fractures are easily confused with degree 1
dislocation of the acromioclavicular joint
Type IV: Periosteal sleeve fractures (in children)
Type V: Comminuted fractures, in which the liga-
ment attachment point is neither proximal nor distal
but is in the crushed bone
–– Group III: Proximal clavicular fracture (5%). If the
sternoclavicular ligament is intact, the fracture is usu-
ally not associated with displacement and often shows
epiphyseal injury in children and adolescents. This
group can be divided into:
Type II: displacement with ligament rupture
Type III: intra-articular fractures
Type IV: epiphyseal separation (in children and
minors)
Type V: comminuted fracture
2.1.5 Assessment of Clavicular Fractures
2.1.5.1 Clinical Assessment
• Typical manifestations: Head bias to the affected side and
adduction of the affected, with the contralateral hand
holding the affected forearm.
• Shortness of breath and weakened respiratory sounds
should be assessed. Weakened respiratory sounds often
suggest lung injury and complication of pneumothorax,
which require immediate treatment.
• The integrity of the skin (except for open fractures) should
be evaluated. If the proximal protrusion of the fracture
pushes the local skin out, there is a potential open risk,
and surgical treatment is recommended.
• The length of the ipsilateral clavicle should be measured
from the sternoclavicular joint to the acromioclavicular
joint, and the result should be compared with that of the
contralateral healthy side.
30
• Nerve and vascular function should be examined: if any
complicated nerve or vascular injury is found, timely sur-
gery is necessary.
2.1.5.2 Imaging Assessment
• X-ray of the anterior and posterior clavicle: routine exam-
ination to diagnose clavicular fracture and reveal the
degree of fracture displacement.
• X-ray for the oblique clavicle: If it is difficult to deter-
mine the degree and direction of the displacement from
fluoroscopy, another fluoroscopy can be applied. In gen-
eral, the projection tilting 20–60° to the head is selected.
In this case, the impact of thorax on the display of the
clavicle is minimal (Fig. 2.7) (Craig 1998; Crenshaw
1992).
• Other special projection angles:
–– Top oblique position: projection with the affected
shoulder tilted by 45° and the bulb tilted 20° for the
diagnosis of mild fractures, such as neonatal fractures
and greenstick fractures in children (Weinberg et al.
1991).
a • Proximal clavicular fracture:
b fracture fragment, and thus, open reduction and inter-
c vascular injury
Fig. 2.7 (a) Anteroposterior radiographic view of the clavicle: visual-
ization of the medial clavicle is unclear due to the thorax. (b) To obtain
an oblique radiographic view of the clavicle, the incident beam should
be projected at an angle of 20–60° with respect to the head. (c) Oblique
radiographic view of the clavicle: the impact of the thorax on the visu-
alization of the clavicle is minimized, creating another angle for
observation
H. Chen et al.
–– Abduction position of the spine lordosis: projection
with shoulder abduction >135° and bulb tilted 25° to
reveal the clavicle and reduction of the fracture below
the steel plate (in abduction of the shoulder, the clavi-
cle has an upward rotation in the vertical axis) (Riemer
et al. 1991).
–– Projection at stress position: to evaluate the integrity of
the coracoclavicular ligament and fracture displace-
ment from the projection in the anteroposterior posi-
tion and the forward and backward oblique 45° position
while the affected limb holds 10 pounds of weight
(Bucholz 2010b).
• CT scan: to identify whether sternoclavicular joint dislo-
cation, epiphyseal injury, and distal clavicular fracture are
involved in the articular surface.
2.2 Surgical Treatment
2.2.1 Surgical Indications and Purpose
2.2.1.1 Surgical Indications
–– Most proximal clavicular fractures show no significant
displacement or have only a small displacement, and
thus non-surgical treatment is preferred.
–– When the fracture fragment shows a significant back-
ward displacement, especially when the bone is pro-
truding into the neck and mediastinum, there is a risk
of compression of the cervical nerve and vessels by the
nal fixation should be performed (Rockwood 2008a).
• Middle clavicular fracture:
–– Most middle clavicular fractures can be treated with
forearm mitella or an 8-shaped bandage (Rockwood
2008a).
–– The indications for surgical treatment (Bucholz 2012)
include the following:
Open fracture
Fracture complicated with subclavian nerve and
Fracture with obvious displacement and raised skin,
which may develop into an open fracture
Ipsilateral clavicle and scapular fracture (floating
shoulder) or facture complicated with the damage
in other parts of the SSSC
Fracture with displacement exceeding the clavicle
diameter or shortened space greater than 2 cm
Fracture combined with scapulothoracic
dissociation
–– Contraindications for surgical treatment:
Fracture with soft tissue injury at the surgical site or
nearby
2 Fracture of the Clavicle
Fracture associated with systemic infection
Pathological fractures with obstruction for adequate
internal fixation or fracture in severe osteoporosis
• Distal clavicular fracture: (Rockwood 2008a)
–– Conservative treatment can be provided for distal cla-
vicular fracture with no displacement.
–– Surgical treatment is preferred for distal clavicle type
II fracture.
2.2.1.2 The Purpose of Surgery
• To restore the stability of the structures including the ster-
noclavicular joint, acromioclavicular joint, and coracocla-
vicular ligament.
• To restore the normal morphology of the clavicle and its
boom function.
• To recover shoulder function as early as possible.
2.2.2 Surgical Techniques
• Proximal clavicular fracture:
–– If symptoms of compression are persistent, partial
resection of the medial clavicle and reconstruction of
the sternoclavicular joint are recommended.
–– Because of the important structure in the rear of the
sternoclavicular joint, a thoracic surgeon must partici-
pate in the operation (Rockwood 2008a).
• Middle clavicular fracture:
–– Internal fixation using a steel plate and screw can be
applied to provide pressure on the fracture end and
effectively control the rotation with the widest appli-
cable range.
–– Intramedullary fixation is suitable for fractures that
are not very comminuted or only in a wedge-shaped
bone fragment. Because the clavicle is S-shaped, it is
difficult to obtain adequate resistance to rotation by
intramedullary fixation, and there is the possibility of
inward displacement or even injury in the mediasti-
num organs, reducing its application (Rockwood
2008a).
–– For comminuted fractures, shortened reduction is not
recommended, and a local bone graft may be consid-
ered to promote healing and retain the length of the
clavicle.
• Distal clavicular fracture:
–– A distal clavicle plate can provide stable fixation after
the anatomical reduction of the fracture through fixa-
tion of the acromioclavicular joint, and early postop-
erative functional exercise is conducive to shoulder
function recovery.
–– In recent years, attention has turned to reconstruction
of the coracoclavicular ligament. Reconstruction
methods include stitch rivet and PDS II suture.
31
2.2.2.1 Partial Resection of the Medial Clavicle
and Reconstruction
of the Sternoclavicular Joint
• Position and preoperative preparation:
–– In supine position, the treatment towel is placed as a
small column in the scapular area (the entire chest is
exposed to enable expansion of the surgical incision if
surgical complications occur).
• Operative incision according to the projection on the body
surface:
–– The important structures, such as the clavicle, the ster-
noclavicular joint, the manubrium of sternum, and the
sternocleidomastoid muscle, are labeled with a marker.
An incision is made along the Langer’s line of the
necklace of the clavicular head and the manubrium of
the sternum (Fig. 2.8).
• Surgical procedures:
–– The skin and the subcutaneous tissue are cut, with sub-
cutaneous dissociation on the platysma surface. The
platysma is cut along the skin incision to expose the
sternoclavicular joint capsule and the starting point of
the sternocleidomastoid muscle (the joint capsule is
marked with silk, and the sternum of the sternocleido-
mastoid muscle should not be cut off).
–– After partial resection of the clavicular head, the ster-
noclavicular joint is reconstructed (non-traumatic dys-
function) (Fig. 2.9).
–– The joint capsule is carefully pushed and lifted from
the clavicular head with an electric scalpel; the out-
ward dissociation should not be too far, and damage to
the posterior sternoclavicular ligament should be
avoided.
–– The joint capsule is carefully cut along the edge of the
articular cartilage in the clavicular head to remove the
articular disc.
Fig. 2.8 Preoperative incision marks by surface projection
32
a b
Fig. 2.9 Resection of the articular disc of the sternoclavicular joint and proximal clavicle. (a) Resection of the articular disc. (b) Partial resection
of the clavicular head. (c) The removed clavicular head
–– The joint capsule is opened using an automatic retrac-
tor to place a blunt periosteal elevator close to the
articular surface. Approximately 0.5–1 cm of the cla-
vicular head is sawed using a small bone saw, or a
small part of the clavicular head is removed, and then
the remaining bone is ground using a grinder to avoid
excessive removal of bone and damage to the posterior
sternoclavicular ligament, which will lead to damage
to the mediastinum by joint capsule injury after cla-
vicular proximal perforation.
–– The clavicle head is pried up using a bone knife. The
posterior lateral capsule is carefully dissected and
separated in the rear of the clavicle, with the sterno-
clavicular ligament carefully protected. It is very
important to maintain the integrity of the joint cap-
sule. After the joint capsule is completely stripped
from the clavicle, the joint capsule ending point in the
clavicle should be reconstructed using a stitch rivet;
if the sternoclavicular ligament is completely rup-
tured, the articular disc and the ligament should be
sutured and fixed through the bone marrow cavity of
the clavicle.
–– A small incision is created at the wrist stripes, the pal-
maris longus tendon is transcutaneously collected
using a tendon stripper, and stitching is sutured at the
end of the tendon for fixation.
–– The tendon palmaris longus is rolled up on a small cyl-
inder and then sutured to maintain a shape similar to an
“articular disc.”
–– The prepared “articular disc” is inserted in the space
created by resection of the clavicular head (a filler is
H. Chen et al.
c
inserted between the clavicle resection surface and the
manubrium of the sternum to replace the function of
the articular cartilage disc).
–– The palmaris longus tendon passing the clavicle and
the first rib is sutured in an “8” shape to fix and
strengthen the unstable sternoclavicular joint
(Fig. 2.10).
–– The joint capsule is closed with intermittent
“8”-shaped, non-absorbable suture, with in situ suture
fixation of the sternal head of the
sternocleidomastoid.
–– The incision is closed layer by layer.
• Postoperative treatment:
–– Protection with a hanging triangular bandage should
last for 6 weeks without movement of the upper limbs
to permit joint capsule healing and prevent the occur-
rence of instability.
–– Beginning 6 weeks after surgery, the range of upper
limb movement is gradually increased.
–– At 12 weeks after surgery, strength exercises of the
upper limbs can be started.
–– At 16 weeks after surgery, voluntary movement can be
performed.
• Experience and lessons:
–– The instability of the sternoclavicular joint may cause
severe discomfort in the rear of the sternum that is pro-
gressively aggravated. If the sternoclavicular ligament
is torn, the articular disc and ligament can be sewn into
the medullary cavity of the clavicle, or the sternocla-
vicular joint can be reinforced by fixing the tendon
around the first rib.
2 Fracture of the Clavicle
a b
Fig. 2.10 Reconstruction of the sternoclavicular joint. (a) Drilling on
the proximal clavicle and the manubrium. (b) The palmaris longus ten-
don or hamstring tendon is sutured in an “8”-shaped pattern to fix and
–– Reconstruction of the unstable sternoclavicular
joint:
Many methods are reported in the literature; we rec-
ommend the “8”-shaped suture fixation.
After exposing the structure above the jugular
notch of the sternum and in the rear of the manu-
brium of sternum, the retractor should be placed in
the rear of the manubrium of sternum for protec-
tion. Two holes can be drilled in the rear of the
manubrium of sternum so that the suture can pass
through, and 2 more holes can be drilled from front
and back in the proximal clavicle. The semitendi-
nosus tendon can pass through the holes in an
“8”-shaped suture, followed by suture and fixation
of the sternoclavicular joint.
The palmaris longus should turn around the first
ribs to strengthen and fix sternoclavicular joint (the
33
strengthen the unstable sternoclavicular joint. (c) Photograph taken dur-
ing surgery
posterior structure of the first rib should be evalu-
ated to avoid damage to the thoracic artery).
The exposure of the posterior sternal notch should
be assisted by a thoracic surgeon.
–– For proximal clavicular fracture, the proximal end can
be removed, and the articular disc and joint capsule
can be pushed and fixed into the clavicle cavity to sta-
bilize the sternoclavicular joint.
2.2.2.2 Steel Plate Above the Clavicle and Screw
Fixation for Middle Clavicular Fractures
• Position and preoperative preparation:
–– The beach chair (semi-sitting) position is used, with a
pillow behind the shoulder and the affected limb
placed beside the body.
–– Operative incision according to the projection on the
body surface.
34
• A longitudinal incision is created along the clavicle sur-
face parallel to the clavicle diaphysis long axis and
slightly lower than the clavicle (Fig. 2.11).
• Surgical procedures:
–– The skin and the subcutaneous tissue are cut, with mild
subcutaneous dissociation on the platysma surface.
The supraclavicular nerve should be carefully pro-
tected. The platysma is cut along the skin incision to
expose the clavicular fracture for reduction (Fig. 2.12).
–– Reduction for the fracture, with fixation using a steel
plate and screws.
Placement of the steel plate: A 3.5-mm LC-DCP
steel plate or anatomical plate is placed on the upper
surface of the clavicle (Fig. 2.13).
a b
Fig. 2.11 (a) The patient is positioned in a semirecumbent position
with a pillow behind the shoulder and the affected limb placed in front
of the body. (b) The preoperative incision marks by surface projection,
supraclavicular sensory nerves
a b
Fig. 2.12 Exposure of the clavicular fracture and reduction of the clavicle with a reduction clamp. (a) Local anatomy. (b) Photograph taken during
surgery
H. Chen et al.
Fixing the screws: At least three screws are needed
on each of the fracture ends to provide adequate
resistance to rotation. Clavicular fractures are usu-
ally oblique fractures, and thus interlocking lag
screws between the fracture fragments can enhance
the stability of the fixed structure.
Bone graft: If the blood supply of the fracture frag-
ments is well protected, bone graft is not necessary;
if the periosteum in the contralateral cortex at the
steel plate surface is extensively stripped or shows
showing a gap, a graft with a small amount of autog-
enous iliac cancellous bone should be considered.
–– After rinsing with a large amount of saline, the inci-
sion is closed layer by layer (the platysma is closed to
including an incision mark created on the skin surface along and paral-
lel to the clavicle on the affected side
2 Fracture of the Clavicle
a b
Fig. 2.13 A patient with a middle 1/3 clavicular fracture received open reduction and internal fixation with a stainless-steel reconstruction plate
placed on the upper surface of the clavicle. (a) Preoperative X-ray image. (b) Postoperative X-ray image
prevent skin scarring and adhesion), with an indwell-
ing negative pressure drainage tube.
–– If skin conditions allow, subcutaneous non-invasive
suture can be performed.
• Postoperative treatment:
–– Immediately after surgery, the patient can be encour-
aged to perform pendulum or small windmill move-
ments with the hand on the side of the body.
–– Shoulder abduction and weight-bearing exercise of the
upper limb should not be performed until the fracture
has healed.
–– Shoulder stiffness rarely occurs but can be quickly
restored after shoulder exercise, and shoulder exercise
is recommended after healing of the fracture.
• Experience and lessons:
–– Incision exposure:
The clavicular nerve traveling on the surface of the
platysma should be protected during fracture expo-
sure as much as possible to avoid postoperative
numbness in the innervation area of the supracla-
vicular nerve in the surgical area.
A small automatic retractor or temporary external
fixator can be used to help maintain the force lines
and temporary fixation.
Stripping of the muscle attachment points and peri-
osteum should be avoided (especially the muscles
on the surface of the isolated fracture fragment) to
preserve the blood supply of the fracture fragments.
–– Fracture reduction and fixation:
The operation should be performed carefully and
not roughly, and temporary external fixation can be
used to aid the reduction.
35
Note: When viewed from the top, the clavicle is
S-shaped. When a DCP steel plate is used for fixation,
the steel plate must be shaped. This process should be
completed in a single attempt as much as possible to
avoid repeated bending, which may cause fatigue of
the plate. The selection of an appropriate anatomical
plate at this time can reduce the difficulty of shaping.
If the steel plate cannot be properly attached, less
than 3 screws may be available for effective fixa-
tion, which will weaken the anti-rotation effect of
the fixed steel plate and cause pullout of the screws.
In this case, a locking plate can provide better resis-
tance to pull out, with certain advantages (Fig. 2.14).
If the fixed plate is too short or the force distribution
of the screws in the two ends is uneven, failure of
the internal fixation may occur (Fig. 2.15).
The lateral bone fragment should be fixed with
locking screws to prevent pullout of the screws.
Fixation of the steel plate in the anterior clavicle
can reduce the degree of steel plate protrusion.
However, the mechanical characteristics of the
clavicle determine the tension side of the supracla-
vicular plane. Based on the principle of tension of a
steel plate, placement of the screws of the steel
plate above the clavicle is more consistent with its
mechanical characteristics.
–– Clavicular locking plate (Fig. 2.16):
In recent years, many manufacturers have intro-
duced anatomical locking plates suitable for the
clavicle, which have reduced the difficulty of intra-
operative shaping and provided angle stability more
suitable for patients with osteoporosis.
36 H. Chen et al.

a b

c d

e f

Fig. 2.14 Example of an internal fixation failure causing fixer and
fracture displacements. (a) An X-ray image showing a middle clavicu-
lar fracture before internal fixation. (b) An X-ray image taken immedi-
ately after internal fixation. (c) An X-ray image showing bone
displacement 2 months after fixation. (d) An X-ray image illustrating
bone fracture healing 1 year after using a triangular bandage to re-­
secure the fixation. (e) A CT scan reconstruction image showing bone
fracture healing and complete shaping 2 years after surgery. (f) An
X-ray image after surgical removal of the internal fixator
2 Fracture of the Clavicle
In the distal plate, a design with multiple locking
screws can be applied to a distal clavicular fracture.
Ryan Will et al. have shown that locking plate fixa-
tion for a clavicular fracture has better anti-rotation
stress performance than a non-locking plate (Will
et al. 2011).
The distal locking plate employs a thin design that
is compatible with percutaneous placement tech-
nology to reduce incision exposure.
In accordance with the principle of a locking steel
plate with angle stability, single-layer cortical screw
fixation can effectively avoid the injury to blood
vessels, nerves and lung caused by penetration of
the cortex below by the drill or screw. However, an
in vitro study by K. J. Little et al. (2012) showed
that the strength of single-layer cortical screw fixa-
tion for the locking plate is significantly lower than
those of double-layer cortical screw fixation for the
a b
c d
Fig. 2.15 (a) Clavicle diaphyseal fracture with sphenoid bone mass.
(b) X-ray after clavicle fixation. (c) Eight months after operation, the
plate was broken, nonunion, and the fracture site was painful during
shoulder joint movement. (d) Surgical removal and internal fixation of
the broken end of the fracture. (e) Broken plates, wires, and screws
37
locking plate and double-layer cortical screw fixa-
tion for the non-locking plate.
Clavicle locking plates are still relatively new, and
reports with a large number of cases are lacking in
the literature.
2.2.2.3 Anterior Clavicle Fixation with a Steel
Plate and Screws for Middle Clavicular
Fractures
• The technique is essentially the same as that for steel plate
fixation for middle clavicular fracture. The only differ-
ence is that the attachment of the pectoralis major and
deltoid is partially disassociated from the outer part of the
periosteum of the anterior clavicle.
• The front view of the clavicle shows a more regular shape
than the top view. The steel plate only needs to be bent in
one dimension, and thus the steel plate shaping is rela-
tively simple.
removed during the operation. (f) Abnormal activity of the broken end
of the fracture was observed when the internal fixation was removed.
(g) After bone grafting and locking plate fixation at the broken end of
iliac crest. (h) X-ray film after revision of nonunion
38 H. Chen et al.

e f

g h

Fig. 2.15 (continued)

a b

Fig. 2.16 Clavicular locking plates. (a) Anterior-superior stainless-­ ing plate: it can be fixed with multiple locking screws on its lateral side
steel locking plate: it employs a thin-end design that is compatible with and thus can be applied to a distal clavicular fracture
percutaneous placement technology. (b) Superior stainless-steel lock-

• Placement of the steel plate in front of the clavicle can of blood vessels and nerves is greatly increased. However,
reduce the protrusion of the internal fixation. The direc- operation in the interior should be performed carefully to
tions for drilling and the screw are backward, not lower avoid reaching too deep and causing damage to the tip of
than the clavicle, and thus the safe area for the protection the lungs (Fig. 2.17).
2 Fracture of the Clavicle
a b
Fig. 2.17 Internal fixation of the anterior clavicle with a stainless-steel plate and screws for a middle clavicular fracture. (a) Photograph taken
during surgery. (b) Postoperative X-ray image
a b
Fig. 2.18 Preparation of the medullary cavity of the proximal clavicle for a middle clavicular fracture. (a) Schematic diagram. (b) Intraoperative
fluoroscopy image
2.2.2.4 Intramedullary Nail Fixation for Middle
Clavicular Fractures
• Position and preoperative preparation:
–– The patient is set in the beach chair position, with a
pillow behind the shoulder. The clavicle, fracture site,
and surrounding anatomical structure are marked.
• Operative incision according to the projection on the body
surface:
–– The fracture site is marked with C-arm fluoroscopy. A
2–3-cm incision is created along the Langer line of the
neck skin folds at the fracture site.
• Surgical procedures: (Rockwood 2008b)
–– Surgical approach:
The skin and subcutaneous tissue are cut to reach
the platysma (if the subcutaneous fat is very thin, a
39
full thickness of the flap can be prepared), followed
by subcutaneous disassociation on the surface of
the platysma.
Blunt dissection is performed along the traveling
direction of the platysma fibers (the supraclavicular
nerve should be identified, retracted, and protected;
the middle branch should be located around the
middle of the clavicle).
With the exposure of the clavicular fracture ends,
the hematoma and embedded muscle tissue in the
fracture ends are removed (for wedge-shaped bone
fragments, the soft tissue attached to the bone
should be retained).
–– Preparation of the medullary cavity in the proximal
clavicular fracture: (Fig. 2.18)
40
The diameter of the medullary cavity: While hold-
ing the proximal end of the clavicular fracture with
a bone holder or towel clips, the diameter is mea-
sured with a suitable drilling bit, and then a C-arm
is used to verify that the drilling bit fills the medul-
lary cavity and to mark the direction of the medul-
lary cavity.
Expansion of the medullary cavity: The drilling bit
and T handle are connected to expand the clavicular
medullary cavity; penetration of the anterior cortex
of the clavicle should be avoided.
Tapping: After connecting the tapper and T handle,
tapping of the medullary cavity is performed to
approach the front lateral cortex.
–– Preparation of the medullary cavity in the distal cla-
vicular fracture: (Fig. 2.19)
With outward rotation of the upper arm, the clavic-
ular fracture distal is raised.
The same drill bit is used to connect the T handle
and expand the medullary cavity in the distal cla-
vicular fracture.
The posterior lateral cortex is penetrated with
C-arm guidance to ensure that the drill bit pierces
from the posterior medial of the acromioclavicular
capsule to the lower part of the posterior lateral
clavicle.
The tapper and T handle are connected for tapping.
–– Reduction, fixation, and compression of the fractures:
The nut of the intramedullary nail is removed to
connect the T handle to the medial end of the intra-
medullary nail without thread.
While holding the lateral part of the clavicular frac-
ture, the clavicular intramedullary nail is penetrated
–– Treatment of wedge-shaped bone fragments and
wound closure:
Fig. 2.19 Preparation of the medullary cavity of the distal clavicle for
a middle clavicular fracture
H. Chen et al.
into the lateral medullary cavity, piercing from the
hole previously drilled.
After palpating the subcutaneous intramedullary
nail, a small incision is created for the blunt separa-
tion of the subcutaneous tissue using a pair of
hemostatic forceps to expose the intramedullary
nail. With protection provided by a pair of hemo-
static forceps or a small retractor, the intramedul-
lary nail is pushed through the incision and then
rotated with a wrench until the medial thread
securely grips the lateral cortex. The T handle is
then connected to the outer head of the
­intramedullary nail to continue rotating the intra-
medullary nail into the medullary cavity.
The upper arm is lifted to reset the fracture ends,
and the intramedullary nail is rotated into the proxi-
mal end of the clavicular fracture. A C-arm can be
used to confirm that the intramedullary nail passes
through the medial fracture line and to ensure that
all medial threads pass through the fracture line
(Fig. 2.20).
Two nuts are cold welded on the outer side of the
intramedullary nail; one nut is threaded first, fol-
lowed by a smaller nut. The inner nut is gripped
with a wrench, and the outer nut is then rotated
using another wrench to lock the two nuts
together.
With guidance from the C-arm, the outer nut wrench
is used to rotate the intramedullary nail into the
proximal end of the clavicular fracture until the
intramedullary nail reaches the anterior cortex.
A wrench is used to unlock the two nuts in reverse
clockwise.
The inner nut is then screwed in to apply compres-
sion onto the position of the clavicular fracture.
The two nuts are then locked again.
The inner nut wrench is used to pull out the intra-
medullary nail system from the soft tissue and
expose the nut by approximately 1 cm to facilitate
cutting of the intramedullary nail at the same level
as the nut.
Finally, the outer nut wrench is used to push the
intramedullary nail system back into the medial cla-
vicular fracture with the same compression on the
fracture site.
For anterior wedge bone fragments, No. 0 or No. 1
absorbable suture is used for cerclage (to move the
suture, a periosteal stripper is placed below the
clavicle, and the suture passes through the perios-
teum of the wedge-shaped bone fragment around
the bone and the clavicle).
2 Fracture of the Clavicle
a b
Fig. 2.20 Placement of an intramedullary nail after reduction, fixation, and compression of the fracture. (a, b) Schematic diagram. (c) Postoperative
X-ray image
An intermittent 8-shaped suture (No. 0 absorbable
line) is used to suture the periosteum at the fracture
site.
An intermittent 8-shaped suture with 2-0 absorb-
able suture is used to suture the fascia of the
platysma.
The subcutaneous tissue and skin of the two inci-
sions are closed.
• Postoperative treatment:
–– Protection with a hanging triangular bandage should
last for 4 weeks. The triangular bandage should be
removed at least five times every day to allow initiative
movements within the elbow movement range and
shoulder-associated initiative flexion by 90°.
–– After 4 weeks, the triangular bandage can be removed,
and exercise of the active function of the shoulder in
full range can be started.
–– If the patient’s shoulder function is not limited, and
fracture healing is confirmed by the clinical and radio-
41
logical examinations, the shoulder joint resistance
exercise can be started and gradually increased after
6 weeks.
–– Once the clavicular fracture heals, the internal intra-
medullary nails can be removed 10–12 weeks
postoperatively.
• Removal of the clavicular intramedullary nail: (Rockwood
2008c)
–– After the fracture heals, i.e., at 10–12 weeks postop-
eratively, the intramedullary nail can be removed.
–– In the lateral position, local block anesthesia is pro-
vided for the patient.
–– The previous lateral incision is cut, and the subcutane-
ous tissue is separated using a hemostatic clamp to
expose the inner nut.
–– The intramedullary nail is pulled out with the inner nut
wrench.
–– The nut is removed, and the T handle and screw are
connected to pull out the intramedullary nail.
42 H. Chen et al.

• Experience and lessons: –– Repair of the coracoclavicular ligament and acromio-

–– Locking technique for the lateral nut of the intramed- clavicular joint:
ullary nail: The rivet is screwed into the base of the coracoid
The medial head should be blunt to technically process. The ruptured coracoclavicular ligament is
avoid penetrating the anterior cortex of the sutured, with no knot.
clavicle. The acromioclavicular joint is reset and temporarily
Under fluoroscopy, the drill bit should pierce from fixed with Kirschner wire.
the posterior lateral to the lower part of the clavicle The appropriate hook plate is selected: if the hook
to avoid excessive protrusion of the lateral intra- is too deep, the fixation for the acromioclavicular
medullary nail, which may lead to skin wear. joint will not be strong; if the hook is too shallow,
If the tapping in the proximal and distal of the cla- the pressure of the hook on the shoulder will be too
vicular fracture is too tight, a drill bit with a large great, and the hook will fall into the shoulder and
diameter should be used to avoid breaking the med- cause pain.
ullary cavity of the clavicle. The clavicular hook is placed below the acro-
mion immediately next to the clavicle. The gap
2.2.2.5 Open Reduction with Clavicular Hook below the acromion is wide in the front and nar-
and Steel Plate Fixation for Distal row in the back, and thus the more backward the
Clavicular Fractures location of the clavicular hook placement, the
• Position and preoperative preparation: deeper the depth of the hook.
–– The patient is in beach chair (semi-sitting) position, First, the size of the hook plate should be deter-
with a pillow behind the shoulder and the affected limb mined using the test mold, starting from 12 mm,
placed beside the body. with the hook end placed under the acromion,
• Operative incision according to the projection on the body and then the clavicular part of the steel plate is
surface: (Fig. 2.21) attached to the upper surface of the clavicle. If
–– An arc-shaped incision is created along the clavicle the steel plate is difficult to attach, a deeper test
and acromioclavicular joint surface, with the middle mold is needed.
arc facing the coracoid process (the coracoclavicular When the hook plate is placed on the clavicle,
ligament is easy to expose and repair); infiltration with the hook end should be in contact under the
diluted adrenaline can reduce bleeding of the skin acromion. During shoulder movement, espe-
edge. cially shoulder abduction and outward rotation,
• Surgical procedures (Bucholz 2010a): the shoulder should be monitored with fluoros-
–– The skin, subcutaneous tissue, and platysma are cut to copy to avoid collision of the hook end and the
dissect under the platysma. Stripping on the muscle humeral head (Fig. 2.22).
attachment point and periosteum should be avoided At least three screws are used to fix the fracture
while exposing the coracoclavicular ligament and proximal (Fig. 2.23).
acromioclavicular joint. A knot is made in the suture to repair the ruptured
coracoclavicular ligament.
If the acromioclavicular ligament is ruptured, PDS
II suture can be used to reinforce the suture.
–– Rinsing with saline is followed by complete hemosta-
sis and incision closure layer by layer.
• Postoperative treatment:
–– Protection with a hanging triangular bandage should
last for 6 weeks. The triangular bandage should be
removed for at least five times every day. The patient
can be encouraged to perform pendulum exercises or
small windmill movements.
–– After 6 weeks, the triangular bandage can be removed,
and exercise of the active function of the shoulder in
full range can be started.
• Experience and lessons:
–– The indications for a clavicular hook plate should be
Fig. 2.21 The preoperative incision marks by surface projection strictly controlled. For a distal clavicular fracture
2 Fracture of the Clavicle 43

a b

Fig. 2.22 Placement of the clavicular hook plate: The hook end is pushed along the posterior clavicle until it is under the acromion. (a) Schematic
diagram illustrating the position of the hook plate. (b) Intraoperative fluoroscopy image for observation of the hook plate

a b

Fig. 2.23 Fixation of the hook plate on the clavicle. (a) Photograph taken during surgery. (b) Radiograph after surgery using rivets to repair the
ruptured coracoclavicular ligament

(Neer II type), because the distal residual bone is small
and the bone is cancellous, ordinary plate screws result
in poor fixation force or even fixation failure, whereas
the clavicular hook steel plate can provide a stable
fixation.
–– The clavicular hook plate restricts the movement of the
acromioclavicular joint, resulting in greater stress at
the turning point of the steel plate hook, which can
lead to complications such as breakage (Fig. 2.24).
Thus, early removal is recommended. In addition, the
hook plate proximal and the clavicle also form a con-
centrated stress, causing complications such as sec-
ondary clavicular fracture (Fig. 2.25).
–– Complications of the hook plate include acromial bone
absorption (Fig. 2.26) and acromial collision. Taneja
reported that 7 of 37 patients with clavicular hook
plate fixation showed symptoms of acromial collision
(Taneja 2009). The timing of hook steel plate removal
is more stringent than that of ordinary steel plate
(Rockwood 2008b):
44 H. Chen et al.

a b

Fig. 2.24 A patient with clavicular and scapular fractures. (a) Hook plate fixation of the clavicle and open reduction and internal fixation of the
scapula. (b) The clavicular hook plate was broken after surgery

a b

c d

Fig. 2.25 (a, b) Fixation with the clavicular hook plate for simple (d) Open reduction and internal fixation using a superior clavicular
acromioclavicular dislocation. (c) A traumatic fracture occurring at the reconstruction plate
stress concentration site of the medial hook plate 4 years after surgery.

a b

Fig. 2.26 (a) The bright acromial bone area between the hooks indicate bone absorption after fixation using a clavicular hook plate. (b) The
acromial bone absorption remains visible after removal of the plate
2 Fracture of the Clavicle
For simple acromioclavicular dislocation (no distal
clavicular fracture), the hook steel plate can be
removed 8 weeks after surgery.
For acromioclavicular dislocation combined with
clavicular fracture, the hook steel plate can be
removed after healing of the fracture (approxi-
mately 12 weeks).
For young patients, the hook steel plate can be
removed late or even left in place; however, for
elderly patients, removal of the hook steel plate as
early as possible once the fracture or coracoclavicu-
lar ligament is healed is recommended.
–– The coracoclavicular ligament is the most important
vertical stable structures of the clavicle (Palastanga and
Soames 2012). If coracoclavicular ligament rupture is
not repaired during surgery, it will be difficult to pro-
vide sufficient vertical stability after removing the hook
plate. This may lead to re-fracture or acromioclavicular
dislocation. Thus, intraoperative repair with a rivet dur-
ing surgery should be performed as much as possible.
2.2.3 Common Surgical Complications
and Prevention Strategies
• Nonunion:
–– McKee et al. reported that the incidence of nonunion
was as high as 21% in non-surgical treatment (McKee
2010), compared with 2.4% in patients undergoing
surgery [51, 52].
–– In patients undergoing surgical treatment, nonunion is
often related to blood supply damage caused by unsta-
ble internal fixation and soft tissue damage. For simple
fractures, fixation with lag screws and compression on
the fracture ends should be applied as much as
possible.
–– The central part of the clavicle is mainly nourished by
the periosteal blood vessels, and the blood supply is
from the thoracoacromial artery branch, which enters
from the pectoralis major and deltoid attachment. In
surgery, periosteal stripping should be minimized to
reduce blood supply damage. A bone graft can be
applied if necessary to restore the blood supply and
promote bone healing (Archdeacon 2012a, b).
–– An appropriate material should be selected for internal
fixation of the clavicle. The strength of a 1/3 or 1/2
tube-type steel plate is insufficient to support the
movement of the upper arm. A 3.5-mm reconstructed
steel plate is easier to pre-bend but is less strong. The
strength of a 3.5-mm LC-DCP is sufficient, but this
plate is difficult to pre-bend. The anatomical locking
plate does not require pre-bending, and strength is suf-
ficient, particularly patients with distal clavicular frac-
45
ture and osteoporosis, but is expensive; in addition,
there is no large-scale study reporting superior effec-
tiveness compared to an ordinary steel plate. The hook
plate shows many complications, and indications for
application should be strictly limited to patients with
distal clavicular fracture and coracoclavicular liga-
ment injury. The clavicle intramedullary nail has an
advantage with respect to postoperative appearance,
but the risk of displacement is a disadvantage.
–– For nonunion after conservative treatment, surgical
treatment should be provided. The medullary cavity is
drilled through for fixation using a steel plate and
screws after cancellous bone graft. If there are obvious
bone defects, cortical iliac bone graft can be performed
to restore the length.
–– For nonunion in the distal clavicle, depending on the
situation, an anatomical locking steel plate or hook
plate can be used for repair. A joint screw can be used
to temporarily fix the acromioclavicular joint, with
timely removal after fracture healing.
–– Old distal clavicular fracture or distal clavicular non-
union is difficult to suture and repair if the coracocla-
vicular ligament injury is complicated and the
coracoclavicular ligament shows contracture. For
these cases, our hospital employs transposition of the
coracoacromial ligament to repair the coracoclavicular
ligament (Fig. 2.27) with good treatment efficacy. This
method ensures the vertical stability of the clavicle
after removal of the clavicular hook plate.
• Malunion: The clavicle is an important component of
the shoulder joint complex, and its malunion after frac-
ture healing will lead to restricted joint movement of the
shoulder. Matrumura showed that clavicle shortening of
greater than 10% will affect the movement of the scap-
ula, resulting in clinical symptoms (Matsumura et al.
2010). To avoid malunion of the clavicle, attention
should be paid to the quality of intraoperative reduction,
including reduction with deformity of length, angle, and
rotation. In addition, postoperative follow-up should be
performed regularly to avoid loss of fixation caused by
internal fixation failure.
• Injury of blood vessels and nerves: Drilling may cause
injury in the subclavian artery and vein. Although the
incidence is low, such injury is dangerous. Consequently,
a set of sharp drill bits should be used for drilling in the
operating room, and retractors should be used below the
fracture for protection. The drill should be carefully
­controlled and should be stopped immediately stop once
penetration is noted. Kloen et al. reported a method for
placing a steel plate under the clavicle. Although the
plate is not placed on the tension side of the clavicle, it
can reduce the damage rate of blood vessels, nerves, and
lungs (Kloen et al. 2009).
46
a b
Fig. 2.27 Transposition of the coracoacromial ligament to repair the
coracoclavicular ligament for an old distal clavicular fracture accompa-
nied by rupture and contracture of the coracoclavicular ligament. (a)
After cleanup of the scar tissue surrounding the fractured bone, the
coracoacromial ligament is cut at its end point on the acromion, and a
hole is drilled in the distal clavicular fracture fragment, followed by
• Implant-related complications (Archdeacon 2012a, b):
–– Protruding screw of the steel plate: Because the skin
above the clavicle is thin and sensitive, it may cause
discomfort. If the fracture had healed based on the
assessment after the occurrence of this complication,
the screw of the plate can be removed; if it is removed
too early, it may cause re-fracture.
–– Displacement of the internal fixation: Especially when
an intramedullary nail and other smooth internal fixa-
tion are applied, regular postoperative review of the
internal fixation position should be conducted to avoid
damage to dangerous areas such as the mediastinum.
–– Hook plate-related complications: Because the hook
end is placed under the acromion, the hook plate can
cause complications such as shoulder stiffness.
Therefore, the internal fixation should be removed as
soon as possible depending on fracture healing, as
described previously.
• Nerve damage and scarring: Damage of the supraclavicu-
lar nerve during the surgical approach may cause postop-
erative pain keloid, anterior chest wall numbness, sensory
abnormalities, and other complications. Without affecting
exposure and reduction, the supraclavicular nerve should
be preserved as far as possible (Archdeacon 2012a, b).
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 Proximal Humerus Fracture
Hua Chen, Zhe Zhao, and Zhengguo Zhu
3.1 Basic Theory and Concepts
3.1.1 Overview
• Fracture of the proximal humerus is fracture of the
humerus including its surgical neck and the parts above.
• Proximal humerus fractures are more common, account-
ing for 5% of all fractures of the body and 45% of humeral
fractures (Koval and Zuckerman 2006a).
• The incidence is two times higher in females than in
males.
• These fractures are most common in elderly patients with
osteoporosis, followed by young people with high-energy
damage, often complicated with injury to the head, neck,
chest, and spine (Koval and Zuckerman 2006b).
3.1.2 Applied Anatomy
• The applied anatomy of the proximal humerus: Codman
divided the proximal humerus into four parts, including
the humeral head, greater tuberosity, lesser tuberosity,
and humeral stem (Fig. 3.1). Other important anatomical
structures are the dissecting neck, intertubercular groove,
and surgical neck of the humerus (Codman 1934).
–– The humeral head is connected to the anatomical neck
of the humerus, in approximately 1/3 of the surface of
the sphere, and the surface is covered with cartilage.
The top view of the humeral head is inclined at an
angle of 30° relative to the transverse axis of the
humeral condyle (Boileau and Walch 1997).
–– The anatomical neck of humerus is closely connected to
the edge of the humeral head and is the site of attachment
H. Chen (*) · Z. Zhu
Chinese PLA General Hospital, Beijing, China
e-mail: chenhua0270@128.com
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_3
3
of the articular capsule of the shoulder. When fracture
and displacement of the anatomical neck occur, the
blood supply of the humeral head is severely damaged,
with poor prognosis. The humeral neck axis and the
humeral stem axis form an angle of 135°, which is known
as the humeral neck stem angle (Iannotti et al. 1992).
–– The lesser tuberosity is located in front of the anatomi-
cal neck and is the site of attachment of the subscapu-
lar muscle.
–– The greater tuberosity is located in the lateral proximal
humerus and is the site of attachment of the supraspina-
tus, infraspinatus, and teres minor. It is lower than the
highest point of the humeral head by 6–8 mm (Visosky
et al. 2003). With abduction of the shoulder by 90–120°,
it can reach the acromion, causing buckle lock of the
glenohumeral joint. Therefore, in the reduction of large
nodular fractures, the position should be lower than the
highest point of the humeral head; also, while placing
the lateral humerus plate, the upper margin of the plate
should be below the greater tuberosity by 5–8 mm, oth-
erwise acromial collision will occur and cause pain.
–– The intertubercular groove is located between the
greater and lesser tuberosity and is an important ana-
tomical marker to determine the rotation and displace-
ment in the reduction process of proximal humeral
fracture. It is also an important positional reference for
placing the steel plate in the lateral of the proximal
humerus. The medial margin of the steel plate should
be located 2–4 mm on the outer side of the intertuber-
cular groove (Saha 1971; Cyprien et al. 1983).
–– The surgical neck of humerus is located below the
greater and lesser tuberosity and is a common site of
fracture. After fracture of the surgical neck of the
humerus, blood supply on both ends of the fracture is
abundant, with a high fracture healing rate.
• Blood supply in the humeral head and judgment of dam-
age to blood supply after displacement of fracture:
–– The blood perfusion of the humeral head is mainly
from the arcuate artery (Fig. 3.2): The ascending
49
50 H. Chen et al.

a b c

135°

30°

Fig. 3.1 (a) Front and rear views of the proximal humerus. The relative to the epicondylar axis of the humerus. (c) Codman divided the
humeral neck axis and the humeral shaft axis form an angle of 135°, proximal humerus into four parts, including the humeral head, greater
which is known as the humeral neck-shaft angle. (b) Top view of the tuberosity, lesser tuberosity, and humeral shaft
proximal humerus: The humeral head is retroverted at an angle of 30°

Fig. 3.2 The blood supply to suprascapular artery

the humeral head is mainly and nerves
from the arcuate artery. The
ascending branch of the axillary nerve and
anterior circumflex humeral posterior humeral artery
artery, which is responsible
for the major blood supply of
the humeral head, travels
along the intertubercular
groove and enters the bone at
the vertex level of the greater
ascending branch of anterior
tuberosity. The remaining circumflex humeral artery
blood supply is derived from thoracoacromial artery
the blood vessels entering the
metaphysis at the attachment axillary artery
points on the greater and
lesser tuberosities and the lateral thoracic artery
posterior medial branch of the
posterior circumflex humeral
anterior cirumflex subscapular artery
artery
humeral artery median nerve

branchial artery
musculocutaneous
nerve ulnar nerve

medial cutaneous nerve

3 Proximal Humerus Fracture 51

branch of the anterior circumflex humeral artery after a

the separation travels with the long head of the biceps
brachii along the intertubercular groove, enters the
bone at the vertex level of the greater tuberosity, and
bends inside the humeral head to the rear, which is
known as the arcuate artery. This artery is responsible
for the major blood supply of the humeral head (Gerber
et al. 1990).
–– The rest of the blood supply is derived from the blood
vessels entering the metaphysis at the attachment point
of the greater and lesser tuberosity and the posterior b
medial branch of the posterior circumflex humeral
artery.
–– Studies have shown that (Hertel et al. 2004) the type of
fracture, the medial metaphyseal retention in the
humeral head bone, and the integrity of the medial soft
tissue can aid the assessment of the possibility of isch-
emic necrosis in the humeral head after the displace-
ment of the fracture:
Fracture of the anatomical neck is very rare. If such
fracture occurs, the arcuate artery is likely to be
severely damaged, which is associated with poor
prognosis.
Long medial metaphyseal retention on the humeral
head bone (>8 mm) suggests that the blood supply Fig. 3.3 (a) In the two cases shown in the left and right images, longer
in the humeral head is good. medial metaphyseal retention (>8 mm) on the bone fragment of the
For posterior medial fracture, if the medial protrud- humeral head (left) suggests a better blood supply in the humeral head.
ing part of the soft tissue remains intact, the humeral (b) For a posterior medial fracture, if the medial protruding part of the
soft tissue remains intact (left), the humeral head blood supply is more
head blood supply is likely to be maintained, which likely to be maintained, which is conducive to reduction. Serious dis-
is conducive to reduction (Fig. 3.3). placement of the medial part and severe damage of the soft tissue are
• The trabecular bone structure of the humeral head and associated with a poor prognosis (right)
fixation with a plate and screw (Fig. 3.4):
–– The trabecular bone structure in the center of the –– The strength of the bone at the greater and lesser tuber-
humeral head and the humeral neck gradually becomes osity is limited. In the reduction process, the excessive
loose with age (Yamada et al. 2007). use of pointed reduction forceps should be avoided to
–– The bone density is highest in the subchondral bone of prevent aggravation of the breakage of the bone. A
the humeral head cartilage. In internal fixation for towel clamp can be used for tendon handling, traction,
proximal humeral fracture, the tip of the screw should reduction, and fixation of the greater and lesser tuber-
stop at 5–10 mm of the subchondral bone to ensure the osity. Ordinary suture needles can easily pass through
fixation strength and prevent cutting of the screw into the cancellous bone of the greater and lesser tuberos-
the glenohumeral joint (Tingart et al. 2003). ity, and a variety of stitching technologies can be
–– The humeral calcar is the thickening of the bone plate applied to repair the greater and lesser tuberosity.
at the medial proximal humerus and is an important • The muscle attachment at the proximal humerus (Fig. 3.5)
support structure of the proximal humerus. In the and the displacement direction during fracture (Fig. 3.6):
reduction process, the restoration of the medial sup- –– The proximal humerus is covered with a large number
port has important significance for the prevention of of muscles, and distraction by the muscles and tendon
collapse of the humeral head after fixation. The ana- can cause displacement of the fracture fragment.
tomical locking plate of the proximal humerus is –– When fracture of the proximal humerus occurs in four
designed with two humerus screws to resist the varus parts, the supraspinatus, infraspinatus, and teres minor
of the humeral head, which greatly improves the can pull the greater tuberosity with upward and back-
medial support and angular stability. The screw should ward displacement; the subscapularis and teres major
be placed in the fixing process if possible (Osterhoff can pull the lesser tuberosity with inward displace-
et al. 2012; Brianza et al. 2012). ment; and the pectoralis major, brachial biceps, and
52 H. Chen et al.

Fig. 3.4 (a) CT scan of the

a b
humeral head. The greater
tuberosity has a remarkably
porous structure with sparse
trabeculae. The high-density
subchondral bone of the
humeral head can serve as a calcar screw
good screw placement site for
internal fixation. (From
Meyer DC, Fucentese SF,
Koller B, Gerber
C. Association of osteopenia
of the humeral head with
full-thickness rotator cuff
tears. J Shoulder Elbow Surg
2004. 13(3)). (b) The
anatomical locking plate of
the proximal humerus is
designed with 2 humerus c
calcar screws to resist the
tendency toward varus
deformity of the humeral
head, which greatly improves
the medial support and
angular stability. The screws
should be positioned for
fixation if possible. (c)
Ordinary suture needles can
easily pass through the
cancellous bone of the greater
and lesser tuberosities,
allowing a variety of stitching
technologies to be used for
fixation of the greater and
lesser tuberosities

deltoid can pull the humeral shaft with upward and
inward displacement (Matsen et al. 2004).
–– When the fracture of the proximal humerus occurs in
three parts (Neer 1970b):
If the greater tuberosity is connected to the humeral
head, the supraspinatus and infraspinatus can pull
upward and backward, leading to outward rotation
of the articular bone fragment such that the articular
surface of the humeral head rotates forward, with
inward displacement of the lesser tuberosity and
medial and proximal displacement of the humeral
shaft.
If the lesser tuberosity is connected to the humeral
head, the subscapularis and teres major can pull
inward, resulting in inward rotation of the fracture
fragment in the joint such that the articular surface
of the humeral head rotates backward, with upward
and backward displacement in the fracture frag-
ment of the greater tuberosity and medial and proxi-
mal displacement in the humeral shaft.
• Rotator cuff: The rotator cuff was described in the chapter
on scapular fractures (see the sections on the applied anat-
omy of scapular fractures and the abduction movement of
the shoulder joint).
–– The rotator cuff is a dense tendon cap wrapping the
humeral head on the upper, anterior and posterior sur-
faces that consists of the supraspinatus, infraspinatus,
and teres minor attached to the greater tuberosity and
the subscapular muscle and long head of biceps brachii
attached to the lesser tuberosity.
–– The function of the rotator cuff (Fig. 3.7) mainly
involves two aspects:
The muscle group forming the rotator cuff provides
the torque for shoulder joint activities: the supraspi-
natus is one of the two main driving muscles for
shoulder joint abduction, and the subscapular mus-
cle and infraspinatus are the main driving muscles
for the internal and external rotation of the shoulder
joint.
3 Proximal Humerus Fracture 53

a coracoid process b
acromion incisura supraspinatus coracoid process
scapulae superior angle acromion
superior scapular spine
greater angle
tuberosity supraspinatus
superior
lesser border greater
tuberosity tuberosity
intertubercular
groove

medial medial
border border

humeral
teres minor shaft
humeral subscapularis infraspinatus
shaft
lateral border
inferior angle
inferior angle
c pectoralis major, d
clavicle part deltoid,
clavicle part acromion
acromion clavicle
deltoid,
coracoid process acromial part
greater tuberosity clavicle
lesser tuberosity
intertubercular groove pectoralis major,
crest of greater sternum and ribs
tuberosity scapula,
sternum costal
coracobrachialis
surface

pectoralis major,
abdominal part
deltoid
humerus
tuberosity
humeral shaft

Fig. 3.5 (a) The subscapularis. (b) The supraspinatus, infraspinatus, and teres minor. (c) The pectoralis major and coracobrachialis. (d) The del-
toid muscle

The rotator cuff is an important stabilization struc-
ture of the shoulder joint: the co-contraction of the
supraspinatus, infraspinatus, and subscapular mus-
cle can provide tension to press the humeral head
on the glenoid, thus playing the role of the fulcrum
in a lever in shoulder movement involving the gle-
nohumeral joint (Matsen and Lippitt 2004).
Treatment of proximal humeral fractures focuses on
resetting and fixing the small and greater tuberosity,
repairing the ending point of rotator cuff, achieving
biological healing of the greater and lesser tuberos-
ity with the humeral shaft, and restoring shoulder
movement function.
• Long head of the biceps brachii (Fig. 3.8):
–– The long head of the biceps brachii starts from the
supraglenoid tubercle of the scapula, passes along the
intertubercular groove, and continues to the biceps.
–– The long head of the biceps brachii is an important
marker in the reduction and reconstruction of the lesser
and greater tuberosity.
–– In the reduction of proximal humeral fracture, it may
insert between the bone fragments, thus obstructing
the reduction or causing nonunion.
–– In the process of shoulder replacement, the tension can
be used as a reference for the insertion depth of a
humeral proximal prosthesis into the humeral shaft.
54
a b
anatomical neck
long head of
biceps brachii
subscapularis
surgical
neck
deltoid
pectoralis major
Fig. 3.6 (a)Four-part fracture of the proximal humerus. The pulling
force from the muscles can cause an upward and backward displace-
ment of the greater tuberosity, an inward displacement of the lesser
tuberosity, and an upward and inward displacement of the distal
humeral shaft. (b) Three-part fracture of the proximal humerus; if the
greater tuberosity (3) is connected to the humeral head fragment (1),
3.1.3 Mechanisms of Injury
• Indirect violence: Proximal humeral fractures are mostly
the result of contact between straight upper limbs and the
ground when falling; the impact is therefore conducted
along the upper limb, causing fracture. This type of
injury is more common in elderly patients with
osteoporosis.
• Direct violence: A small number of proximal humerus
fractures are due to car accidents and other high-energy
damage, which are more common in young people, or the
shoulder striking the ground while falling, which is more
common in elderly patients with osteoporosis.
• Rare situation: Pathological fractures can be caused by
electrical shock or epilepsy.
H. Chen et al.
1+3
2
c
3
1+2
then the articular facet of the humeral head rotates forward with dis-
placement of the humeral shaft (4). (c) Three-part fracture of the proxi-
mal humerus: if the lesser tuberosity (2) is connected to the humeral
head fragment, then the articular facet of the humeral head rotates
backward
3.1.4 Classification of Fractures
• As the classification of proximal humeral fractures, the
Neer classification is currently widely recognized and the
most widely used in clinical practice.
• The Neer classification (Fig. 3.9) follows the four-part
theory of the proximal humerus of Codman, and proximal
humeral fractures are divided into six types according to
the displacement of the fractures (Neer 1970a).
• This classification notes the destruction of the soft tissue
attachment by the fracture displacement and emphasizes
the increased probability of necrosis of the humeral head
after the loss of soft tissue attachment.
• In the Neer classification, the degree of displacement of
the fracture is determined using the humeral head as a
3 Proximal Humerus Fracture
a b deltoid
sffective acting point of force
f force
line o
acting
c subscapularis
Fig. 3.7 (a, b) The muscle groups forming the rotator cuff participate
in internal and external rotations and abduction of the shoulder joint. (c)
The rotator cuff can provide tension to press the humeral head on the
reference. Referring to the humeral head, an angle of the
fracture fragment ≥45° or distance between the fracture
fragment >1 cm is considered a displacement; if the shift
does not meet the standard, regardless of the number of
fracture fragments, the fracture will be regarded as no dis-
placement. This definition is too precise and dogmatic
and was based on the requirement of the editor of JBJS
before the publication of this classification by Neer.
• Special types of fractures in the Neer classification:
–– Anatomic neck fracture of the humerus: This type of
fracture is a 2-part fracture in the Neer classification
but is very rare and differs from the other type of 2-part
fracture. The blood supply of the humeral head in such
fractures is seriously damaged. Some scholars believe
55
supraspinatus
infraspinatus
scapular glenoid and maintain the stable position of the humeral head
inside the scapular glenoid fossa, thus playing the role of the fulcrum in
a lever during shoulder movement
that the probability of secondary humeral head necro-
sis is high for treatment by internal fixation is high, and
thus replacement treatment of the humeral head is rec-
ommended (Court-Brown et al. 2001; Neer 1970b).
–– The outreach insertion type of four-part fractures
(Fig. 3.10) is characterized by an angle of the humeral
head ≥45° angular and displacement in the greater and
lesser tuberosity. Despite severe crushing of the frac-
ture fragments, with a large displacement, the integrity
of the soft tissue hinge of the medial proximal humerus
is good, and the retention of the blood supply of the
humeral head is maximized. The prognosis of this type
of fracture is better than that of classic four-part
fracture.
56 H. Chen et al.

scapula,
a Subglenoid Coracoid b
tubercle process anterior surface

greater
tuberosity

lesser
tuberosity

inertubercular
groove

long head of short head of

biceps brachii biceps brachii

Fig. 3.8 (a) The long head of the biceps brachii runs along the intertu- of the fractured greater tuberosity, obstructing the reduction or even
bercular groove and can be used as a reference marker in reduction and causing nonunion of the lesser and greater tuberosities if it is not
fixation of the greater and lesser tuberosities. (b) The long head of the reduced
biceps brachii may be embedded in the gap between the bone fragments

3.1.5 Assessment of Proximal Humeral
Fractures
3.1.5.1 Clinical Assessment
• Typical manifestations: The hand on the healthy side
helps hold the affected limb close to the chest wall, with
swelling and pain, and limb activity is limited.
• Blood vessels:
–– For complicated anterior dislocation of the humeral
head or significant inward shift of the humeral shaft,
axillary vascular function should be examined.
–– After injury, arterial angiography or vascular ultra-
sound should be performed immediately, followed by
active treatment.
• Nerves:
–– The probability of damage is highest for the axillary
nerve. The physical examination should include an
assessment of neurological function. If the injury is
complicated, conservative treatment is recommended,
with minor impact on fracture treatment.
–– At 3–4 weeks after injury, EMG examination can be
performed to understand the scope of the nerve injury.
3 Proximal Humerus Fracture 57

Fig. 3.9 The Neer

classification: One-part 2-part 3-part 4-part articular surface
fractures include proximal
humerus fractures without
displaced fragments anatomical
regardless of the number of neck
fracture lines; two-part
fractures include surgical
neck fractures, avulsion
fractures of the greater and A C
surgical
lesser tuberosities, and neck
anatomic neck fractures of the
humerus; three-part fractures B
are divided into two types
based on whether the greater
tuberosity or the lesser greater
tuberosity is connected to the tuberosity
humeral head fragment; and
four-part fractures refer to
fractures with displacements
of the humeral head, the lesser
humeral shaft, and the greater tuberosity
and lesser tuberosities

anterior

fracturedislocation

posterior

headsplitting
58
Fig. 3.10 Everted and compressed four-part fractures:
The fractured bone is displaced, the soft tissue hinge of
the medial proximal humerus remains intact, and
the blood supply to the humeral head is
partially retained
–– If no sign of nerve recovery is observed at 3 months
after the injury, nerve exploration surgery should be
performed.
3.1.5.2 Imaging Assessment
• Assessment of the proximal humerus by X-ray (Fig. 3.11):
–– The anteroposterior position: In the anteroposterior
position, the glenoid partially overlaps the humeral
head. When the angle of projection is 45° to the sagit-
tal line of the body, that is, when the photoreceptor
plane is parallel to the plane of the scapula, the true
anteroposterior position of the shoulder joint is
revealed, and the glenoid and humeral head do not
overlap.
–– Axillary position: In the axillary position, the relation-
ship between the glenoid and the humeral head is
clearly exposed, showing the fracture of the humeral
head. ① In the conventional axillary projection mode,
with the upper arm outstretched by 70–90°, the X-ray is
projected from the bottom of the armpit, and the photo-
Fig. 3.11 Radiographic evaluation of the proximal humerus. (a) In
standard anteroposterior and lateral X-rays, the glenoid partially over-
laps the humeral head. The true anteroposterior view of the shoulder
joint is obtained only when the beam projection forms an angle of 45°
to the sagittal line of the body. (b) X-rays at a body anteroposterior
H. Chen et al.
The humeral head slips into the
synthetic cavity
graphic plane is parallel to and above the shoulder
plane (Lawrence 1918, 1915). ② Velpeau axillary posi-
tion: For patients who cannot outstretch, the X-ray is
projected downward from the top, with the body tilted
back by 20–30° and the upper arm pressing the chest,
and the photographic plane is placed on the console
close to the rear of the body (Bloom and Obata 1967).
–– Lateral position: For the lateral position of the gleno-
humeral joint, the X-ray bulb is located at the rear of
the body, with the projection direction parallel to the
scapula, the photographic plane perpendicular to the
projection direction, and the shoulder blade in the
Y-shape (Rontgen 1896).
• CT scanning and reconstruction (Fig. 3.12) can facilitate
the judgment of whether fracture of the joint has occurred,
the degree of displacement in the fracture, and the identi-
fication of compression fracture and fracture at the edge
of the glenoid.
• MRI is not used for fracture diagnosis but can be used to
determine the integrity of the rotator cuff.
position and humeral anteroposterior position. (c) A standard axillary
projection. (d) A Velpeau axillary projection with the affected limb
fixed. (e) Axillary lateral X-ray of the humerus. (f, g) Schematic dia-
grams of a lateral projection of the humerus (the shoulder blade shows
a “Y” shape). (h) Lateral X-ray image of the humerus
3 Proximal Humerus Fracture 59

routine anteroposterior shoulder

a

true anteroposterior
shoulder
posterior
anterior glenoid rim
glenoid rim
anterior and
posterior glenoid
rims superimposed

45°
b

c d

90°

f g h

R
60
a b
Fig. 3.12 CT scan and reconstruction images clearly showing the degrees of comminution and displacement of the fractured bone. (a) Coronal
view. (b) Sagittal view. (c) Reconstructed 3D image
3.2 Surgical Treatment
3.2.1 Surgical Indications
• Non-surgical treatment: Of proximal humeral fractures,
80–85% exhibit no displacement or mild displacement,
and satisfactory results can be obtained through non-­
surgical treatment. Non-surgical treatment should also be
employed for frail patients suffering from a variety of dis-
eases or who cannot tolerate anesthesia or surgery
(Iannotti et al. 2003).
• Surgical treatment:
–– Closed reduction and percutaneous pinning fixation
(Chen et al. 1998; Ebraheim et al. 1996; Kocialkowski
and Wallace 1990; Soete et al. 1999; Williams and
Wong 2000):
This type of treatment can be applied for fracture of
the surgical neck with good bone quality, some
3-part fractures and the outreach insertion type of
four-part fractures.
Metaphyseal comminution is a relative
contraindication.
–– Open reduction and internal fixation (Nho et al. 2007;
Haidukewych 2004):
It is very important to determine whether the bone
meets the requirements for internal fixation during
the preoperative evaluation.
This treatment can be applied in patients with 2-part
or 3-part fractures and in young patients
(age ≤ 45 years) with four-part fractures.
Limited internal fixation can be used for simple
fractures of the greater tuberosity and lesser
H. Chen et al.
c
tuberosity or non-comminuted fractures of the
humeral surgical neck, as well as some 3-part
fractures and the outreach insertion type of four-
part fractures.
–– Intramedullary nail fixation (Roberts et al. 2006;
Rajasekhar et al. 2001; Agel et al. 2004):
Intramedullary nail fixation can be used for surgical
neck fracture with displacement and for 3-part frac-
tures involving the greater tuberosity.
–– Humeral head replacement (Neer 1970a; Zuckerman
et al. 1997):
Absolute indications include comminuted frac-
tures of the humeral head, old compressive frac-
tures with compression in more than 40% of the
articular surface of the humeral head, and severe
absorption of the humeral head due to delayed
operation showing affected function of the shoul-
der joint.
Relative indications include fractures complicated
with dislocation of the humeral head, split fracture
of the humeral head (Fig. 3.13), and severe
osteoporosis.
For young patients (<50 years), open reduction and
internal fixation are preferred, and joint replace-
ment surgery should be carefully chosen.
Local acute soft tissue infection and chronic osteo-
myelitis are contraindications of joint replacement
surgery.
Deltoid paralysis caused by axillary nerve injury is
a relative contraindication, and shoulder joint
replacement in this case can partially restore joint
function.
3 Proximal Humerus Fracture 61

Fig. 3.13 A patient who had

a b
comminuted fractures of the
proximal humerus and a split
fracture of the humeral head
received a first-stage surgery
of humeral head replacement.
(a) Preoperative X-ray image
demonstrating a remarkable
displacement of the humeral
head. (b) Preoperative
CT-scan-reconstructed 3D
image demonstrating a
proximal humerus fracture
complicated by a split fracture
of the humeral head. (c) X-ray
image after the first-stage
surgery of humeral head
replacement

3.2.2 Surgical Procedures
• The conventional procedures are open reduction and
internal fixation at the proximal humerus or humeral head
replacement through the deltopectoral interval approach.
• The deltoid cleft approach is only used in the fixation of
simple greater tuberosity fractures.
• For fractures of the greater tuberosity with backward dis-
placement, fixation simply through the deltopectoral
interval approach may be difficult, and a combination of
the conventional approach and split approach can be
applied.
3.2.2.1 Open Reduction and Plate Fixation
for Proximal Humeral Fractures
Position and Preoperative Preparation
• The patient is in the beach chair position, with the trunk
positioned on the edge of the bed, a soft cushion behind
the patient to enable a slight tilt to the opposite side, and
a radiolucent holder for the upper arm or shoulder along
the side of the bed. The entire upper limb must be free to
move or operate during surgery.
• Intraoperative C-arm assisted fluoroscopy: A multi-angle
perspective should be available, including the axillary and
AP positions. In the AP position, the upper arm should be
carefully rotated to observe the length of the screw at
multiple angles (Fig. 3.14).
Operative Incision According to the Projection
on the Body Surface (Fig. 3.15)
• The bone markers of the clavicle, acromion, scapula, and
coracoid process are labeled with a marker pen.
• The deltopectoral interval approach: The incision begins
between the coracoid process and the clavicle and extends
to the distal deltoid attachment in an oblique line.
Surgical Approach (Fig. 3.16)
• For the specific process, refer to the procedures for scapu-
lar surgery.
62
a b
30°-45°
c d
Fig. 3.14 (a) The patient is in the beach chair position for fluoroscopic
examination, with the affected arm placed on the side of the bed or on a
holder to allow free adjustments of the arm during surgery. The C-arm
is placed at the head side of the patient. (b) The projection direction and
Fig. 3.15 The preoperative incision marks by surface projection: The
bone markers of the clavicle, acromion, scapula, and coracoid process
are labeled with a marker pen. The incision marking begins between the
coracoid process and the clavicle and extends to the ending point of the
deltoid in an oblique line
H. Chen et al.
e
position in the axillary position. (c–e). After placement of the plate
screws, the upper arm should be carefully rotated to observe the screws
from multiple projection angles to avoid penetration of the screws into
the glenohumeral joint due to an excessive length
–– The skin and subcutaneous tissue are cut to isolate the
deltoid and pectoralis major at the distal end of the
incision, where the cephalic vein can be easily found.
–– Blunt dissection of the deltoid fibers at the lateral
cephalic vein is performed with protection by the
inward retraction of the cephalic vein and small strips
of deltoid fibers, followed by blunt dissection of the
deltopectoral interval to the clavipectoral fascia and
exposure of the proximal humerus.
–– At the distal end of the incision, the first 1/3 of the
deltoid before the ending point is dissociated along the
surface of the humerus to the lateral. In the middle of
the incision, the upper part of the pectoralis major
­ending point is dissociated in the crest of the greater
tuberosity of the humerus to easily expose, reset, and
fix the fracture fragments.
–– Damage to the axillary nerve or musculocutaneous
nerve should always be avoided.
3 Proximal Humerus Fracture 63

b
a

fascia over deltoid

fascia over
pectoralis major

cephalic vein

c
d
deltoid

coracoid process

biceps brachii
conjoint
fascial tendon
incision

subscapularis pectoralis
tendon major

anterior circumflex
humeral artery

Fig. 3.16 (a, b) Exposure of the cephalic vein. (c, d) Blunt dissection dissociated along the surface of the humerus. Next, the upper part of the
of the deltoid fibers at the lateral cephalic vein is performed with pro- pectoralis major at its ending point is dissociated from the crest of the
tection by inward retraction of the cephalic vein and part of the deltoid greater tuberosity of the humerus to expose the fracture fragments
fibers. (e) The first 1/3 of the deltoid before the ending point is laterally
64 H. Chen et al.

–– Intraoperative abduction of the upper limb can relax
the deltoid, which is conducive for exposure of the
incision.
Techniques for Fracture Reduction and Fixation
• Different types of fractures in the Neer classification
require different reduction techniques, as described
below.
–– Two-part fractures of the surgical humeral neck
(Fig. 3.17):
Reduction can be performed by pulling the affected
limb.
If the insertion is in the fracture end, while applying
traction, a blunt periosteum stripper can be inserted
into the gap between the ends as a lever to pry in the
reduction.
After reduction of the proximal humeral fracture by
the surgical neck, rotation should be performed to
confirm the position of the reduction with the
matched fracture line and intertubercular groove.
The backward tilt angle of the humeral head should
also be checked by turning the elbow by 90° to con-
firm that the angle between the axis of the humeral
head and the axis of the humeral condyle (vertical
to the forearm) is 30°.
–– Three-part fracture in the proximal humerus:
In the subscapular muscle and the ending of the
supraspinatus tendon, a thick non-absorbable suture
is stitched in with forward stretch. With exposure of
the end of the infraspinatus tendon in the rear by
pulling forward, the same thick non-absorbable
suture is also stitched in.
For patients with osteoporosis, an indwelling suture
should be pulled and tied in the reduction to convert
the 3-part fracture to a 2-part fracture. The use of
reduction forceps may further crush the bone, thus
increasing the difficulty of reduction and affecting
the stability after reduction (Fig. 3.18).
The reduction should be performed under direct
vision to confirm that the fracture lines are
matched.
For 2-part fractures, a threaded guiding needle can
be placed in the proximal bone fragment as a lever,
or the positional relationship with the humeral
shaft can be reset using a non-locking screw
(Fig. 3.19).
Kirschner wire should be used for temporary fixa-
tion after the reduction. The Kirschner wire should
be placed from the front to avoid affecting the
placement of the lateral plate.

Fig. 3.17 (a) For a two-part

a b
fracture passing through the
surgical humeral neck, a
reduction can be performed
by pulling the affected limb
toward the distal end. (b) For
a fracture with an insertion
that is difficult to reduce by
simple traction, a blunt
periosteal stripper can be
inserted into the gap between
the fracture ends as a lever to
pry for reduction. (c) After
reduction, a careful
examination regarding
rotational displacement
should be performed based on
whether the fracture line and
c
the intertubercular groove are
well aligned
3 Proximal Humerus Fracture 65

Fig. 3.18 (a) At each ending

a b
point of the subscapular,
supraspinatus, and
infraspinatus tendons, a thick
non-absorbable suture is
stitched. (b) The sutures are
tied, and the fractured bone is
reduced to convert the 3-part
fracture to a 2-part fracture.
(c) The use of a reduction
clamp should be minimized to
avoid further crushing of the
bone fragments

Fig. 3.19 (a) After

a b
conversion to a 2-part
fracture, a threaded guiding
needle can be placed as a
lever for reduction of the
humeral metaphysis and shaft.
(b, c) Another approach is to
use a stainless-steel plate
combined with non-locking
screws for reduction of the
humeral shaft and metaphysis.
The direction for screw
placement is determined
based on the fracture
displacement status, and the
drilling direction should be
perpendicular to the displaced
humeral shaft. This operation c
requires specific skills
66
After reduction and temporary fixation of the frac-
ture, in addition to checking the backward tilt angle
of the humeral head, the recovery of the angle
between the humeral neck and shaft should also be
examined. The neck-shaft angle between the
humeral neck axis and the long humeral axis should
be 135° and should be reset (Fig. 3.20).
–– Four-part fracture of the proximal humerus:
For four-part fracture of the proximal humerus,
after retracting the bone fragment in the greater and
lesser tuberosity, reduction of the bone fragment in
the humeral head should be performed first. A
folded drape or a fist under the armpit of the patient
can serve as a fulcrum. While pulling the limb, the
outstretched humeral head can be reset using the
lever principle. Alternatively, periosteal stripping
with a blunt head can be used to assist the reduction
of the fracture in the humeral head (Fig. 3.21).
a b
greater tuberosity
c greater tuberosity
before reduction after reduction
Fig. 3.20 (a) The reduction should be performed under direct vision to
avoid any misalignment of the fractured bone fragments. (b) After
reduction, Kirschner wires are used for temporary fixation, which
should be placed from the front to avoid affecting the placement of the
H. Chen et al.
After the reduction, Kirschner wire is used to tem-
porarily fix the humeral head and the humeral
shaft.
Next, an indwelling suture should be pulled to reset
the bone fragments in the greater and lesser tuber-
osity and then fastened.
In addition to the anteroposterior examination of
the neck-shaft angle, axillary or lateral fluoroscopy
is also needed to confirm the forward or backward
angle between the humeral metaphysis and the
humeral shaft (Figs. 3.22 and 3.23).
• Steel plate fixation (Fig. 3.24):
–– Along the axis of the humerus, the highest point of the
steel plate is located 5–8 mm below the top of the
greater tuberosity; the medial edge of the steel plate is
slightly biased rearward to the intertubercular groove
by 2–4 mm.
lateral plate. (c) After reduction and temporary fixation of the fracture,
recovery of the humeral neck-shaft angle should be examined by
fluoroscopy
3 Proximal Humerus Fracture 67

a a

c
c

Fig. 3.22 (a) After reduction, Kirschner wires are used to temporarily
fix the humeral head. (b) The sutures in the greater and lesser tuberosi-
ties are pulled to reset the bone fragments. (c) An axillary or lateral
fluoroscopic evaluation should be performed to confirm whether there
Fig. 3.21 (a) After retracting the bone fragments of the greater and is an anteversion or retroversion angle between the humeral metaphysis
lesser tuberosities, a periosteal stripper with a blunt head can be used to and the humeral shaft
assist the reduction of the fracture in the humeral head. (b) Reduction
of the fractured bone can also be achieved by pulling the distal end
while placing a supporting object as a fulcrum under the armpit of the
patient based on the lever principle. (c) If the integrity of the medial soft
tissue is damaged, special attention should be paid to avoid displace-
ment of the fractured fragments in the humeral head
68
a b
Fig. 3.23 Intraoperative temporary fixation with Kirschner wires (a) and fluoroscopic confirmation (b)
–– The height of the steel plate is evaluated by fluoros-
copy to ensure that the steel plate does not protrude to
the top (the Kirschner wire on the top of the steel plate
cannot exceed the highest point of the humeral head),
or collision injury of the acromion will occur after
fixation of the steel plate.
–– The locking screw is inserted, with the screw length
fixed in the articular surface of the humeral head carti-
lage; the anti-pullout force at this location is maximal.
For patients with medial support instability and osteo-
porosis, one to two humeral calcar screws must be
inserted to obtain sufficient medial support (Fig. 3.25).
Usually, five screws are screwed into the humeral
head. The number of screws depends on the condition
of the bone, and more screws are needed in the case of
osteoporosis.
–– To stabilize the greater and lesser tuberosity, a suture
can be stitched at the tendon and bone junction of the
tendon ending of the supraspinatus, infraspinatus, and
subscapular muscle. The suture should pass through
the suture hole around the steel plate and tightened to
form a tension band, thus further stabilizing the struc-
ture of the rotator cuff.
Wound Closure
• After confirmation of reduction and fixation by fluoros-
copy, the deltopectoral is closed, and drainage is not rou-
tinely needed.
Postoperative Treatment
• Exercise should begin as soon as possible (function recov-
ery is superior in patients beginning functional exercise
H. Chen et al.
immediately after surgery than in those starting functional
exercise 3 weeks after surgery).
• Pendulum exercise should be started immediately after
surgery (for large tuberosity fracture, active abduction,
and external rotation should be avoided for 4–6 weeks
after surgery; for lesser tuberosity fracture, active internal
rotation, and passive external rotation should be avoided
for 4–6 weeks after surgery).
• Active exercise should be started 4–6 weeks after surgery,
and resistance exercise should be started at 8–12 weeks.
Experience and Lessons
• Fracture exposure:
–– Before disinfecting and draping, actual images are
captured with the C-arm equipment to ensure adequate
visibility and ease of operation for the reduction.
–– Abduction of the shoulder joint can relax the deltoid
muscle, which is conducive to fracture exposure.
–– The ending point of the rotating sleeve should be fixed
with a suture to facilitate the reduction and fixation of
the fracture fragment.
• Fracture reduction and fixation:
–– Humeral fracture at the surgical neck is prone to form-
ing a forward angle. The deformity of the angle can be
corrected by holding the distal arm and pushing the
fracture site toward the ground.
–– In the reduction and fixation process of proximal
humeral fractures, the medial cortex is an important
support structure. Good reduction and fixation of the
medial cortex is an important step to avoid postopera-
tive collapse and varus of the humeral head. Bone
graft, screw fixation for the medial bone fragment, or a
3 Proximal Humerus Fracture 69

a b
1
2

5-8mm

c d

Fig. 3.24 Stainless-steel plate placement. (a) The stainless-steel plate
is placed along the axis of the humerus, 5–8 mm below the apex of the
greater tuberosity and 2–4 mm behind the intertubercular groove. (b, c)
Anteroposterior and lateral views of the position of the stainless-steel
plate. (d) A fine Kirschner wire is inserted from a guide hole on the top
of the plate. The Kirschner wire does not exceed the highest point of the
humeral head, indicating that the height of the stainless-steel plate is
appropriate. (e) Intraoperative fluoroscopy image confirming the height
of the stainless-steel plate. (f) Screw placement after confirmation of
the position of the stainless-steel plate. Usually, five or more screws are
screwed into the humeral head. The number of screws depends on the
condition of the bone, and more screws are needed in the case of osteo-
porosis. (g) To further stabilize the structure of the rotator cuff, the ten-
don endings of the supraspinatus, infraspinatus, and subscapular muscle
are sutured more securely with the sutures passing through the suture
hole around the stainless-steel plate. (h, i) To improve the fixation of
bone fragments in the lesser tuberosity, some companies have designed
special micro-plates that can be connected to the locking plate using
stainless-steel wires
70 H. Chen et al.

e f

g h

Fig. 3.24 (continued)

3 Proximal Humerus Fracture 71

a b

Fig. 3.25 Intraoperative fluoroscopy images. (a) Lateral view demonstrating a normal position relationship between the humeral head and the
humeral shaft. (b) Anteroposterior view: The screws must not protrude from the subchondral bone, and two humeral calcar screws are placed

Fig. 3.26 The medial cortex

is an important support
structure for reduction and
fixation of proximal humeral
fractures. Good reduction and
fixation of the medial cortex
is an important step to avoid
postoperative collapse and
varus deformity of the
humeral head. (a) Hollow
screw fixation for the medial
bone fragment. (b) A
micro-plate as a support plate
(buttress) for severely crushed
medial cortex

a b

micro-plate as a support plate (buttress) can be applied
(Figs. 3.26, 3.27, and 3.28).
–– The locking screw of the locking steel plate should
enter the plate in the lower part of the humeral head
along the humeral calcar, which is very important for
the stability of the fracture:
If this locking screw cannot be inserted due to the
steel plate design or placement, a non-locking screw
can be used instead in the lower medial part of the
humeral head.
–– Location of the steel plate:
If the location of the steel plate is too forward, the
distance to the intertubercular groove will be too
close, thus affecting the long head of the biceps bra-
chii and the ascending branch of the anterior cir-
cumflex humeral artery running in the intertubercular
groove, which will affect the blood supply of the
humeral head.
The location of the steel plate cannot be too high.
The method for determining the height of the steel
72 H. Chen et al.

a b

c d

Fig. 3.27 A 46-year-old female patient with a Neer Type II fracture of
the left proximal humerus. (a) A non-locking stainless-steel plate fixa-
tion was applied, with two screws on each of the proximal and distal
bone fragments and without contacting the medial cortex. (b) X-ray
image at postoperative month 18 demonstrating bone nonunion. (c)
Fixation with a clover-shaped stainless-steel plate 18 months after the
first surgery. (d) X-ray image at 18 months after the second surgery
demonstrating a varus deformity of the humeral head and fracture of the
stainless-steel plate. (e) Locking plate fixation and autologous cancel-
lous bone implantation in the third surgery. (f) The locking plate frac-
tured again within 5 months after the third surgery. (g) During the
fourth surgery, an autologous fibula graft was screw-fixed on the medial
humeral head using a stainless-steel plate to provide satisfactory medial
support. (h) X-ray at 8 months after the fourth surgery demonstrating
bone fracture healing. (i) Functional recovery of the affected arm after
fracture healing
3 Proximal Humerus Fracture 73

e f

g h

Fig. 3.27 (continued)

74 H. Chen et al.

a b

c d e f

g h

Fig. 3.28 For patients who experience an internal fixation failure, a
medial support can be reconstructed by appropriately shortening the
fractured bone in revision surgery. (a) A three-part fracture of the proxi-
mal humerus. (b) The fractured bone was fixed with a locking plate.
One year later, the plate was fractured, and bone nonunion occurred due
to the unstable medial support. (c, d) Revision surgery: the scar tissue
at the fracture site was removed, and the fractured bone was appropri-
ately shortened to reconstruct a strong medial support using a new lock-
ing plate. (e) Postoperative X-ray. (f) A regular follow-up radiograph
illustrating satisfactory bone healing. (g, h) Satisfactory functional
recovery of the affected arm. (i) The internal fixators were removed
more than 2 years after surgery
3 Proximal Humerus Fracture 75

plate has been introduced previously. If the steel

plate is placed too high, abduction of the shoulder
movement may cause acromion collision, and the
high position of the humeral calcar screw will not
provide good medial support (Fig. 3.29).
–– If the fracture causes too much shortening, the effec-
tive length cannot be obtained by a surgical technique.
Schanz nails can be placed in the coracoid process and
the humeral shaft, and a humerus retractor can be used
to maintain the reduction.
–– An anatomical plate can be used for reduction; the ana-
tomical morphology of the steel plate can be used as a
lever in the reduction.
–– The suture technique is used for fixation of the tendon-­
bone junction mainly for the reduction and fixation of
the greater and lesser tuberosity.
–– Excessive reduction in the gap of the fracture ends
should be avoided.
• The importance of the length of the screw and intraopera-
i tive fluoroscopy:
–– In drilling, the “knock the door” technique should be
Fig. 3.28 (continued) used. The surgeon should repeatedly drill as percus-

a b

Calcar screw

Fig. 3.29 (a) The screws of the stainless-steel plate should be inserted strengthen the medial support, as shown in the figure. (b) If the stainless-­
deep enough to ensure their tips reach the subchondral bone of the steel plate is placed too high, not only can shoulder abduction move-
humeral head. In addition, for patients with an unstable medial support ment cause acromion collision but the high position of the humeral
or osteoporosis, it is necessary to place two humeral calcar screws to calcar screws will also fail to provide sufficient medial support
76
sion and assess the difference in drilling in the cancel-
lous bone and cartilage compared to the more compact
cancellous bone to determine the depth of the drilling.
–– To prevent postoperative displacement in patients with
osteoporosis, the operation should be performed as
close to the subchondral bone as possible; however, to
Fig. 3.30 Case example: The patient underwent an internal fixation
with a stainless-steel plate and screws for a proximal humeral fracture.
However, because no thorough fluoroscopic observation was performed
during surgery, and one excessively long screw was found to mistakenly
enter the joint on the postoperative radiograph, another surgery was
required to replace the screw
Fig. 3.31 Postoperative
a b
anteroposterior (a) and
axillary (b) radiographs
H. Chen et al.
prevent postoperative cutting-out of the screw, a dis-
tance of 5–10 mm should be maintained.
–– After the screws are inserted, the length of the screws
should be checked based on the fluoroscopy method
described above (Fig. 3.30). Because of the natural 30°
rearward inclination of the humeral head, the upper
arm should rotate inward as much as possible, so that
the majority of the articular surface of the humeral
head can be observed with fluoroscopy in the antero-
posterior position (Fig. 3.31).
–– Treatment of 4-part proximal humeral fractures in
elderly patients with an anatomical intramedullary
support system.
Open reduction and internal fixation with locking com-
pression plates is the most widely performed procedure in
the treatment of proximal humeral fractures in elderly
because of allowing for high primary stability in the osteopo-
rotic bone (Tepass et al. 2013). The fixed-angle construct
could improve the fracture stability and increase the resis-
tance to pullout through the bone-plate interface with a sin-
gle beam construct, especially useful in poor-quality
cancellous bone of the proximal humerus. However, moder-
ate and poor results still reported in approximately one-third
of the patients because of loss of fixation leading to second-
ary complications (Biermann et al. 2019). High complication
rates of up to 49% in proximal humeral fractures patients by
using locking plating method have been reported, and the
most two common complications are varus malunion and
screw perforation (Sproul et al. 2011a). One study showed
3 Proximal Humerus Fracture 77

that the osteoporotic proximal humeral fracture was similar

to the breakage of eggshell, and the contents in humeral head
were nearly empty (Hertel 2005). Studies have also revealed
the important role of medial cortex integrity and reconstruc-
tion in the shoulder-preserving treatment of proximal
humeral fractures with locking plate especially in the elderly
patients and medial support augmentation of plate osteosyn-
thesis came to the existence (Gardner et al. 2007). Many
efforts have been made to achieve medial support augmenta-
tion, such as medial support screws (Osterhoff et al. 2011),
cement augmentation (Somasundaram et al. 2013), addi-
tional medial plate (He et al. 2015), and bone autograft
(Gerber et al. 1990; Zhu et al. 2014). These treatments have
partly decreased the complication rates, but meanwhile
caused other problems, including humeral head necrosis
(Osterhoff et al. 2011), cement-related heat injuries
(Schliemann et al. 2015), neurovascular injuries (He et al.
2015), and donor-site morbidity (Heary et al. 2002).
To improve the therapeutic efficacy of the treatment of
proximal humeral fractures in elderly patients and avoid
complications, a novel implant named anatomical intramed-
ullary support system was invented by Pro. Tang and Chen’s
team. This anatomical intramedullary support system con-
sisted of two main components, anatomical intramedullary
nail and extramedullary greater tuberosity locking plate,
which constitute a stable augmentation fixation structure of
anatomical intramedullary support combined extramedullary
fixation. Fig. 3.32 Anatomical intramedullary support system

Anatomical Intramedullary Support System

This anatomical intramedullary support system consisted of
two main components, anatomical intramedullary nail and
extramedullary greater tuberosity locking plate (Fig. 3.32).
The characteristic feature of anatomical intramedullary sys-
tem is the supporting plane at 45° to the horizontal plane in
proximal part of the intramedullary nail which provide stable
mechanical supporting force for humeral head by planar sup-
port instead of point support. And the expansional proximal
part also provide intramedullary supporting augmentation to
medial cortex, calcar region, and greater tuberosity where
poor-quality cancellous bone and comminuted fractures could
affect the stability of fixation. This novel anatomical intramed-
ullary support system combined the advantages of existing
internal fixations to improve the stability of fixation and avoid
failure. It can provide a much more stable medial mechanical
supporting force like intramedullary nail by the anatomical
intramedullary nail compared to using locking plate in a single
beam construct and retain the advantage of locking plate in the
treatment of comminuted fragility fractures with the extra-
medullary greater tuberosity locking plate. This novel anatom-
ical intramedullary support system constitutes a stable fixation
structure by anatomical intramedullary supporting force com-
bined with extramedullary fixation (Fig. 3.33).
Surgical Procedure
The patient is placed in the beach chair position with a 3-cm-­
thick, padded cushion under patient’s scapular region. After
sterile preparation, anterolateral approach is selected to
expose the fracture. Inserting sutures into the rotator cuff
bony insertions to provide anchors for reduction, and tempo-
rary fixation of the greater and lesser tuberosities. Make the
affected limb in varus and the anatomical intramedullary nail
is inserted through the expanded lateral fracture window.
The humeral head is reduced by the proximal supporting
plane of nail and valgus force applied to the affected limb
under fluoroscopy. The proper placement of the nail is con-
firmed by image intensification. Drilling carefully just to the
level of the subchondral bone through the sliding screw hole
with the image intensifier. The sliding screw length can be
determined from the measurements of the drill bit. Anti-­
rotation screws should be inserted through corresponding
screw holes if available in the same way. As for the distal
locking screws, drill through both humeral cortices until the
bit just breaks through the medial cortex and insert moderate
length screw. The lateral fracture is reduced by pulling the
sutures, and valgus force applied to the affected limb
expanded the exposure of lateral cortex surface to avoid axil-
78
a b
Fig. 3.33 Serial radiographs of a 69-year-old woman who presented to
our outpatient 3 days after falling onto her right shoulder. Preoperative
radiographs depicting a four-part, varus-angulated proximal humerus
lary nerve injury. The extramedullary greater tuberosity
locking plate is placed in the proper placement and the end
cap of sliding screw insert through the hole in the plate. The
locking screws are inserted through the holes in the plate in
moderate length confirmed by image intensification. Secure
H. Chen et al.
fracture (a, b). Radiograph at postoperative X-ray immediately (c) after
fixation using an anatomical intramedullary support system
the tendons of the rotator cuff with pre-set sutures through
the small holes in the plate. The screws in the plate, espe-
cially the distal monocortical locking screw, compose the
tension band mechanism with the sutures fixed rotator cuff to
increase the stability of internal fixation.
3 Proximal Humerus Fracture
3.2.2.2 Shoulder Replacement for Proximal
Humeral Fractures
Position and Preoperative Preparation
• The patient is in the beach chair position: the head side of
the operating bed is lifted, and the foot side is lowered.
The patient sits on the operating bed at 40–50°, with slight
flexion in the hip and knee. A pillow is place behind the
affected shoulder so that the affected shoulder is lifted off
the bed. The upper limb is placed on an arm holder, and
the position of the upper limbs can be freely adjusted dur-
ing surgery (Fig. 3.34).
Surgical Techniques
• The proximal humeral fracture can be exposed by the del-
topectoral interval approach (identical to open reduction
and internal fixation with locking screws for proximal
humeral fractures).
• The long head of the biceps brachii tendon and the greater
and lesser tuberosity in the medial and lateral tendon are
identified, hung and marked with non-absorbable suture,
Fig. 3.34 The patient is in the beach chair position, with the affected
upper limb placed on an arm holder and the position of the upper limbs
freely adjustable during surgery. (Photo provided by Prof. Zhongguo
Fu)
79
followed by inward and outward retraction to expose the
humeral head and glenoid.
• The crushed humeral head is removed. If the dislocated
bone fragment of the humeral head is below the coracoid
process, the axillary blood vessels and nerves should be
carefully protected when removing the crushed bone. If
the dislocated bone fragment of the humeral head is in the
rear of the joint, the greater tuberosity and humeral shaft
can be pulled outward to facilitate removal of the humeral
head. For old fractures, the humeral head may be caught
in the scar. In this case, the humeral head can be crushed
and then gradually removed.
• The indwelling non-absorbable suture at the tendon-bone
junction of the greater and lesser tuberosity is stretched.
• The proximal humerus is reset and repaired, with mild
reaming using a myelocavity file.
• A hole is drilled in the proximal humeral cortex, and wire
or non-absorbable suture is passed through the bone hole
to fix the greater and lesser tuberosity.
• Bone cement is injected into the medullary cavity of the
proximal humerus, and a suitable prosthesis is inserted
(Fig. 3.35):
–– Backward tilting of the humeral head: The backward
angle is usually 25–40°. The forearm can be placed in
the neutral position, with the thumb and index finger
pinching the medial-lateral condyle at the distal end of
the humerus as a horizontal reference to adjust the
prosthesis backward 25 and 40°. At this time, the pros-
thesis fin should be aligned with the rear of the intertu-
bercular groove. The prosthesis is reset with internal
and external rotation. Upon internal and external rota-
tion by 50°, a stable joint exhibits an appropriate tilt
angle. For fracture and dislocation in the back, the
backward tilt should be reduced by 5–10°. For fracture
and dislocation in the front, the backward tilt should be
increased by 5–10°. The backward tilt angle should not
be <20° or >40°.
–– Appropriate depth of the prosthesis: If the prosthesis is
too deep, the length of the humerus will be reduced,
and the effective length of the deltoid will be short-
ened. A space under the humeral head should be avail-
able to place the greater and lesser tuberosity, and the
appropriate tension for the biceps tendon should be
maintained.
–– Osteoporosis may lead to a large medullary cavity in
the proximal humerus, preventing a tight fit with the
prosthesis, and fixation of the prosthesis with bone
cement is commonly used. Note that before injection
of the bone cement, a hole should be drilled in the
humeral end, and wire or non-absorbable suture should
be pre-set; otherwise, the operation will be difficult to
perform after injecting the bone cement into the med-
ullary cavity.
80
a b
greater tuberosity
lesser
tuberosity
c d
Rotation
neutral position
recovery of
Retroversion
Degrees
Fig. 3.35 (a) After the crushed humeral head is removed, non-­
absorbable sutures are pre-placed in the bone fragments of both greater
and lesser tuberosities. (b) In the bone fragments of the greater and
lesser tuberosities, non-absorbable sutures should be pre-placed at the
tendon- bone connecting site rather than the position crossing the tuber-
osity. (c) During prosthesis insertion, the retroversion angle of the
humeral head must be restored. (d) A sufficient space under the humeral
head should be available so that the greater and lesser tuberosities can
be completely reduced and tightly connected to the humeral shaft. (e) If
the prosthesis is too deep and the length of the humerus cannot be
restored, then the lever arm for the deltoid will be shortened. (f) An
absorbable suture is pre-placed through the bore holes drilled in the
H. Chen et al.
e
distal bone fragment. (g) Bore holes are drilled in the bone fragments of
the greater and lesser tuberosities for placement of a suture, and the
suture can be tied to pull together the greater and lesser tuberosities.
The suture at this site can resist the stress along the long axis of the
humerus. (h) The pre-placed suture at the tendon-bone junction of the
greater and lesser tuberosities is wrapped around the medial prosthesis
to complete the cerclage to resist the separation stress of the greater and
lesser tuberosities. (i, j) Reduction of the greater and lesser tuberosities
should be performed under direct vision to avoid misalignments. In
addition, the greater and lesser tuberosities must be fixed below the
humeral head and tightly connected with the humeral shaft. (k) Finally,
the gap in the rotator cuff is sutured and the reduction completed
3 Proximal Humerus Fracture 81

f g
drilled holes in the lateral
greater tuberosity fragment
for placement of a suture

reduction of greater drilled holes in the medial

and lesser tuberosities lesser tuberosity fragment
by suture for placement of a suture

h i

Cerclage suture

j k
greater tuberosity greater tuberosity

humeral prosthesis humeral prosthesis

Fig. 3.35 (continued)

82
• After drilling holes in the bone of the greater and lesser
tuberosity, the pre-set suture can be used to pull the
greater and lesser tuberosity closer. The suture at this site
can resist the stress along the long axis of the humerus.
The pre-set suture at the tendon-bone junction of the
greater and lesser tuberosity can wrap around the medial
prosthesis to complete the cerclage to resist the separation
stress of the greater and lesser tuberosity.
• A pre-set wire or non-absorbable suture in the humeral
shaft can be passed through the greater and lesser tuberos-
ity and tightened to fix the greater and lesser tuberosity
together with the humeral end and the prosthesis fin to
form a whole movement unit.
• The cancellous bone in the humeral head is collected to
implant in the fracture space.
• The rotator cuff is repaired using non-absorbable suture.
• After rinsing, indwelling negative pressure drainage is set
up, and the incision is closed layer by layer.
Postoperative Treatment
• Exercise should begin as soon as possible, and pendulum
exercise can be started immediately after surgery.
• At 4–6 weeks after surgery, active exercise can be started.
At 8–12 weeks, resistance exercise can be started.
Experience and Lessons
• The goal of joint replacement is to reconstruct a stable,
painless, well-functioning shoulder joint. Good reduction
and strong fixation are prerequisites for early postopera-
tive functional exercise.
• Re-attachment and fixation of the greater and lesser tuber-
osity: Using wire or suture, the greater and lesser tuberos-
ity and the humeral end are fixed with the prosthesis fin to
form a whole movement unit and restore the power func-
tion of the shoulder.
• The cancellous bone in the humeral head is collected to
implant in the fracture gap between the greater and lesser
tuberosity and the humeral shaft to obtain a full greater
tuberosity of the humerus and facilitate bone healing
between the greater and lesser tuberosity and the bone
shaft, with reduced bone absorption in the greater and
lesser tuberosity. Only after bone healing of the fracture
between the greater and lesser tuberosity and the humeral
shaft can good shoulder function be achieved.
• Poor repair of rotator cuff injury can lead to postoperative
pain, and thus restoration of the integrity of the rotator
cuff is very important. The rotator cuff can be repaired by
suture to enhance healing, thereby reducing postoperative
pain and other complications.
H. Chen et al.
• Control of the backward angle: The tilt angle device of
the shoulder prosthesis implant system is used to control
the backward angle of the prosthesis at approximately
30°. The intertubercular groove can be used as a refer-
ence for prosthesis placement, with the fin of the pros-
thesis placed 1 cm behind the intertubercular groove.
Only when the tilt of the humeral head is controlled in
an appropriate angle range can normal anatomical loca-
tion in reduction of the greater and lesser tuberosity be
ensured. Poor reduction and poor healing of the greater
and lesser tuberosity are important factors affecting the
prognosis.
• Control of the height of the prosthesis: Fractures may
cause damage to bone markers, and thus a reference for
the height of prosthesis placement may be lacking,
increasing the difficulty of prosthesis implantation. The
height of the prosthesis determines the tension of the
soft tissue around the shoulder joint. A prosthesis height
that is too high will limit shoulder joint activity and
cause large tension between the greater and lesser tuber-
osity and the shaft, thus affecting the healing of the
greater and lesser tuberosity and the shaft. A prosthesis
height that is too low will decrease the tension of the
surrounding tissue, resulting in instability of the shoul-
der joint.
• Trans-shoulder replacement is rarely used in the initial
shoulder replacement and is mostly for ultimate
treatment.
–– The loss of rotator cuff function due to any cause will
lead to a loss of the inward tension in the humeral
head. The shoulder will then be unable to act as the
fulcrum in the movement of the lever and thus be
unable to complete its normal function. The special
design of the trans-shoulder prosthesis (Fig. 3.36) can
ensure that the shoulder joint acts as a fulcrum and
completes the shoulder function even when the func-
tion of the rotator cuff is lost.
–– In some cases in which the rotator cuff is damaged
before fracture or the connection between the greater
and lesser tuberosity and the humeral shaft with the
prosthesis cannot be reconstructed during surgery, that
is, repair of the rotator cuff cannot be achieved, trans-­
shoulder replacement can be used to reconstruct the
function of the shoulder.
–– Trans-shoulder replacement is subject to many com-
plications, and the life of the prosthesis is limited.
Trans-shoulder replacement is the ultimate solution for
shoulder joint function. The surgical indications should
be strictly controlled for careful use.
3 Proximal Humerus Fracture
Fig. 3.36 The reverse shoulder prosthesis
3.2.2.3 Open Reduction with Hollow Nail
(Tension Band) Fixation for Fractures
in the Greater Tuberosity of the Humerus
Position and Preoperative Preparation
• The patient is in the beach chair position, with the trunk
placed on the edge of the bed, a soft cushion behind the
patient slightly tilted to the opposite side, and a radiolu-
cent holder for the upper arm or shoulder along the side of
the bed.
Operative Incision According to the Projection
on the Body Surface
• The bone markers of the clavicle, acromion, scapula, and
coracoid process are labeled with a marker pen.
–– Shoulder lateral approach: The incision starts from
the lateral acromion toward the distal end by 5 cm to
split the deltoid and expose the displacement in the
greater tuberosity of the humerus. This approach is
relatively deep, with a high risk of damage to the
axillary nerve, and thus the running area of the axil-
lary nerve should be carefully marked preoperatively
from 5 cm below the acromion outward with a width
of 2 cm (Fig. 3.37).
Surgical Approach (Fig. 3.38)
• In the safe area outside the marked zone, an incision of
5 cm from the acromion downward along the long axis of
the humerus is created to cut the skin and the subcutane-
ous tissue.
83
• The deltoid is split along the direction of the muscle fibers
to expose the capsule under the acromion in the deep area;
a protecting stitch should be sutured at the lower vertex of
the split deltoid to avoid the tearing down the incision and
axillary nerve injury.
• The articular capsule under the acromion is cut to expose
the upper lateral part of the humerus.
Fracture Reduction and Fixation Techniques
• A non-absorbable suture is stretched at the junction of the
tendon and bone at the end of the supraspinatus tendon.
• The indwelling suture is retracted, and the greater tuber-
osity fracture is reset.
• Kirschner wire is used for temporary fixation, and the
reduction of the fracture is assessed by fluoroscopy
(Fig. 3.39).
• The method of fixation is selected according to the
patient’s bone condition:
–– For patients with osteoporosis, tension band fixation
can be selected, with an 8-shaped suture or fixation
with a screw (Fig. 3.40).
–– For patients with good bone quality, 1–2 hollow screws
with compression can be used to fix the fractured bone
in the greater tuberosity (Fig. 3.41) with no additional
shim for the hollow screw at a higher position; other-
wise, the protrusion of the screw tail will be too high,
resulting in acromial collision.
Incision Closure and Postoperative Treatment.
Refer to the section on open reduction and internal fixation.
84 H. Chen et al.

Fig. 3.37 (a) Surface

a b
projection for a shoulder
lateral approach through the
deltoid. (b) Before a skin
incision is made, the running
area of the axillary nerve that
is 5 cm below the acromion
outward with a width of 2 cm
should be marked as a acromion
5 cm
dangerous zone greater tuberosity

axillary nerve
axillary nerve
2 cm

a b c

deltoid
acromion
humeral head

Subacromial deltoid
Supraspinatus
fascia over deltoid capsule Subacromial insertion point
protection suture capsule

axillary nerve capsule incision

Fig. 3.38 (a) An incision, which cannot exceed the safe area, is made lower vertex of the split deltoid to avoid a tearing injury of the axillary
to cut the skin and the subcutaneous tissue. The deltoid is split along the nerve. (c) The subacromial joint capsule is opened to expose the upper
direction of the muscle fibers. (b) The deltoid is split to expose the joint lateral part of the humeral head
capsule under the acromion, and then a protecting stitch is made at the

Fig. 3.39 (a) Similar to the

a b
operation of open reduction
and internal fixation with
stainless-steel plates and
screws, a suture is placed at
the ending point of the
supraspinatus and tied to
reduce the greater tuberosity.
(b) Kirschner wires are used
for temporary fixation after
reduction
3 Proximal Humerus Fracture 85

Fig. 3.40 (a) Internal

fixation using hollow screws
a b c
in patients with good bone
quality: One or two hollow
screws are used to fix the
fractured bone, and it is
important to ensure that the
screws reach the subchondral
bone. (b, c) For patients with
osteoporosis, tension band
fixation with an 8-shaped
suture or with a wire and
screw can be applied

Fig. 3.41 A 61-year-old

a b
female patient with an
avulsion fracture of the
greater tuberosity of the
humerus. (a) Preoperative
X-ray image. (b) Preoperative
plain CT scan-reconstructed
3D image. (c) Two hollow lag
screws were placed
unparalleled for fixation. (d)
X-ray after post- healing
internal fixator removal

c d
86
Experience and Lessons
• If the displacement of the greater tuberosity is not obvi-
ous, the anterior shoulder approach is preferred for the
incision. This incision is superficial, and thus inward rota-
tion of the upper arm can expose the fracture site. If the
upward and backward displacement of the greater tuber-
osity is large, an auxiliary lateral incision can be used to
facilitate fracture reduction.
• Two hollow screws are recommended for fixation:
–– One screw is vertical to the fracture surface, and the
depth of the screw must reach the subchondral bone.
–– The other screw is in the humeral shaft direction and
must penetrate the medial cortex.
3.2.2.4 Other Internal Fixation of Proximal
Humeral Fractures
• Closed reduction and percutaneous pinning internal fixa-
tion for humeral fracture at the surgical neck (Figs. 3.42
and 3.43):
–– Position and preoperative preparation: same as above.
–– Closed reduction: The common displacement in the
surgical neck of humerus is distal shortening, accom-
panied by a forward angle. In this case, the distal frac-
ture should be pressed down at the angular position
while pulling the distal end of the affected limb with
the assistance of C-arm fluoroscopy.
–– Surgical approach: Attention to the safe area in
Kirschner wire fixation of the proximal humerus is
needed.
The long head of the biceps brachii should be
avoided and should not be fixed on the humerus.
The needle should enter below the aforementioned
axillary nerve risk area.
The needle entry area is located at the lateral of the
deltoid; the depth should not be too far beyond the
cortical bone; otherwise damage to the axillary
blood vessels and nerves may occur.
–– Fixation of the fracture: Fixation using Kirschner wire
can be divided into three steps.
A Kirschner wire enters from the outside through
the humeral shaft to the subchondral bone of the
humeral head cartilage; another Kirschner wire is
placed roughly parallel to the first wire.
The Kirschner wire is obliquely placed from
front to back, roughly vertical to the first 2
Kirschner wires, to fix the humeral head from
another plane.
If avulsion fracture of the greater tuberosity is com-
plicated, the Kirschner wire can be placed in a
downward direction.
H. Chen et al.
–– Postoperative treatment:
The affected limb is fixed with hanging for 3 weeks.
X-ray is reviewed weekly to assess displacement in
the fracture and the Kirschner wire.
The Kirschner wire is removed under local anesthe-
sia after 3–4 weeks.
After the blur of the fracture line is observed in the
follow-up check-up, passive and active functional
exercise can start.
• Closed reduction and intramedullary nail fixation for
fractures in the surgical neck of the humerus:
–– For the position, preoperative preparation and surgical
approach refer to the relevant sections on fractures in
the humeral shaft.
–– Fracture reduction and internal fixation (Figs. 3.44 and
3.45):
The fracture reduction technique has been described
for the closed reduction and percutaneous pinning
internal fixation. If the proximal humerus is in the
abduction position, the entry point of the intramed-
ullary nail should be under the acromion, and the
thread guide pin can be used as a lever to pry and
reset the proximal fracture.
The technique for intramedullary nail placement
refers to the closed reduction and intramedullary
nail internal fixation for humeral shaft fractures.
Due to the special design of the nail for the proxi-
mal humerus, a different fixation method is
employed for the proximal end, such as a spiral
blade or multi-plane locking. Locking can be per-
formed according to the type of selected material. If
the integrity of the medial cortex is damaged, a
humeral calcar screw should be placed to obtain
better medial support and avoid postoperative val-
gus and collapse of the humeral head.
The placement of the distal locking screw should be
in the distal end of the safe zone for the axillary
nerve as described above to avoid damage the axil-
lary nerve.
–– Postoperative treatment: refer to open reduction and
internal fixation.
–– Experience and lessons:
In the process of placement of the intramedullary nail
in the proximal humerus, the supraspinatus tendon
must be split, which may cause rotator cuff injury.
According to the location of the end of the intra-
medullary nail, a tail cap of an appropriate length
should be selected. After it is completely placed, it
should not protrude into the nail entry point to avoid
rotator cuff injury.
3 Proximal Humerus Fracture 87

a b

c
Axillary neurovascular bundle

long head of posterior

d
axillary biceps brachii
nerve

Fig. 3.42 (a) Closed reduction with traction of the distal end of the
affected limb. (b) If the fractured bone forms an anteversion angle, the
fractured end can be pressed down. (c) The safe area for Kirschner wire
fixation is located at the lateral end of the deltoid. The insertion points
of the wires should be positioned below the aforementioned dangerous
area of the axillary nerve to avoid damaging the nerve and vessel. The
Kirschner wires should not be inserted too deep; otherwise, the risk of
damaging nerves and vessels will increase. (d) Three groups of
Kirschner wires for fracture fixation: The first group is inserted from the
lateral end of the humeral shaft toward the humeral head until it reaches
the subchondral bone; the second group is placed from front to back;
the third group is inserted into the greater tuberosity in patients with the
humeral surgical neck fracture complicated by avulsion fracture of the
greater tuberosity
88 H. Chen et al.

Fig. 3.43 A humeral surgical

a b
neck fracture treated with
closed reduction and
percutaneous pinning internal
fixation. (a) Preoperative
X-ray. (b) Postoperative
X-ray

a b

Sagittal
plane

retroversion
α angle of the
humeral head

Coronal plane

c d e

dangerous zone

Fig. 3.44 (a) If the proximal fragment of the fractured humerus is in
the abduction position, the entry point of the intramedullary nail should
be under the acromion, and the threaded guide pin can be used as a lever
to pry and reset the proximal fracture. (b) When the elbow joint of the
affected arm is flexed to make the line connecting the medial and lateral
epicondyles perpendicular to the forearm, the retroversion angle of the
humeral head can be restored by moving the handle rearward to create
a 30° angle. (c, d) Different types of internal fixators can be selected for
proximal humeral fractures. If the integrity of the medial cortex is dam-
aged, a humeral calcar screw should be placed. (e) The distal locking
screw should be placed distal to the dangerous zone of the axillary
nerve
3 Proximal Humerus Fracture
a b
Fig. 3.45 (a, b) Anteroposterior and lateral X-ray images of a humeral surgical neck fracture. (c, d) Anteroposterior and lateral X-ray images after
placement of an intramedullary nail in the proximal humerus
3.2.3 Surgical Complications and Prevention
Strategies
• Robert C. Sproul et al. (Sproul et al. 2011b) systemati-
cally reviewed 12 studies on the application of locking
plate treatment in proximal humeral fractures with a total
of 514 cases to identify complications: the varus rate was
16%, the humeral head necrosis rate was 10%, the inci-
dence of screw cut into the joint was 8%, the incidence of
acromial collision was 6%, and the incidence of infection
was 4%.
• Varus deformity and screw cutout:
–– When applying a locking plate for fixation, anatomical
reduction should be performed first before final fixa-
tion by inserting the screw.
–– The importance of posterior medial cortical support:
Georg Osterhoff et al. (Osterhoff et al. 2012) indicated
that comminution of the humeral calcar can be used as
a predictor of poor prognosis in proximal humeral
fractures. The importance of posterior medial cortical
support must be emphasized, and medial support can
be reconstructed through bone contact or a humeral
calcar screw to prevent varus deformity.
–– Bone density and the pullout resistance ability in dif-
ferent parts of the humeral head: M. J. Tingart et al.
(Tingart et al. 2003) investigated the bone mineral den-
sity in different parts of the humeral head by quantita-
tive CT. The bone mineral density was highest in the
middle of the humeral head and lowest in the anterior
upper quadrant, and the bone mineral density was
related to the pullout resistance of the screw (Fig. 3.46).
89
c d
–– Number of screws and humeral calcar screw: In a
cadaver study, Johannes B. Erhardt (Erhardt et al.
2012) et al. showed that an increased number of screws
can reduce the probability of screw cutout, and the
placement of at least 5 locking screws in the humeral
head was recommended. The importance of the
humeral calcar screw was also emphasized.
–– The depth of the screw: To prevent screw cutout while
ensuring the strength of the fixation, the screw should
be placed in the subchondral bone by 5–10 mm.
–– Improvement of the material for internal fixation:
Devices have been designed and produced to prevent
screw cutout into the joints, such as Hand Innovations
smooth screws (Yamamoto et al. 2012).
• Acromial collision:
–– Acromial collision is usually caused by a high position
of the implant. The implant should be below the high-
est point of the greater tuberosity by 5–8 mm during
surgery to avoid acromial collision, which will affect
the limb abduction angle and cause pain (Fig. 3.47).
–– Another cause of acromial collision is poor fixation of
the greater tuberosity with postoperative proximal
displacement.
• Ischemic necrosis of the humeral head:
–– The previously described method of Hertel et al. to
evaluate the effect of fracture on the blood supply of
the humeral head provides a definitive basis for the
prediction of prognosis.
–– Wijgman et al. (Wijgman et al. 2002) reported that,
after treatment of 3-part or 4-part proximal humeral
fractures using cerclage and T-plate, ischemia and
90 H. Chen et al.

surperior
a b c

su
r

p
rio

ra
te

p
os
an

te
pr

rio
su

r
anterior posterior

r
in

rio
fra

te
nt

os
er

p
surgical neck

io

fra
r

in
inferior

d e f

Fig. 3.46 (a, b) Using quantitative CT and biomechanical techniques
to examine the humeral head dissected from the surgical neck, M. J.
Tingart et al. found that the bone mineral density is highest in the mid-
dle of the humeral head and lowest in the anterior upper quadrant and
that the bone mineral density is related to the pullout resistance of the
screw. (c) Design of smooth screws on a locking plate of the proximal
humerus. (d–f) Radiographs of a proximal humeral fracture compli-
cated by osteoporosis (female, 75 years old): a locking plate was used
for fixation, and displacement of the humeral head occurred 3 months
after surgery

necrosis of the humeral head occurred in 37% of
patients; however, 77% of these patients still obtained
satisfactory scores for shoulder function.
–– In our experience, surgical indications for shoulder
replacement should be controlled, and the appropri-
ate surgical procedure should be chosen according to
the patient’s age and degree of injury. For patients
with comminuted humeral head, especially elderly
patients, 1-stage shoulder replacement surgery can be
provided. Most patients can still undergo open reduc-
tion and internal fixation to achieve anatomical reduc-
tion as far as possible. For the case of ischemic
necrosis of the humeral head due to surgical failure or
absorption of old fracture of the humeral head,
humeral head replacement surgery can be applied
(Fig. 3.48).
3 Proximal Humerus Fracture 91

a b

Fig. 3.47 (a) Postoperative X-ray of a proximal humeral fracture demonstrating an acromial collision caused by high position of the PHILOS
stainless-steel plate. (b) No acromial collision after removal of the plate and screws

• Heterotopic ossification: –– For high-risk cases, oral indomethacin 25 mg can be

–– The heterotopic ossification of proximal humerus frac-
tures is not uncommon. Neer reported a group of 3-part
and four-part fractures with a total of 117 cases in
which the incidence of heterotopic ossification was
12% (Neer 1970a).
–– The risk factors for heterotopic ossification include
delay of surgery for more than 7 days, soft tissue injury,
and damage to the central nervous system (Fig. 3.49).
provided after surgery three times daily, or local radio-
therapy can be performed to prevent heterotopic
ossification.
–– For the cases showing heterotopic ossification, if limb
movement is affected, secondary surgery may be
needed for release.
92 H. Chen et al.

b
a

c d

Fig. 3.48 Case example: The patient received the first-stage surgery of replacement. (a) Preoperative X-ray image. (b) Postoperative X-ray
cerclage fixation for a proximal humeral fracture, but the reduction image. (c) X-ray image at postoperative month three demonstrating
failed, and osteonecrosis of the humeral head occurred after surgery. osteonecrosis of the humeral head. (d) X-ray image after the second-­
The patient then received the second-stage surgery of humeral head stage surgery of humeral head replacement
3 Proximal Humerus Fracture
a b
Fig. 3.49 A 57-year-old female with comminuted fracture of the prox-
imal humerus and craniocerebral injury caused by a car accident. (a)
Preoperative X-ray image. (b) Postoperative X-ray image demonstrat-
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 Fracture of the Humeral Shaft
Hua Chen, Zhe Zhao, and Gaoxiang Xu
4.1 Basic Theory and Concepts
4.1.1 Overview
• Humeral shaft fracture is a common fracture, accounting
for 3–5% of all fractures (Koval and Zuckerman 2006;
Brinker and O’Connor 2004; Praemer et al. 1999;
Schemitsch and Bhandari 2001a). The age of onset shows
a double peak distribution: it is common in populations of
20–30 years of age and 60–70 years of age. For young
people, these fractures are mostly caused by high-energy
injuries such as car accidents; among the elderly, these
fractures are mostly due to falling and other low-energy
injuries (Tytherleigh-Strong et al. 1998; Ekholm et al.
2006; Morrey 2013a).
–– The AO classification (see the fracture classification in
this chapter) shows 63% type A, 26% type B, and 10%
type C (Tytherleigh-Strong et al. 1998).
–– Fracture in the middle 1/3 is the most common, fol-
lowed by fracture in the proximal 1/3 (Zhang 2009).
• Open fractures <10% (Tytherleigh-Strong et al. 1998).
• The humerus is a long bone with the largest movement
range in the body. Normal shoulder and elbow joint activ-
ity can partially compensate for the impact of deformed
humeral fracture healing on upper limb function, and
thus, deformities of forward tilt of 20°, varus of 30°, and
shortening of 3 cm are acceptable (Koval 2006; Sarmiento
et al. 2000; Canale 2012a).
• This fracture is frequently complicated with radial nerve
injury, resulting in radial nerve palsy, in 12% of fractures
(Archdeacon 2012).
H. Chen (*) · G. Xu
Chinese PLA General Hospital, Beijing, China
e-mail: chenhua0270@129.com
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_4
4
• Vascular damage associated with humeral shaft fractures
is rare, with an incidence of approximately 3%, and the
associated median nerve and ulnar nerve injury are rare.
4.1.2 Applied Anatomy
• The blood supply of the humeral shaft is from the branches
of the posterior circumflex humeral artery and deep bra-
chial artery, and the main nutrient artery enters the shaft
from the middle and distal humerus.
• Radial nerve groove:
–– The radial nerve groove is located in the rear of the
middle of the humerus and runs obliquely outward and
downward with the radial nerve and deep brachial
vessels.
–– The radial nerve groove is located between the medial
and lateral heads of the triceps. The radial nerve pierces
the lateral muscle septum at the junction of the middle
and lower 1/3 of the humerus, where the position of the
radial nerve is fixed, and thus, fracture displacement at
the middle and lower 1/3 of the humerus is likely to
cause radial nerve injury (Fig. 4.1).
• Morphology, biomechanics, and steel plate fixation posi-
tion of the humeral shaft:
–– The humeral shaft shows a top-down transition in the
cross section: the upper end is irregularly rounded; the
middle is a triangle with a forward vertex dividing into
the anteromedial, anterolateral, and posterior sides; the
distal end gradually becomes flat (Palastanga and
Soames 2012a; Goss 1950) (Fig. 4.2).
Proximal and middle fracture: The steel plate
should be placed in the anterolateral side.
Distal fracture: The steel plate should be placed in
the posterior side or either the medial or lateral side.
–– The tension of the humerus differs depending on
whether the elbow is normal or not.
For patients with normal elbow, the tension side is
located in the rear of the cortex; for patients with
95
96 H. Chen et al.

cords of brachial
a plexus:
lateral cord
medial cord
posterior cord
ulnar nerve
humerus radial nerve
radial nerve and deep
artery of arm in radial
groove musculocutaneous nerve

brachial fascia enclosing median nerve

posterior compartment
brachial artery
of arm
ulnar nerve
brachial fascia enolosing
lateral intermuscular
anterior compartment
septum of arm
medial intermuscular
radial nerve septum
brachioradialis brachialis

biceps brachii
brachial fcscia
brachioradialis median nerve
brachialis medial epicondyle
lateral cutaneous of humerus
nerve of forearm brachial artery
radial nerve biceps tendon
ulnar nerve

b c
intertubercular
groove lesser tubercle anatomical neck greater tubercle
greater intertubercular head of
tubercle head of groove humerus
greater head of
humerus
tubercle humerus lesser
anatomical tubercle
neck anatomical
surgical crest of lesser neck
neck tubercle
crest of greater
crest of lesser surgical neck
tubercle
tubercle

radial groove

deltoid
tuberosity posterior aspect
humeral shaft anteromedial
radial groove
aspect of
humeral shaft

anteroposterior
aspect of humeral
shaft
lateral
supracondylar
medial
ridge
supracondylar lateral medial
ridge supracondylar supracondylar
radial fossa
coronoid fossa ridge lateral ridge
supracondylar trochlea of humerus
lateral olecranon
lateral medial ridge
epicondyle fossa
epicondyle epicondyle capitulum

capitulum trochlea of groove for trochlea of lateral epicondyle medial epicondyle

humerus ulnar nerve humerus
olecranon fossa
condyle of humerus

Fig. 4.1 Anatomy of the humerus. (a) Vessels around the humerus: the radial nerve groove and the triangular middle segment of the humerus.
radial nerve runs behind the medial humerus and along the surface of (c) Lateral and medial views of the humerus
the humeral shaft. (b) Front and rear views: The rear view illustrates the
4 Fracture of the Humeral Shaft
antero-lateral medial
Fig. 4.2 The cross section of the middle segment of the humerus is
triangular, forming three facets (anteromedial, anterolateral, and poste-
rior) for stainless-steel plate placement. In general, anterolateral plates
are suitable for humeral fractures from the proximal to the distal 1/5,
posterior plates are suitable for distal fractures of the humeral shaft, and
medial plates are rarely used except for complicated reconstruction
elbow stiffness, the tension side is in the front of the
cortex.
The radial nerve runs through the rear of the
humerus, and thus, it is difficult to place the steel
plate in this area.
Although placement of the steel plate in the front
side is in violation of biomechanical principles,
healing is still achievable because the loading of the
humerus is not as important as loading of the femur.
4.1.3 Mechanisms of Injury (Palastanga
and Soames 2012b)
• Direct violence:
–– Direct violence mostly includes high-energy damage,
such as direct hitting, mechanical extrusion, and fire-
arm injury.
–– The fracture is in a high degree of comminution and
often shows cracks and compression between the soft
tissues, affecting fracture reduction and healing.
• Indirect violence:
–– Sports injuries include the twisting mechanism of
wrestling; hand or elbow hitting the ground with rota-
tion of the body while falling; and excessive muscle
stretching caused by throwing. Such violence often
leads to spiral or oblique fractures.
–– Cracks and compression of the soft tissues often occur
between the bone fragments in spiral fractures, affect-
ing fracture reduction and healing.
97
4.1.4 Classification of Fractures
• Currently, the AO long bone fracture classification (AO/
ASIS classification) is usually used for the classification
of fractures of the long bone (Sarmiento et al. 2000;
Müller 1997; Bucholz 2010a; Anonymous 1996; OTA
Classification 2007; Orthopaedic Trauma Association
2017; Bell et al. 1985; Tingstad et al. 2000).
–– This is a systemic classification, and the first Arabic
numeral represents the number of the bone.
–– The second Arabic numeral represents the proximal,
middle, and distal ends of the long bone.
–– According to morphology, fractures are divided into
three basic types, A, B, and C (Fig. 4.3):
Type A is simple fractures with only one fracture
line and can also be divided into three subtypes,
including type A1 for spiral fracture, type A2 for
oblique fracture, and type A3 for transverse
fracture.
Type B is wedge fractures with three or more frac-
ture fragments and contact between the main bone
fragments after reduction. Type B1 contains spiral
wedge-shaped bone fragments, type B2 contains
bending wedge-shaped bone fragments, and type
B3 contains fragmentized wedge-shaped bone
fragments.
Type C is complex fractures with more than
three fracture fragments and no contact between
the main bone fragments after reduction. Type
C1 shows spiral fracture in the main bone frag-
ments of both ends, type C2 is multi-segment
fractures, and type C3 is irregular comminuted
fractures.
–– The difficulty of the surgery gradually increases from
type A to type C in the AO classification.
4.1.5 Assessment of Humeral Shaft Fractures
4.1.5.1 Clinical Assessment (Morrey 2013b)
• Typical manifestations: pain, swelling, deformity, and
limb shortening.
• Blood vessels: The pulses of the ulnar artery and radial
artery are checked to determine whether the blood vessels
are damaged by comparison with the contralateral healthy
side; Doppler arterial ultrasound is used for the examina-
tion if necessary.
• Nerve: The sensation of the area of the hand between the
thumb and index finger and the functions of wrist dorsi-
flexion and thumb dorsiflexion are checked to assess
whether the radial nerve is damaged. Before and after
manual reduction, radial nerve damage should be care-
fully assessed to avoid cracks and compression of the
98 H. Chen et al.

Fig. 4.3 The AO fracture

classification for the humeral Simple 12-A1 12-A2 12-A3
fractures Spiral Oblique Transverse
shaft
(>30°) (<30°)

Wedge 12-B1 12-B2 12-B3

fractures Spiral Bending Fragmented
wedge wedge wedge

Complex 12-C1 12-C2 12-C3

fractures Spiral Segmental Irregular

radial nerve between the bone fragments in the process of

reduction. 4.2 Surgical Treatment
• For patients with open injury, skin condition (including
armpits) should be assessed. 4.2.1 Surgical Indications and Purpose

4.1.5.2 Radiological Assessment 4.2.1.1 Surgical Indications

• AP (anteroposterior) view: The ipsilateral shoulder and
elbow should be covered to exclude fracture out of the
shaft or associated elbow joint injury (such as olecranon
fracture) and to assess the degree of fracture displace-
ment, shortening, and comminution.
• If the forearm is swelling or the bone is unstable, forearm
images are needed to determine whether there is floating
elbow injury (such as ipsilateral humeral shaft fracture
complicated with forearm double fracture) (Ring et al.
2001).
• CT, bone scan, and MRI are often used to exclude patho-
logical fractures.
• In humeral shaft fractures, the surrounding muscles are
rich, with a good blood supply, and certain angles, rota-
tion and shortening can be compensated by the activities
of the joints. Consequently, conservative treatment can
achieve good efficacy in most cases. Surgical indications
(McKee 2006) include the following:
–– Difficulty resetting or difficulty maintaining the reduc-
tion after resetting: shortening >3 cm, rotation defor-
mity >30°, and angular deformity >20°
–– Open fracture
–– Bilateral humeral shaft fractures or multiple injuries,
floating elbow
4 Fracture of the Humeral Shaft
–– Humeral shaft fracture complicated with arterial or
nerve injury
–– Humeral shaft nonunion
–– Pathological fracture
4.2.1.2 The Purpose of Surgery
• To correct the humeral shaft rotation, shortening, and
angular deformities.
• To restore the blood supply and nerve continuity.
4.2.2 Surgical Techniques
1. Surgical approach selection:
(a) For proximal 2/3 fractures, the anterolateral humerus
approach is preferred (Goss 1950; DePalma 1970;
Gregory 2001; Hollinshead 1958; Hoppenfeld and
De Boer 1984; Schemitsch and Bhandari 2001b).
(b) For middle and distal 1/3 fractures, the lateral
humerus approach is preferred (Mills et al. 1996).
(c) For distal 1/3 fractures, the posterior humerus
approach is preferred (Kettlekamp and Alexander
1967; Pollock et al. 1981).
(d) Simple fracture of the humeral shaft can be treated
with anterograde or retrograde intramedullary nail
fixation (Canale 2012b).
(e) Spiral fracture with a large segment involving more
than 1/3 of the shaft circumference will lead to a lack
of stability after intramedullary nail fixation, and thus
these patients should undergo open reduction and
internal fixation (Bucholz 2010b).
2. Plate screw fixation technology for fractures (Colton and
Fernandez 2000a): The reduction and fixation of most
fractures in this book involves steel plate screw fixation
technology, and thus a variety of steel plate screw fixation
technologies are systematically introduced for the first
long bone shaft fracture.
(a) Compression steel plate: for simple fractures, such as
short oblique and transverse fractures (Pollock et al.
1981) (Fig. 4.4).
• A pre-bent steel plate is placed between the poste-
rior steel plate of the fracture site and the shaft,
and a gap of 1 mm should be maintained.
• The fracture is reset, and the steel plate is tempo-
rarily fixed on the shaft using a bone holding
device; the first screw is inserted through the slid-
ing hole, and then the second screw is inserted
through the compression hole at the opposite side
of the fracture end to achieve the compression on
the fracture end.
• In the fracture end, a lag screw is screwed vertical
to the fracture plane to achieve the second com-
pression on the fracture end.
99
• The remaining screws are screwed into the steel
plate.
(b) Lag screw and protection plate: for long oblique, spi-
ral, and wedge-shaped fractures (Colton and
Fernandez 2000b) (Fig. 4.5).
• Fixation of wedge fragments.
–– Compression fixation for the wedge fragment
and main bone is first performed to convert the
type B fracture into a type A fracture.
• Compression steel plate for the fixation of type A
fractures.
–– A lag screw is screwed into the fracture end
vertical to the fracture plane to achieve the sec-
ond compression on the fracture end of the
wedge fragment and the main bone.
–– The remaining screws are then screwed on the
steel plate.
(c) Bridging plate: for comminuted fractures (Colton
and Fernandez 2000c; Morrey 2013c) (Fig. 4.6).
• Without exposing the fracture ends, the shaft is
exposed in the distal part of the fracture site, and
the steel plate is percutaneously inserted and fixed
to complete the fracture fixation under
fluoroscopy.
• Two screws are used to fix the proximal end of
the fracture to ensure the alignment of the steel
plate and bone for position and fracture line
matching.
• The distal fracture is temporarily fixed with a bone
holder to ensure the alignment of the fracture end
for position and fracture line matching under fluo-
roscopy; two screws are used to fix the distal
fracture.
• The alignment of the fracture end for position and
fracture line matching is confirmed under fluoros-
copy, and the remaining screws are placed if the
reduction of the fracture is satisfactory.
4.2.2.1 Proximal 2/3 Fractures
of the Humeral Shaft
(Anterolateral Approach)
Position and Preoperative Preparation
• The patient is in the supine position, with a pillow under
the scapula. The affected limb is free, allowing exposure
of the neck (subclavian blood vessels), and the forearm is
placed on a small table next to the operating table.
Intraoperative C-arm auxiliary fluoroscopy is used.
Operative Incision According to the Projection on the
Body Surface
• The coracoid process, deltopectoral interval, intertuber-
cular groove, and lateral condyle are labeled on the body
100 H. Chen et al.

a b

c d

8 mm

e f

g h

Fig. 4.4 Compression stainless-steel plate technique. (a) The stain-
less-steel plate is re-shaped to allow a close contact with the fixation
site. (b) The pre-bent stainless-steel plate is placed at the fracture site,
ensuring a 1-mm-wide gap between the plate and the shaft. (c) If the
plate is not pre-bent to fit the fractured bone, the two fracture ends at the
fixation site will be separated at the side opposite to the plate, increas-
ing the fatigue stress on the plate, which will cause instability of the
fixation and eventual fixation failure. (d) The fracture is reset, and the
stainless-steel plate is temporarily fixed on the shaft using a bone hold-
ing device; the first screw is inserted 8 mm away from the fracture end
through the neutral position of the guide device. (e) After the first screw
is positioned, the contact between the plate and bone is checked. (f) The
second screw is inserted at the opposite side of the fracture end through
the eccentric position. (g) The screws at both sides are tied to achieve
compression on the fracture ends. (h) The remaining screws are screwed
into the stainless-steel plate through the neutral position. (i) For a long
fracture with a short-oblique shape, a proximal cortex broaching - lag
screw fixation technique can be applied, with the third screw across the
fracture line. (j) The order of screw placement
4 Fracture of the Humeral Shaft 101

4 2 3 1 5
i j

Fig. 4.4 (continued)

a b

c d

e f
6 7 1 4 3 8 5

Fig. 4.5 The lag screw and protection plate technique. (a) Fracture
reduction, temporary fixation with a pointed reduction clamp, and
stainless-steel plate re-shaping. (b) A lag screw is screwed into the cen-
ter of and vertical to the fracture plane; if the fracture line is too long,
another lag screw can be used to enhance the fixation stability. (c)
Guided by a 3.5 mm guiding sleeve, a 3.5 mm diameter drill is used to
drill through the proximal cortex. (d) A 2.5 mm diameter sleeve is
inserted, through which a 2.5 mm diameter drill is used to drill through
the cortex on the opposite side. (e) The plate is placed, and then all the
screws are inserted to fix the plate in the neutral position. (f) A Type B
fracture with butterfly-shaped bone fragments: The Type B fracture is
first converted to a Type A fracture, and then the fracture is fixed follow-
ing the procedures shown in the figure
102
a b
c d
Fig. 4.6 The bridging plate technique: Without exposing the fracture
ends, the bone shaft segments proximal and distal to the fracture site are
exposed, and a stainless-steel plate is percutaneously inserted and fixed
to complete the fracture fixation under fluoroscopy. (a) After the frac-
ture is reduced by hand, a long bone distractor is used for temporary
fixation, and then the tissue proximal and distal to the fracture site is cut
to expose the bone shaft. (b) Two screws are fixed in the proximal frac-
ture fragment to ensure good alignment of the fracture end for position
surface. The projections of the coracoid process and del-
topectoral interval and the intertubercular groove and
outer epicondyle on the body surface are connected
(Fig. 4.7), and the appropriate incision site is selected
according to the position of the fracture.
Surgical Approach
• The skin and the subcutaneous tissue are cut, with separa-
tion of the skin and the fascia to expose the deltopectoral
interval and the biceps triceps interval.
• Proximal port:
–– Entering along the deltopectoral interval, the middle of
the biceps is pulled inward, and the deltoid and
cephalic vein are pulled outward to avoid damaging
the proximal cephalic vein and the transverse anterior
circumflex humeral artery.
–– Sharp outward dissection of the deltoid muscle ending
point is performed in the tuberosity site of the deltoid
to expose the proximal humerus.
H. Chen et al.
and fracture line matching. (c) The distal fracture fragment is temporar-
ily fixed with a bone holder to ensure alignment of the fracture ends for
position and fracture line matching under fluoroscopy; and then the
distal fracture fragment is fixed with two screws. (d) The alignment of
the fracture ends for position and fracture line matching is confirmed
under fluoroscopy, and the remaining screws are placed if the reduction
of the fracture is satisfactory
• Distal port:
–– Separation along the interval between the biceps bra-
chii and brachial muscle is performed to reveal the bra-
chialis muscle.
–– The brachialis muscle is longitudinally split along the
lateral middle line of the brachial muscle to directly
reach the humeral surface and expose the middle of the
humerus.
–– The lateral part of the brachial muscle is controlled by
the radial nerve, and the medial part is controlled by
the musculocutaneous nerve. Thus, the longitudinal
split of the brachialis muscle minimizes damage to the
motor function of the brachial muscle.
–– The radial nerve controlling the lateral brachial muscle
should be carefully protected.
• With flexion in the elbow, sharp dissection of the deltoid
ending point and medial brachialis ending point are per-
formed to allow the fracture to be reset and placement of
the steel plate on the anterolateral humerus (Fig. 4.8).
4 Fracture of the Humeral Shaft 103

Fig. 4.7 (a) The patient is

a
placed in a supine position,
with the affected limb placed
on a radiolucent holder. (b)
The coracoid process,
deltopectoral interval, and
lateral epicondyle of the
humerus are labeled on the
body surface; the line
connecting the three labeled
points indicates the
preoperative incision marked
by the surface projection

b coracoid process

coracoid
process

lateral antebrachial cutaneous n.

biceps

Fracture Reduction and Fixation
• Based on the AO classification, the appropriate steel plate
screw technique is selected according to the above steel
plate screw technology: (www.AOfoundation.org).
• For type A2 and type A3 humeral shaft fractures, com-
pression plate technology can be used. For type A2
­fracture, lag screws on or outside the steel plate can be
used to increase stability.
• For type A1, B1, and B2 humeral shaft fractures, lag
screw and protection plate technology can be applied.
Type B1 and B2 fractures are first converted into a type A
fracture using a lag screw, followed by further fixation.
Notably, even for long oblique fractures, it is not possible
to use multiple lag screws without using protective plates
for fixation.
• Type B3 and C fractures can be fixed using bridging plate
technology (Fig. 4.9).
4.2.2.2 Distal 1/3 Fractures of the Humeral Shaft
(Lateral Straight Approach)
Position and Preoperative Preparation
• The patient is in the lateral position, with a pillow under
the armpit for protection (Fig. 4.10a). The affected limb is
free and placed on a radiolucent holder, and intraoperative
C-arm auxiliary fluoroscopy is used (Fig. 4.10b).
Operative Incision According to the Projection on the
Body Surface
• The lateral humeral epicondyle is labeled on the surface
of the body, and the connecting line with the tuberosity of
104 H. Chen et al.

Fig. 4.8 (a) The proximal a

port: Entering along the
deltopectoral interval, the fascia over deltoid
middle of the biceps is pulled cephalic vein
inward, and the deltoid and
cephalic vein are pulled delitoid
outward. The deltoid muscle long head of blceps
is dissociated outward to the cephalic vein
fascia over
tuberositas deltoidea and pectoralis major
inward to the ridge of the short head of blceps
greater tuberosity. (b) The
biceps brachialis
distal port: Separation along
coracobrachialis
the interval between the
biceps brachii and brachialis
muscle is performed to reveal
the brachialis muscle. (c)
With the elbow in flexion, pecloralis major
sharp dissection is performed
at the proximal side to biceps
separate the deltoid ending
point and medial brachialis
ending point, and longitudinal
splitting of the brachialis
muscle is performed to
expose the humerus. Next, the b anterior circumflex
fracture is reduced, and a deltoid humeral artery
stainless-steel plate is placed
brachialis
at the lateral biceps brachii

musculocutaneous n.

pectoralis
major tendon

biceps

long head of biceps

c bicipital groove
periosteum

deltoid

brachialis

short head of biceps

pectoralis
major tendon

biceps
humerus covered
with periosteum

the deltoid is the incision projection on the surface
(Fig. 4.11).
Surgical Techniques
• Surgical approach (Figs. 4.12, and 4.13):
–– The skin and the subcutaneous tissue are cut, with sep-
aration of the fascia under the skin.
–– The gap between the brachioradialis muscle and the
brachialis muscle above the distal elbow plane is
located, and the deep fascia of the muscle is cut. In this
gap on the elbow plane, the radial nerve is retracted
with the finger using a rubber band for protection.
–– The radial nerve is pulled forward to expose the inter-
val between the brachialis and brachioradialis muscle.
4 Fracture of the Humeral Shaft 105

Fig. 4.9 Postoperative X-ray

images. (a) Anteroposterior
position. (b) Lateral position

a b

a b

Fig. 4.10 The patient is in the lateral decubitus position (a) on the unaffected side (b), with the affected limb placed on a radiolucent holder

This interval is sharply dissected to open the brachialis

muscle forward, thus exposing the lateral and antero-
lateral side of the distal humeral shaft.
–– The interval between the brachialis and triceps in the
proximal end is identified, and the exposure distance is
extended upward to reveal the radial nerve through the
Brachioradialis muscle interval. The upward separation process should
be carried out under the periosteum to avoid damaging
the spiral radial nerve running around the humerus.
• Fracture reduction and fixation: refer to the previous sec-
tions (Fig. 4.14).
Biceps
Experience and Lessons
• The middle-distal 1/3 part of the humeral shaft has an
internal rotation of 20–30°, and thus, the steel plate must
Fig. 4.11 The line connecting the lateral humeral epicondyle and the
tuberositas deltoidea indicates the preoperative incision mark by sur- be re-shaped for better attachment if placed in the anterior
face projection lateral side (Fig. 4.15).
106 H. Chen et al.

a a
brachialis

brachioradialis brachioradialis brachialis

lateral antebrachial
cutaneous n.
radial nerve

humerus
biceps

periosteum
b
b
brachialis lateral intermuscular
septum
radial nerve
brachioradialis

brachioradialis

biceps
humerus covered
musculocutaneous nerve with periosteum
brachialis
c

Fig. 4.12 (a) A finger-assisted blunt separation is conducted to expose

the brachialis muscle, brachioradialis muscle, and triceps. (b) The lat-
eral cutaneous nerve of the forearm (LCNF) is identified in the gap
between the biceps and brachialis muscle and protected using a rubber
band. (c) The rubber band protecting the LCNF is placed in the gap
between the biceps (medial) and brachialis muscle (lateral)
Fig. 4.13 (a) First, the interval between the brachioradialis muscle and
brachialis muscle is located. Next, the biceps, brachialis muscle, and
LCNF are pulled medially to expose the radial nerve in the distal inter-
val, which is then pulled away for protection by a rubber band. (b) A
separation is performed along the periosteal surface to expose the lat-
eral and anterolateral sides of the distal humeral shaft; a stainless-steel
plate is placed after fracture reduction. (c) During surgery, the radial
nerve is identified in the interval between the brachialis muscle and the
brachioradialis muscle and protected using a rubber band
4 Fracture of the Humeral Shaft 107

Fig. 4.14 Postoperative

a b
X-ray images. (a)
Anteroposterior X-ray image.
(b) Lateral X-ray image

a b

Fig. 4.15 A stainless-steel plate is placed anterolaterally to fix a lateral humerus during surgery. (a) Re-shaping of stainless-steel plate.
middle-­distal 1/3 humeral fracture: the distal end of the plate is rotated (b) Re-shaped plate. (c) Intraoperative fluoroscopy image
inward 20–30°, allowing close contact between the plate and the antero-
108 H. Chen et al.

4.2.2.3 Distal 1/3 Fractures of the Humerus

(Posterior Approach) acromion
Position and Preoperative Preparation
• The patient is in lateral position; with a soft pillow under
the armpit, the elbow of the affected limb is in flexion and
placed on a radiolucent holder; intraoperative C-arm aux-
iliary fluoroscopy is used (Fig. 4.16).

Operative Incision According to the Projection on the

Body Surface
• The posterolateral corner of the acromion and olecranon
are labeled and connected on the body surface. The appro-
priate incision site is selected according to the position of
the fracture (Fig. 4.17).

Surgical Techniques
• Surgical approach (Fig. 4.18):
–– An incision is created along the center of the posterior
approach to directly reach the olecranon; the skin, sub-
cutaneous tissue, and fascia are cut to find the distal
thick and white triceps tendon.

a
Fig. 4.17 The preoperative incision mark by surface projection is the
line connecting the posterolateral corner of the acromion and olecra-
non; the length of the incision is determined according to the location of
the fracture

–– Blunt separation is carried out along the proximal tri-

ceps between the long head and the lateral head, and
the soft tissue under the periosteum in the humeral sur-
face is pushed toward both sides.
–– After a sharp vertical split of the triceps tendon in the
distal end, the muscle tissue is retracted to both sides.
b –– The medial head of the triceps is located deep on the
long and lateral head. The radial groove separates
the starting point of the medial head from the start-
ing point of the lateral head. Therefore, the radial
nerve should be found in the proximal end of the
medial head of the triceps and pulled out using a
rubber band for protection.
–– The medial head of the triceps is split to retract the
muscle tissue toward both sides and expose the distal
fracture of the humerus.
• Fracture reduction and fixation: See the previous sections
(Fig. 4.19).
• Closure of the incision: The triceps muscle fascia and the
superficial fascia tissue can be sutured with an absorbable
Fig. 4.16 (a) The patient is in the lateral decubitus position, with a soft
suture, followed by suture of the subcutaneous tissue and
pillow under the armpit and the affected limb placed on a holder; the
affected limb is placed on a holder with the elbow in flexion. (b) C-arm-­ skin.
assisted fluoroscopy
4 Fracture of the Humeral Shaft 109

deltoid muscle

axillary nerve
posterior circumflex
humeral artery
superior lateral brachial
cutaneous nerve
profunda brachii (deep brachial) artery
radial nerve
lateral head of triceps brachii muscle
posterior brachial Inferior lateral brachial cutaneous nerve
cutaneous nerve
middle collateral artery
long head of triceps
brachii muscle radial collateral artery
the nerve innervating the anconeus
muscle passes under the medial head of medial head of triceps brachii muscle
triceps brachii muscle
ulnar nerve posterior antebrachial cutaneous nerve
medial supracondylar of humerus lateral supracondylar of humerus
olecranon (of ulna)
anconeus muscle

b c

long head of triceps

lateral head of triceps

humeral periosteum

medial head of triceps

capitellum

olecranon (of ulna)

triceps tendon

Fig. 4.18 (a) The medial head of the triceps is located deep in the long radial nerve and deep brachial artery. (c) After a sharp longitudinal split
and lateral heads. The radial groove separates the starting point of the of the triceps tendon in the distal end, the muscle tissue is retracted to
medial head from the starting point of the lateral head. (b) Proximal: both sides to expose the distal fracture fragment of the humerus
The long and lateral heads are separated to expose and protect the deep
110
a b
Fig. 4.19 A distal 1/3 fracture of the humeral shaft. (a) Preoperative
X-ray image: The fracture is located at the distal 1/3 of the humeral
shaft and is a Type B1 fracture according to the AO classification. (b)
4.2.2.4 Closed Reduction of Percutaneous
Minimally Invasive Internal Fixation
Position and Preoperative Preparation
• The position is the same lateral approach as before.
Operative Incision According to the Projection on the
Body Surface
• The coracoid process, deltopectoral interval, intertubercu-
lar groove, and biceps lateral margin are labeled on the
body surface using a marker pen. A 5–7-cm proximal inci-
sion is created from the coracoid process along the delto-
pectoral interval, and a 5–7-cm distal incision is created in
the distal 1/3 upper arm along the biceps lateral margin.
Surgical Approach (Fig. 4.20)
• Proximal port:
–– The skin and the subcutaneous tissue are cut to find the
cephalic vein, which is used as a reference to identify
the deltopectoral interval and perform blunt separation
of the deltoid and the pectoralis major muscle.
–– In the lateral side of the long tendon of the biceps, the
deltoid muscle and the pectoralis major muscle are sepa-
rated, and the ending point of the pectoralis major is par-
tially cut off to facilitate the placement of the steel plate.
• Distal port:
–– The skin and the subcutaneous tissue are cut, and the
deep fascia of the upper arm is cut along the direc-
H. Chen et al.
c
Postoperative anteroposterior X-ray image demonstrating fixation
using a posterolateral anatomical locking plate of the humerus com-
bined with lag screws. (c) Postoperative lateral X-ray image
tion of the incision to find the interval between the
biceps and brachial muscle. Separation along this
interval is carried out, and the biceps is pulled
inward. Note that the lateral forearm nerve is located
in this interval and should be carefully protected by
pulling inward.
–– Longitudinal splitting of the brachialis muscle is car-
ried out. The separation can be performed outside the
periosteum between the deep surface of the brachialis
and the humerus.
• Tunneling:
–– A stripper with a blunt tip is inserted from the distal port
to separate strictly close to the anterior of the humerus
and pierced upward in the upper margin of the brachia-
lis, with convergence to the proximal port. If necessary,
a stripper can be inserted through the proximal port to
achieve the convergence of the two operating ports.
Fracture Reduction and Internal Fixation (Fig. 4.21)
• Fracture reduction:
–– Reduction is performed by manual traction. Note that
for this fixation method, the comminuted fracture area
does not require anatomical reduction. Only the large
and sharp fracture fragments require anatomical reduc-
tion to protect the surrounding soft tissue.
–– In manual reduction, rotation deformity must be cor-
rected, and a shortening deformity of 2 cm is
acceptable.
4 Fracture of the Humeral Shaft 111

proximal incision
a b
(deltopectoral groove) B deltoid

radial n. biceps
distal incision
(lateral biceps) brachialis

pectoralis major tendon

long head of biceps
musculocutaneous n.

c d
humerus
finger inserted beneath
biceps along humerus
deltoid
brachialis split to bone
elevator advanced
brachialis beneath brachialis
along humerus

pectoralis tendon
biceps (partially detached
elevator exits superior
(retracted) from humerus)
border of brachialis to
meet fingertip
biceps
(retracted)

elevator exits superior

border of brachialis to
meet fingertip

Fig. 4.20 (a) To establish the proximal port, an incision is made along
the interval of the deltoid and the pectoralis major muscle below the
acromion; to establish the distal port, the incision is made along the
lateral margin of the biceps. (b) In the proximal port, the separation is
made along the gap between the deltoid and the pectoralis major mus-
cle, and in the distal port, the biceps is retracted medially to expose the
brachialis muscle in the deeper layer. (c) To establish the proximal port,
the ending point of the pectoralis major may be cut off. (d) After split-
ting of the brachialis muscle, a stripper with a blunt tip is inserted along
the periosteal surface to create a tunnel connecting the two ports. (e)
The operator can place one finger through the proximal port to meet the
stripper on top of the brachialis muscle
112
a
c
e f
Fig. 4.21 A Type B1 fracture of the humeral shaft. (a) Preoperative
anteroposterior and lateral X-ray images. (b) Closed reduction using
traction. (c) Selection of internal fixators according to the location and
range of the fracture. (d) Pre-shaping of the proximal end of the stain-
less-steel plate to ensure close contact. (e) The stainless-steel plate was
inserted into the pre-set tunnel from the distal port. (f) The plate was
H. Chen et al.
d
locked through the proximal and distal ports or a small incision. (g)
There were only two mini-incisions at the proximal and distal sides
after surgery, reducing the operation-associated damage. (h)
Postoperative anteroposterior and lateral X-ray images. (i) X-ray image
4 months after surgery illustrating good bone healing
4 Fracture of the Humeral Shaft
h i
Fig. 4.21 (continued)
–– The situation of the reduction is observed under fluo-
roscopy. If the large fragments cannot be reset after
traction, soft tissue may be incarcerated at the fracture
ends, and open reduction is needed in this case.
• Fracture fixation:
–– First, the appropriate LCP plate is selected based on
the location and extent of the fracture.
–– The proximal end of the steel plate is pre-curved to
enhance attachment.
–– The steel plate is inserted in the pre-set tunnel from the
distal port, and the position of the steel plate is appro-
priately adjusted. After adequate contact with the
proximal end of the bone fragment, a screw can be
used for temporary fixation. The location of the steel
plate is determined under fluoroscopy to ensure that
the steel plate is parallel with the humerus long axis in
the lateral image.
–– Next, a second screw can be screwed in at the proximal
end of the fracture. After the position of the distal frac-
ture fragment is adjusted and satisfactory, it is held
with a bone clamp for the final fracture fixation.
• Experience and lessons:
–– Locking technique.
–– For the percutaneous minimally invasive technique,
the locking holes in the proximal and distal ports of the
steel plate can be directly locked.
–– For the remaining nail holes that must be locked, a
steel plate with the same length can be used as a refer-
ence to create the percutaneous small incision and
insert the locking sleeve for drilling and locking.
113
–– Selection of steel plate length:
The length of the steel plate and the position of the
screw will affect the load of the screw. The nearest
screw to the fracture bears the maximum load. The
length of the plate determines the arm of this screw.
A longer plate has a longer arm, which will reduce
the load on this screw.
When the locking plate is used as an internal fixa-
tion bracket, it is mainly subjected to the bending
force. When the distance between the ends of the
adjacent fracture segments is too close, the bending
effect on the steel plate will produce a strong local
stress, and when the distance between the screws on
the ends of the adjacent fracture fragments is too
large, the stress will be dispersed to avoid fatigue
damage to the implant (Fig. 4.22).
To select the length of the implant in the commi-
nuted fracture, the range of fractures should first
be determined, and then a plate with a length of
three times the length of the fracture should be
selected.
The ratio of the length of the plate to the length of
the fracture area is referred as the span of the plate
and should be >3.
–– Position and number of screws:
When the LCP plate is used as a bridging plate, the
screw density should be <50%; that is, 50% of the
screw can be placed into the nail hole of the bone plate.
In addition, the length of the entire bone plate
should be considered as three segments. The area
114 H. Chen et al.

a
stress dispersion

density
=3/6
=50%

Plate-screwdensity=6/14=43%

plate length: 14 holes

Plate-screw density
b stress concentration density
=0/4
=0

density
=3/4
=75%

Fig. 4.22 (a) When the two screws closest to the fracture site are
located distantly from each other, the stress caused by the bending force
on the plate is dispersed. (b) When the two screws closest to the fracture
site are too close to each other, the stress caused by the bending force
on the plate is concentrated, which may facilitate plate fatigue and frac-
ture. (c) The plate span ratio is approximately 3, the proximal screw
density is 50%, the screw density at the fractured segment is 0, the distal
screw density is 75%, and the overall screw density is 43%, which is
lower than 50%

between the most inner two screws is the fracture
area, where no screw is inserted. For the proximal
and distal ends, the placement of three screws is
recommended. For patients with osteoporosis, the
number of screws can be increased accordingly.
4.2.2.5 Fractures of the Humeral Shaft
(Antegrade Intramedullary Nail
Technique)
Position and Preoperative Preparation
• The patient is in the beach chair position, with a pillow
under the interscapular region. The shoulder is extended
backward to allow the greater tuberosity of the humerus
to move downward from the acromion to the anterior
shoulder and under the coracoacromial ligament
(Fig. 4.23).
• The C-arm is placed at the head side of the bed and paral-
lel to the operating table.
• Before disinfection and draping, multi-directional projec-
tion is applied to determine the fracture site and the nee-
dle entry point, and the appropriate position of the C-arm
should be adjusted.
Operative Incision According to the Projection on the
Body Surface
• The acromion is marked on the body surface. A 3-cm-­
long longitudinal incision is created from the anterior
margin of the acromion to the distal end. The observation
from top to down should show the incision in the projec-
tion of the humeral shaft cavity (Fig. 4.24).
Surgical Techniques
• Surgical approach and needle entry point (Fig. 4.25):
• The skin, the subcutaneous tissue, and the deltoid fascia
are cut, followed by longitudinal splitting of the deltoid
fibers to expose the coracoacromial ligament.
4 Fracture of the Humeral Shaft 115

a b

Fig. 4.23 (a) The patient is in the beach chair position, with a pillow joint of the patient is placed in the backward extension position to move
under the interscapular region. The shoulder is extended backward. (b, the greater tuberosity of the humerus from below the acromion to the
c) Because the entry point of the intramedullary nail is covered by the front of the acromion and under the coracoacromial ligament
acromion when the shoulder joint is in the neutral position, the shoulder

a b

Fig. 4.24 (a) The acromion is marked on the body surface. A 3 cm long longitudinal incision is created from the anterior margin of the acromion.
(b) The observation from top to down shows the incision is overlapped with the projection of the humeral shaft
116
greater tuberosity of humerus intramedullaty nail chammel
Fig. 4.25 (a) The skin, the subcutaneous tissue, and the deltoid fascia
are cut, followed by longitudinal splitting of the deltoid fibers to expose
the coracoacromial ligament, which is then partially severed to expose
the entry point of the intramedullary nail. (b) The entry point of the
–– A small portion of the coracoacromial ligament is cut,
with blunt separation of the subacromial bursa by fin-
ger, to expose the humeral greater tuberosity and rota-
tor cuff.
–– The entry point of the intramedullary nail is in the
medial portion of the greater tuberosity and the lateral
portion of the intertubercular groove. The Kirschner
wire is inserted in the needle entry point.
–– The needle entry position is confirmed by anteroposte-
rior fluoroscopy, and the direction of the needle enter-
ing the medullary cavity is confirmed by lateral
fluoroscopy at the insertion site.
• Intramedullary nail placement (Fig. 4.26):
–– A sharp cone or hollow drill is placed along the
Kirschner guidewire, with the opening in the proximal
humerus cortical.
–– For humeral shaft fractures with displacement, appro-
priate traction reduction should be performed by the
H. Chen et al.
intramedullary nail is in the medial portion of the greater tuberosity and
the lateral portion of the intertubercular groove. (c) Intraoperative
anteroposterior radiograph demonstrating that the intramedullary nail is
lateral to the extending line of the medullary cavity of the humerus
assistant to preliminarily restore the angular and rota-
tion displacement.
–– The tip of the wire can be properly bent to allow the
guidewire to easily pass through the fracture end by
changing the direction of the guidewire under
fluoroscopy.
–– If the reduction is difficult, a small incision can be cre-
ated in the lateral portion of the fracture to allow place-
ment in a Kocher clamp and help control the direction
of the fracture ends, thus placing the needle into the
distal medullary cavity of the fracture.
–– The end of the intramedullary nail should be more than
16 mm from the distal end of the humerus; otherwise it
may damage the cortex of the distal bone and even
mistakenly enter the olecranon fossa, measuring the
length of intramedullary nails.
–– Soft drilling is used to gradually ream to reach the
appropriate diameter, which is usually 1–1.5 mm larger
4 Fracture of the Humeral Shaft 117

a b

d e

Fig. 4.26 (a) The rotator cuff is sharply cut along the Kirschner guide-
wire to minimize the damage to the rotator cuff. (b) Guided by the
Kirschner guidewire, a pointed cone is used to drill a hole in the proxi-
mal humerus cortex. (c) The tip part of the ball-head guidewire can be
pre-bent to allow the guidewire to easily pass through the fracture ends.
(d) A small incision is created at the lateral side of the fracture, through
which a Kocher clamp is inserted and used to push the lateral cortex
medially for fracture reduction. Under fluoroscopy, the ball-head guide-
wire is inserted in the medullary cavity and pushed through the fracture
ends. (e) While ensuring a reduction assisted by the Kocher clamp, the
tunnel in the medullary cavity is gradually drilled and expanded toward
the distal humerus
118
a b
c d
Fig. 4.27 Intramedullary nail locking with a distal screw. (a) The posi-
tion of the C-arm is adjusted for the vertical projection. (b) The surface
of the image receiver is covered with a sterile sheet, and the C-arm is
raised to shoulder level and close to the operating table. The upper arm
is placed flat on the image receiver. The humeral trochlea and the han-
dle of the intramedullary nail are manually maintained in the horizontal
than the diameter of the selected intramedullary nail.
Note that the rotator cuff structure should be protected
during reaming to avoid damage from the soft drilling.
–– After reaming, the intramedullary nail is manually
inserted along the guidewire. Hammering in this step
is strictly prohibited and will risk fracture at other
sites, such as the entry point of the nail.
–– The location of the end of the intramedullary nail
should be determined under fluoroscopy. The intra-
medullary nail may appropriately knock back after
completing the distal fixation, and thus the end of the
intramedullary nail must be completely inserted in and
below the level of the vertex of the humeral great
tuberosity.
H. Chen et al.
e
position. (c) The angle of the forearm is adjusted until it appears in a
round shape under fluoroscopy. (d) A pointed Kirschner wire is used to
drill, and multi-angle fluoroscopy is applied to confirm that the
Kirschner wire passes through the distal screw hole. (e) Distal screw
locking
• Distal fixation (Fig. 4.27):
–– The position of the C-arm is adjusted for the vertical
projection, and the surface of the image receiver, which
is close to the operating table and raised to shoulder
level, is covered with a sterile sheet. The upper arm is
placed flat on the image receiver.
–– The humeral trochlea and intramedullary nail are man-
ually maintained in the horizontal position, and the
distal nail hole of the intramedullary nail is found by
adjusting the position of the upper arm.
–– After cutting the skin from front to back, the soft tissue
is separated to the bone surface using a hemostatic for-
ceps; a pointed Kirschner wire is used to drill, with the
direction of drilling adjusted under fluoroscopy.
4 Fracture of the Humeral Shaft
a b
Fig. 4.28 (a, b) Restoring of a rotation deformity: to determine
whether the rotation displacement is corrected, the distal fracture frag-
ment is rotated by controlling the handle of the intramedullary nail to
observe the thickness of the medial cortex of the distal and proximal
Fig. 4.29 (a) Postoperative
C-arm fluoroscopy of the
proximal humerus: It is better
to completely bury the nail in
the greater tuberosity cortex
to avoid collision of the
intramedullary nail with the
acromion, which will affect
the function of the shoulder.
(b) Postoperative C-arm
fluoroscopy demonstrating
satisfactory fracture reduction
a b
–– Multi-angle fluoroscopy is applied to confirm that the
Kirschner wire passes through the screw hole, and then
the Kirschner wire is pulled out to screw in the locking
screw.
• Proximal fixation:
–– The fracture reduction is further adjusted under fluo-
roscopy. The thickness of the bone cortex at the proxi-
mal and distal ends of the fracture should be compared.
A difference in the thickness of the bone cortex sug-
gests that the rotation deformity is not restored
(Fig. 4.28).
–– By controlling and adjusting the angle of the forearm
and the handle of the intramedullary nail, the rotation
displacement is further corrected. After completing the
reduction, the inserted handle is gently knocked back
119
c
fragments. (c) Using a knocking device equipped on the handle of the
intramedullary nail, the nail is knocked backward to press the fracture
ends. At this position, the proximal screw is locked through the sighting
device
in with a rolling weight to contact the fracture ends
with compression.
–– The end of the intramedullary nail must be completely
below the top vertex of the greater tuberosity
(Fig. 4.29). After connecting the sighting device to the
handle, the proximal screw is locked through the sight-
ing device.
–– The length of the tail cap is determined depending on
the position of the end of the intramedullary nail.
• Incision closure:
–– After the incision is rinsed with a large amount of
saline, the rotator cuff and the coracoacromial liga-
ment are sutured and repaired, with indwelling nega-
tive pressure drainage, followed by incision closure
layer by layer (Fig. 4.30).
120
4.2.3 Surgical Complications and their
1. Nonunion.
Fig. 4.30 Suture repair of the rotator cuff and coracoacromial
ligament
Experience and Lessons
• Distal screw fixation technology:
–– A fixation position of distal locking that passes through
the biceps muscle is preferred. Medial bias may dam-
age the brachial artery, and lateral bias may cause
injury to the radial nerve.
–– The intramedullary nail should be manually main-
tained parallel to the long axis of the humeral trochlea,
and the screw is locked through the “full circle”
technique.
–– Because the proximal end of the fracture cannot be
fixed, rotation deformity of the shaft can be corrected
by rotating the intramedullary nail handle and observ-
ing the cortical thickness. The position is held to lock
the distal end of the locking nail.
–– If the technique of fixing the distal locking screw first
with the fracture end knocking back is applied to
achieve compression on the fracture end, it is impor-
tant that before locking the distal, the insertion depth
of the intramedullary nail is below the greater tuberos-
ity to maintain space for the knocking back and com-
pression of the fracture end. Otherwise, the proximal
intramedullary nail will protrude to the large nodular
cortex. Even if the intramedullary nail does not exceed
the surface of the rotator cuff, it will still affect the
function of the shoulder.
• Insertion depth of the intramedullary nail: It is better to
completely bury the nail in the greater tuberosity cortex to
avoid collision of the intramedullary nail with the acro-
mion, which will affect the function of the shoulder
(Fig. 4.31).
–– If the thickness of the rotator cuff is 10 mm or less,
visual observation of the intramedullary nail insertion
depth may easily lead to shallow insertion of the intra-
medullary nail, thus affecting shoulder function. The
intramedullary nail insertion depth should be con-
firmed under fluoroscopy.
H. Chen et al.
Prevention and Treatment
(a) Causes of postoperative nonunion in humeral shaft
fractures:
• Poor intraoperative reduction:
–– The DCP is not attached without solid pres-
sure, resulting in instability, loose steel, and
ultimately nonunion.
–– The locking screw is not located in the center
of the shaft. Consequently, only a single layer
of cortex is fixed, and the effective working
distance of the screw is reduced, resulting in
instability.
• Incorrect fixation method: As mentioned above, an
appropriate fixation technique should be selected
for different types of fractures. Common mistakes
include the following (Colton and Fernandez
2000c):
–– Application of bridging plate technology for
the fixation of type A2 and type A3 fractures
with an insufficient work distance will result in
high stress near the fracture line, causing
breakage of the steel plate and nonunion.
–– The use of only a lag screw or strapping tech-
nology to fix type A1 and type B1 fractures will
result in insufficient anti-rotation and anti-­
bending ability.
–– The use of bridging plate technology for the
fixation of type B3 and type C fractures with
multiple screws inserted in the fracture area
will interfere with the fracture area.
–– The application of bridging plate technology
for the fixation of type B3 and type C fractures
with an insufficient length of the steel plate
(Fig. 4.32) and an insufficient number of
screws at both ends of the fracture area will
result in stress concentration and an increased
risk of screw pull-out.
–– Intramedullary nail fixation is used for long
spiral fractures involving more than 1/3 of the
humeral circumference (Figs. 4.33 and 4.34).
• Systemic diseases may affect fracture healing.
(b) Surgical techniques to prevent the occurrence of
nonunion:
• Use an appropriate approach: For fractures in the
proximal and middle humerus, the anterolateral
approach can be used. For fractures in the middle,
the lateral straight approach can be used. For
fractures in the distal humeral shaft, the postero-
lateral approach can be used to obtain good
exposure.
4 Fracture of the Humeral Shaft
a
b
Fig. 4.31 Example of closed reduction and internal fixation with an
intramedullary nail for humeral shaft fracture. (a) Postoperative antero-
posterior and lateral X-ray images demonstrating that the end of the
intramedullary nail exceeds the vertex of the greater tuberosity. (b–d)
Abduction and flexion of the shoulder are limited. (e, f) Shoulder
121
d
arthroscopy shows that the end of the intramedullary nail exceeds the
vertex of the greater tuberosity, and the rotator cuff was injured due to
collision and wearing by the nail. (g) The wearing injury of the rotator
cuff caused by the end of the intramedullary nail is visible during
surgery
122
e f
Fig. 4.31 (continued)
• Select the appropriate implant and fixation
method:
–– For simple fractures, direct reduction with
compression steel plate fixation or a lag screw
with compression between the fracture frag-
ments and steel plate protection can be
applied.
–– For complex fractures, indirect reduction and
bridging plate fixation are more often used.
Excessive exposure of the fracture ends will
increase the soft tissue injury and reduce the
blood supply in the fracture ends, thus affect-
ing healing.
–– A 4.5-mm locking or non-locking steel plate is
usually used for plate fixation.
H. Chen et al.
–– The techniques for the use of a steel plate and
screws are described above.
2. Radial nerve palsy:
(a) The incidence of radial nerve palsy is approximately
18% and primarily occurs at the time of injury due to
nerve contusion and traction. A small fraction occurs
in the closure or incision treatment process.
Approximately 90% of radial nerve paralysis will
eventually recover (Morrey 2013c).
(b) The methods to protect the radial nerve are described
in the previous sections for the surgical approach. In
the application of intramedullary nail treatment for
humeral shaft fractures, especially for middle and
lower 1/3 fractures, the number of reductions should
be reduced to avoid nerve damage.
4 Fracture of the Humeral Shaft
a b
c d
Fig. 4.32 Case example of a patient who received open reduction and
internal fixation for a humeral shaft fracture and had postoperative bone
nonunion (original preoperative images are missing). (a) Anteroposterior
and lateral X-ray images after the first surgery: The fracture was fixed
with a locking plate; however, while two screws were mistakenly used
in the fracture segment, only one bi-cortical screws and one uni-cortical
screw were used to fix the actual proximal fracture fragment. (b)
Anteroposterior and lateral X-ray images at 14 months after surgery
123
illustrating removal of the proximal screw, remarkable angulation
deformity, and bone nonunion. (c) Anteroposterior and lateral X-ray
images after a revision surgery: a longer locking plate was used, the
fracture was fixed with the bridging fixation technique, no screw was
placed in the fracture site, and autologous cancellous bone grafting was
applied in the fracture site. (d) Anteroposterior and lateral X-ray images
11 months after revision surgery illustrating good bone healing. (e)
Satisfactory functional recovery of the affected limb
124
a b
Fig. 4.33 Example of a Type B1 fracture of the humeral shaft. (a) The
long spiral fracture fragment was larger than 1/3 of the circumference
of the humeral shaft. (b) Closed reduction and internal fixation with an
intramedullary nail was applied, with two screws for distal locking and
three screws for proximal locking; the spiral fracture fragment was not
H. Chen et al.
c
reduced. (c) Anteroposterior and lateral X-ray images at 15 months
after surgery: Bone nonunion and enlargement of the medullary cavity
of the distal fracture fragment were observed; a bright area around the
distal screw indicated an unstable fixation that caused the withdrawal
and fracture of the distal locking screw
4 Fracture of the Humeral Shaft 125

a b

Fig. 4.34 A Type C3 fracture of the humeral shaft. (a) Preoperative tional external fixation with a supporting device was immediately
anteroposterior and lateral X-ray images. (b) After internal fixation applied, and the fracture later healed, confirming the importance of
with an intramedullary nail, the distal humerus showed a split shaft and stable fixation for bone healing
an enlarged medullary cavity, causing an unstable fixation. (c) An addi-
126 H. Chen et al.

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Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft:
Anonymous. Orthopaedic trauma association classification scheme for
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1996;10:81–6.
Archdeacon MT. Prevention and management of common fracture
Morrey BF. Master techniques in orthopaedic surgery: fractures. 3rd ed.
complications. West Deptford: Slack incorporated; 2012. p. 93.
Philadelphia: Lippincott Williams & Wilkins; 2013a. p. 148.
Bell MJ, Beauchamp CG, Kellam JK, et al. The results of plating
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 Fracture of the Distal Humerus
Hua Chen, Zhe Zhao, and Bin Shi
5.1 Basic Theory and Concepts
5.1.1 Overview
• The incidence of distal humeral fracture is relatively low,
accounting for 2% of all fractures of the body and 33% of
all fractures of the humerus (Koval and Zuckeman 2006;
Anglen 2005).
• The age and gender of onset show a double-peak distribu-
tion. The peak incidence in males occurs at 12–19 years
of age, whereas the peak incidence in women occurs at
greater than 80 years of age (Robinson et al. 2003;
Robinson 2005a).
• The elbow is one of the most important joints of the upper
limb. If elbow joint activity is decreased by 50%, the
function of the entire upper limb will be reduced by 80%.
Thus, the aim of distal humeral fracture treatment is to
provide a stable, powerful, and painless elbow with good
range of movement, thereby providing better upper limb
function.
• The elbow is one of the most complex joints of the
human body, with a single articular capsule containing
the humeroulnar joint, humeroradial joint, and distal
radioulnar joint. Thus, treatment of intra-articular frac-
tures in the distal humerus requires anatomical reduc-
tion, strong fixation, and early functional exercise to
minimize complications such as elbow stiffness and
ensure restoration of elbow function (Gabel et al. 1987;
John et al. 1994).
H. Chen (*) · B. Shi
Chinese PLA General Hospital, Beijing, China
e-mail: chenhua0270@130.com
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_5
5
5.1.2 Applied Anatomy
• Measurement of the elbow on the body surface and
activity:
–– When the elbow is straight, the medial epicondyle of
the humerus, ulnar olecranon, and lateral epicondyle
of the humerus can be palpated in a straight line on the
body surface.
–– When the elbow is in flexion, the lateral view shows
that the medial epicondyle of the humerus and the
ulnar olecranon are in a straight line, while the rear
view shows that the medial epicondyle, lateral epicon-
dyle of the humerus, and the ulnar olecranon form an
approximate isosceles triangle (Fig. 5.1).
–– When the elbow is dislocated, this alignment relation-
ship changes.
–– Under normal circumstances, the flexion and extension
activities of the elbow are in the range of 0–150°, with
pronation and supination of 80°/85° (Fig. 5.2).
–– After treatment for fracture near the elbow, the mini-
mum range of flexion and extension activities should
be 30–130°, with pronation and supination each of
50°.
• Anatomical characteristics of the distal humerus: The
morphology of distal humerus is very irregular, and its
anatomical morphology is closely related to its function.
–– The 3-column theory of the distal humerus (Jupiter
and Mehne 1992): When the distal humerus is observed
from the rear side, the humeral shaft is longitudinally
divided into the medial and lateral columns due to the
presence of the olecranon fossa, and these 2 columns
terminate at the connection point of the trochlea. The
distance from the medial column to the trochlea is
approximately 1 cm, and the lateral column extends to
the distal end of the trochlea containing the humeral
capitellum (Fig. 5.3).
Medial column: The medial column is derived out-
ward, with an angle of approximately 45° to the
humeral shaft, and the distal end forms the medial
127
128 H. Chen et al.

Fig. 5.1 (a) When the elbow

a b c
is straight, the rearview shows
that the medial epicondyle,
lateral epicondyle of the
humerus, and the ulnar
olecranon are in a straight
line. (b) When the elbow is in
flexion, the lateral view shows
that the medial epicondyle of
the humerus and the ulnar
olecranon are in a straight
line. (c) When the elbow is in
flexion, the rearview shows
that the medial epicondyle,
lateral epicondyle of the
humerus, and ulnar olecranon
form an approximate isosceles
triangle

a b

130°-150° 0° 0°

axis of
movement
90° 90°

10° 0°

Fig. 5.2 (a) The flexion and extension movements of the elbow range from 0–150°. (b) The motion range of the elbow is 80° for pronation and
85° for supination

condyle. The medial epicondyle is not only the
starting point of the forearm flexor group but also
the attachment point of the anterior and posterior
bundles of the medial collateral ligament, which
plays an important role in the stability of the elbow
joint. Therefore, the accurate reduction and fixation
of the medial condylar fracture is conducive for the
stability of the elbow joint in reconstruction.
Lateral column: The lateral column forms a 20°
angle with the humeral shaft and is derived at the
same level of the medial column. The distal end
contains the humeral capitellum. Observation from
the rear shows no articular surface coverage of the
humeral capitellum, and the articular surface
appears in the farthest point of the lateral column.
The lateral epicondyle at the distal end of the lateral
column is the starting point of the brachioradialis
and the extensor carpi radialis longus. It is also the
attachment point of the lateral collateral ligament.
The lateral collateral ligament complex is the
5 Fracture of the Distal Humerus
a b
lateral medial
column column
coronoid
radial fossa anconal
fossa
fossa
medial epicondyle
lateral
epicondyle
trochela trochela
capitulum
Fig. 5.3 (a) The 3-column theory of the distal humerus: The humeral
shaft is longitudinally divided into the three columns due to the pres-
ence of the olecranon fossa and coronoid fossa, with the lateral column
including the humeral capitellum and radial fossa; observation from the
p­ rimary factor limiting posterolateral instability of
the elbow joint. Thus, reduction and fixation of lat-
eral epicondyle fracture is conducive to preventing
instability (Mehne and Jupiter 1992; Diederichs
et al. 2009).
Trochlea: As the connection arch in the 3-column
structure, the shape of the trochlea is similar to a
bobbin. The trochlea consists of the inner and outer
lips together with the central groove. The central
groove matches the half-moon notch of the proxi-
mal ulna. In the flexion and extension movement of
the elbow, a 5° internal and external valgus is
allowed, and thus, the elbow is called a “loose”
restricted joint.
In the surgical treatment process of distal humeral
fractures, the triangular stability of the 3 columns
must be reconstructed; otherwise, instability of the
elbow joint will occur. In addition, the width of the
trochlea must be restored to avoid affecting the
reduction of the other 2 columns and the movement
trajectory of the ulnar half-moon notch during flex-
ion movement of the elbow, which will lead to
activity disorders.
–– Understanding of the distal anatomy of the humerus
and changes in the placement of the internal fixation:
For open reduction and internal fixation of distal
humeral fracture, there are two types of plate and
screw placements: vertical and parallel placement
of the steel plate (Fig. 5.4). These two strategies are
both based on the distal 3-column theory of the
humerus.
129
lateral medial
column column
lateral
epicondyle
connect arch
rear shows no articular surface coverage of the humeral capitellum. (b)
Schematic of the 3-column model of the distal humerus: the lateral col-
umn ends at the latera distal trochlea, and the medial column ends at the
medial proximal trochlea
Vertical placement of steel screws: In addition to
the 3-column theory, this model also considers the
shape of the distal humerus. The ulnar nerve travels
below the medial epicondyle of the humerus. After
the ulnar nerve is intraoperatively released and
moved, the distal end of the medial plate can be
shaped 90° distal to fit the angle of the medial con-
dyle. In the lateral column, because the articular
surface of the posterior humeral capitellum is not
covered, the lateral plate can be placed in the rear of
the lateral column. The length of the screw should
not exceed the contralateral articular surface, and
the steel plate should not exceed the distal end of
the humeral capitellum. Otherwise, the humeral
capitellum may hit the steel plate during extension
of the elbow, resulting in limited extension of the
elbow (Jupiter et al. 1985a; Ring and Jupiter 2000).
Parallel placement of steel screws: This model is
based on the following biomechanical model. The
parallel placed plates serve as the column on both
sides of the arches, and the long interlocking screws
in its distal region will connect the medial and lat-
eral columns, thus providing stability for the col-
umns in both sides as the dome on top of the arch
(Sanchez-Sotelo et al. 2008, 2007).
–– Olecranon fossa, coronoid fossa, and radial fossa
(Fig. 5.5):
The olecranon fossa is a sagging structure located
above the middle trochlea in the rear of the distal
humerus, as the deepest of the 3 depression struc-
tures. When the elbow is straight, the olecranon is
130 H. Chen et al.

Fig. 5.4 (a) Vertical

a b
placement of stainless-steel
plates for fixation. (b) Parallel
placement of stainless-steel
plates for fixation: the parallel
placed plates serve as the
columns on both sides of an
arch, and the long
interlocking screws in their
distal region will directly
connect them, thus providing
stability for the columns on
both sides as the dome on top
of the arch

a b

4°-6° 4°-6°

Fig. 5.5 (a) Front view of the distal humerus: The distal humeral
trochlea and humeral capitellum are covered by articular cartilage, and
their axis forms a valgus angle from 4° to 6° with the longitudinal axis
of the humerus. The depressions located on top of the trochlea and
humeral capitellum are the coronoid fossa and radial fossa, respec-
tively, where the ulna coronoid process and capitulum radii return when
the elbow is in flexion. (b) Rear view of the distal humerus: The poste-
rior humeral capitellum is not covered by articular cartilage, and the
olecranon fossa is a large and deep depression on top of the trochlea,
where the ulnar olecranon returns when the elbow is in flexion
contained in this bone fossa, which is an important
anatomical structure to ensure the active extension
range of the elbow.
The coronoid fossa is located in the middle of the
anterior distal humerus and is more shallow than the
olecranon fossa. The radial fossa is in the lateral
region of the coronoid fossa and above the humeral
Fig. 5.6 The elbow can be considered a hinged joint
capitellum. When the elbow is in flexion, the ulnar
coronoid process and radial capitellum are contained
in these 2 fossae, which are the anatomical structures
that ensure the flexion range of the elbow joint.
In surgery, entry of these 3 bone fossae by the inter-
nal fixation implant should be avoided; otherwise,
the movement range of the flexion and extension of
the elbow will be affected.
• Anatomy of the distal humerus and movement of the
elbow:
–– The elbow can be considered a hinged joint (Fig. 5.6)
whose physiological function is to place the hand in
5 Fracture of the Distal Humerus 131

Fig. 5.7 (a) The olecranon a b c d

fossa and coronoid fossa enable
the distal humerus to have a
tuning-fork-like structure, with
the ulna semilunar notch fitting
well in the middle section of
the rotation axis. (b) The
anteversion angle of the distal
humerus and proximal ulna
allows the olecranon fossa to
contain the ulnar olecranon
when the elbow is extended,
contributing to the 0° elbow
extension. (c, d) The coronoid e
process begins to contact the
coronoid fossa in elbow flexion
exceeding 90° and returns to g
the fossa up to 145° flexion. (e, f
f) Without the anteversion
angle of the distal humerus and
proximal ulna, the coronoid
process would contact the
coronoid fossa during elbow
flexion less than 90°. (g)
Further elbow flexion will
cause overlapping of muscles
and bones

any position in space to complete the function of the
upper limb. In addition, in contrast to simple hinge
joints (Mac Ausland and Wyman 1975), the elbow can
also execute pronation and supinations through the
movement of the humeroradial joint as well as the
proximal and distal radioulnar joint.
–– The morphology of the distal humerus and proximal
ulna and the flexion and extension angle of the elbow
(Fig. 5.7):
The distal part of the humerus has an overall for-
ward inclination of 40°, such that the trochlea and
humeral capitellum are located in front of the
humeral shaft to accommodate the greater elbow
flexion angle (Fig. 5.8). Therefore, in the reduction
and fixation of the fracture, this forward angle
should be restored for the restoration of the contact
of the metaphyseal and humeral shaft.
The half-moon shaped notch of the proximal ulna
resembles a semicircle, and the semicircular notch
of the lateral view also has an inclination of approx-
imately 45° to the long axis of the humerus, which
also increases the elbow flexion angle.
When the elbow is in flexion, the coronal fossa and
radial fossa of the anterior distal humerus also play
a role in containing the coracoid process of the ulna
and radial capitellum and further increasing the
elbow flexion angle.
When the elbow joint is straight, the olecranon
fossa in the distal humerus plays a role in contain-
ing the ulnar olecranon and further increasing the
elbow extension angle.
–– Characteristics of the articular surface and the carrying
angle for the distal humerus: When the elbow joint is
straight, the long shaft of the humerus and the long
axis of the forearm form an angle of 165–170°, with a
supplementary angle of 10–15°. This angle is greater
in females than in males and is known as the carrying
angle of the elbow.
The valgus angle of the trochlea: The axis of the
trochlea is not completely perpendicular to the long
axis of the humerus. Instead, there is an overturned
angle of 4–6°, which provides a partial elbow val-
gus angle (Fig. 5.5).
The axis of the anterior and posterior articular
planes of the trochlea: Kapandiji et al. reported that
the front view of the humeral trochlea shows a basi-
cally parallel central groove and humeral shaft,
whereas the rear view shows the central groove tilt-
ing to the distal and lateral. Thus, in the extension
of the elbow joint, the ulnar semicircular notch con-
tacts the posterior of the trochlea, with an increase
in the valgus angle. In the flexion of the elbow, the
semicircular notch of the ulna is in contact with the
anterior of the trochlea, and the forearm is bent to
132
45°
Fig. 5.8 The distal part of the humerus has an anteversion angle of
40°, which incorporates with the inclination of the ulnar olecranon
to increase the angle range of motion of elbow flexion
Fig. 5.9 (a) The axial line of
the humeral trochlea does not
form a regular circle, but
instead is spiral; as a result, it
creates an outward angle at the
elbow extension and follows the
same direction as the humeral
shaft during elbow flexion. (b)
To carry a heavy object, the
humerus usually rotates inward
by 45°, the forearm rotates
outward by 45°, and the palm
faces inward. At this time, the
center of the heavy object
should be in the same vertical
line as the shoulder rotation
center
H. Chen et al.
the front of the upper arm, which is more conducive
to the feeding function of the hand (Kapandji 2007)
(Fig. 5.9a).
Understanding the carrying angle: It is generally
believed that the upper arm eversion allows heavy
objects to be lifted away from the body to avoid
impact on the pelvis. However, the carrying angle
disappears with forward rotation of the forearm. In
addition, to carry a heavy object, the humerus usu-
ally rotates inward by 45°, and the forearm rotates
forward by 45°. At this time, the center of the heavy
object should be in the same vertical line as the
shoulder rotation center, which is mechanically
optimal (Fig. 5.9b). Thus, the role of the carrying
angle of the elbow should be reconsidered, but dur-
ing surgery, elbow varus and excessive valgus
40°
should be avoided (Paraskevas et al. 2004).
• The stable structure of the elbow (Armstrong et al. 2002):
–– The stable structure when the elbow is extended
(Fig. 5.10):
Olecranon and olecranon fossa: When the elbow is
straight, the tip of the olecranon contacts the olecra-
non fossa, providing stability in the rear.
The anterior joint capsule and ligament: The ante-
rior joint capsule and ligament tissue are taut, pro-
viding stability in the front.
The tension of the flexor: The flexors of the elbow
(biceps brachii, brachial muscle, etc.) are tense
a b
shoulder rotation
center
heavy object
center
gravity vertical line
5 Fracture of the Distal Humerus
Fig. 5.10 When the elbow is
extended, the mechanisms
contributing to stability are
mainly the contact between
the ulnar olecranon and
olecranon fossa, the anterior
joint capsule, and the tension
of the flexor. Overextension
of the elbow may cause
olecranon fracture, tearing of
the anterior joint capsule, and
dislocation of the elbow
while preventing further excessive extension of the
elbow.
Further extension of the elbow may cause olecranon
fracture or tearing of the anterior articular capsule
and ligament, which are associated with dislocation
of the elbow or injury of the brachial artery.
–– The stable structure when the elbow is in flexion
(Fig. 5.11):
Compression of the elbow flexor group: In active
elbow flexion, the elbow flexor is contracted and
becomes short and thick, which squeezes the fore-
arm muscles against each other to limit further flex-
ion of the elbow.
Coronoid and coronoid fossa: In passive elbow flex-
ion, the muscle is relaxed, and the coronoid is in
contact with the distal bone structure of the humerus
to provide stability in the front.
Posterior articular capsule: When the elbow is in
flexion, the posterior articular capsule is taut to par-
tially provide stability in the rear.
Tension of the extensor group: With flexion of the
elbow, the triceps is gradually retracted, and the
tension gradually increases, which helps maintain
stability in the rear.
–– The stable structure of the internal and external valgus
in the elbow:
Trochlea and ulnar half-moon shaped notch: The
ulnar half-moon shaped notch matches the humeral
trochlea, providing a certain degree of internal sta-
bility, but the auxiliary of other elbow structures is
still needed.
133
Medial collateral ligament: The medial collateral
ligament is the most important anti-valgus stable
structure and includes the front beam, rear beam,
and oblique beam, of which the front beam is the
most important (Armstrong et al. 2002; O’Driscoll
et al. 1992).
Humeral capitellum and radial head: Contact of the
humeral capitellum and radial head is the second
most important anti-valgus stable structure of the
elbow.
Lateral collateral ligament: In the case of forearm
backward rotation, the lateral collateral ligament
can prevent rotating separation and backward dislo-
cation of the humeroulnar joint, providing postero-
lateral rotation stability (Lockard 2006; Dunning
et al. 2001; Imatani et al. 1999).
5.1.3 Mechanisms of Injury (Robinson 2005b)
• Direct violence:
–– Car accident and other high-energy damage, which are
more common in young people
–– Fractures caused by the elbow directly hitting the
ground while falling, which are more common in
middle-­aged women
• Indirect violence:
–– Sports injuries, which are more common in young
people
–– Striking of the ground with a straight upper limb;
transfer of the power along the forearm to the elbow
134
Fig. 5.11 In active elbow
flexion, the elbow flexor is
contracted, which limits
further flexion of the elbow;
in passive elbow flexion, the
stability of the elbow is
attributed to mainly the
structures including the ulnar
coronoid process and
coronoid fossa, the posterior
joint capsule, and the tension
of the triceps
causes fracture, which is more common in middle-­
aged women
• Analysis of the fracture line direction and force factor:
–– In elbow flexion of 90°, the forearm receives the force,
resulting in distal humeral fracture in a single column
or single condyle
–– In elbow flexion of greater than 90°, the olecranon
receives the force, resulting in humeral comminuted
fracture in the condyle or double column
5.1.4 Classification of Fractures
• The AO classification for distal humeral fracture: For the
complex distal humeral form, the current clinical applica-
tion is the AO classification. According to the principles
of the AO classification of metaphyseal fractures, type A
fractures are extra-articular fractures (Fig. 5.12), type B
fractures are partial intra-articular fractures (Fig. 5.13),
and type C fractures are complete intra-articular fractures
Fig. 5.14). However, depending on the morphological
characteristics of the distal humerus, all types are consid-
ered as much as possible, and distal humeral fractures are
further divided into 27 subtypes and a total of 61 sub-
groups. The treatment and prognosis of distal humerus
fracture are dependent on the involved area and displace-
ment of the fracture, as well as the extent of the comminu-
tion. In the AO classification, for the same type A fracture,
the prognosis and treatment methods for type A1 are very
different than those for type A2 and type A3, and type B3
fracture is also very different from type B1 and type B2
fractures. Therefore, the simple application of classifica-
tion to determine prognosis is difficult. In terms of prog-
H. Chen et al.
nosis, the prognosis of type A2, A3, and C fractures is
usually poor (Marsh et al. 2007).
• Classification of radial head fractures or coronary frac-
tures of the distal humerus:
–– Bryan & Morrey classification (Fig. 5.15): After Bryan
& Morrey divided humeral capitellum fractures into 3
types, McKee et al. added type IV: this type is related
to the treatment option and prognosis (Ring et al. 2003;
Elkowitz et al. 2002).
Type I: complete fracture of the humerus capitel-
lum; may be accompanied by the involvement of a
small amount of the lateral trochlea;
Type II: humeral capitellum anterior/cartilage frac-
ture; the fracture fragments contain only a small
amount of subchondral bone;
Type III: compression fractures or comminuted
fractures of the humeral capitellum;
Type IV: humeral capitellum coronal fracture
extending inward to involve the vast majority of the
trochlea. The proportion of type IV fractures is not
low and includes up to 50% of all coronal fractures
of the humeral capitellum.
–– David Ring classification: David Ring divided the dis-
tal humerus into 5 parts: the humeral capitellum and the
lateral trochlea, lateral epicondyle, the lateral column
behind the humeral capitellum, the rear of the trochlea,
and the medial condyle. Based on preoperative images
and intraoperative observation of the morphology, dis-
tal humeral fractures are divided into 5 types. This clas-
sification has significance in guiding decision-making
for the surgical approach, surgical techniques, and fixa-
tion method (Ruchelsman et al. 2008).
5 Fracture of the Distal Humerus
a1.1 a1.2
a2.1/2 a2.3
a3.1/2 a3.3
Fig. 5.12 In the AO classification, Type A fractures are extra-articular
fractures: Type A1 encompasses avulsion fractures of the medial or lat-
eral epicondyles; Type A1.1 are lateral epicondyle fractures; Type A1.2
are medial epicondyle fractures; Type A1.3 are medial epicondyle frac-
tures with fragments embedded in the joint, which are rare types; Type
A2 are simple metaphyseal fractures; Type A2.1 are oblique metaphy-
seal fractures with a fracture line obliquely downwards to the medial
Type I: Fractures involving only the humeral capi-
tellum and lateral trochlea;
Type II: Type I fracture with epicondyle fracture;
Type III: Type II fractures with lateral column frac-
ture behind the humeral capitellum;
Type IV: Type III fracture with fracture in the rear
of the trochlea;
Type V: Type IV fracture with medial condyle
fracture.
135
a1.3
position; Type A2.2 are oblique metaphyseal fractures with a fracture
line obliquely downwards to the lateral position; Type A2.3 are trans-
verse metaphyseal fractures; and Type A3 are metaphyseal oblique frac-
tures, including Type A3.1 (with an intact butterfly-shaped bone
fragment), Type A3.2 (with multiple crushed butterfly-shaped bone
fragments), and Type A3.3 (comminuted metaphyseal fracture)
5.1.5 Assessment of Distal Humeral Fractures
5.1.5.1 Clinical Assessment
• For patients with fractures with different displacements
and limb swelling, the symptoms and signs vary widely.
–– For cases with severe swelling of the elbow, the body
surface signs often cannot be clearly touched.
–– Whether the ulnar olecranon, medial condyle, and lat-
eral condyle can form an isosceles triangle should be
roughly determined to exclude joint dislocation.
136
b1
b2.1 b2.2
b3.1 b3.2
Fig. 5.13 In the AO classification, Type B fractures are partial intra-­
articular fractures: Type B1 are lateral sagittal fractures, including Type
B1.1 (fractures passing through the humeral capitellum), Type B1.2
(simple fractures passing through the trochlea), and Type B1.3 (com-
minuted fractures passing through the trochlea); Type B2 are medial
sagittal fractures, including Type B2.1 (simple fractures passing
c1 c2
Fig. 5.14 Type C fractures are complete intra-articular fractures,
including Type C1 (simple fractures of both joint surface and metaphy-
sis), Type C2 (simple fracture of the joint surface and comminuted
H. Chen et al.
b2.3
b3.3
through the medial trochlear articular surface), Type B2.2 (simple frac-
tures passing through the medial trochlear groove), and Type B2.3
(trochlear fractures with multiple fragments); and Type B3 are coronal
fractures, including Type B3.1 (coronal fractures of the humeral capi-
tellum), Type B3.2 (coronal fractures of the trochlea), and Type B3.3
(coronal fractures of the humeral capitellum and trochlea)
c3
metaphyseal fracture), and Type C3 (comminuted fractures of both joint
surface and metaphysis)
5 Fracture of the Distal Humerus
Type I Type II
Type III Type IV
Fig. 5.15 (a) Bryan & Morrey classification of the humeral capitel-
lum: Type I: complete fracture of the humerus capitellum, which may
be accompanied by involvement of a small amount of lateral trochlea.
Type II: humeral capitellum anterior/cartilage fracture, with fracture
fragments containing only a small amount of subchondral bone. Type
III: compression fractures or comminuted fractures of the humeral capi-
• The bony crepitus and joint instability in the process of
elbow activities can indicate the presence of fracture.
–– Do not attempt to repeatedly induce the bony crepitus
due to the risk of nerve and vascular injury.
• The assessment of nerve and vascular function is very
important (Faber 2004).
–– The end of the proximal fracture may pierce or con-
tract the radial artery, the median nerve, and the radial
nerve.
• When severe swelling occurs, it is necessary to repeatedly
check nerve and vascular function and monitor interfas-
cial compartment pressure (Ergunes et al. 2006; Meissner
et al. 1991).
–– The swelling of the elbow fossa may cause blood sup-
ply disorder, palm lateral fascial compartment syn-
drome, and Volkmann ischemic muscle contracture.
5.1.5.2 Imaging Assessment
• X-ray assessment (Fig. 5.16):
–– Anteroposterior position:
The image is captured with the elbow straight and
the forearm rotated backward and placed flat on the
X-ray receiver, with the fingers slightly buckled.
137
b
1
5
2
4
medial lateral
tellum. Type IV: humeral capitellum coronal fracture extending inward
to involve the vast majority of the trochlea. (b) Cross section of the
distal humerus: (1) humeral capitellum and lateral trochlea; (2) lateral
epicondyle; (3) lateral column posterior to the humeral capitellum; (4)
posterior trochlea; (5) medial epicondyle
The anteroposterior position of the elbow joint can
clearly reveal the distal humerus, especially the
medial and lateral epicondyle, but the medial of the
radial head, radial neck are overlapped with the
proximal ulna.
–– Lateral position:
The elbow is in 90° flexion, with the forearm down-
ward at the ulnar side and the fingers slightly
buckled.
With the lateral position of the elbow joint, the
elbow fat pad can be observed. In front of the elbow,
the fat pad is usually parallel to the small translucent
band in the cortex in front of the distal humerus, and
the fat pad of the rear is deeply hidden in the olecra-
non fossa and usually cannot be visualized clearly.
When the articular capsule expands, the fat pads in
front and behind the elbow may shift upward, showing
a convex shape, which is known as the fat pad sign.
If the flat film does not show the fracture and the fat
pad sign is observed, the occurrence of occult frac-
ture should be suspected because at this time, intra-­
articular hemorrhage may cause expansion of the
articular capsule.
138
a c
Fig. 5.16 Standard X-ray images of the distal humerus. (a)
Anteroposterior X-ray image demonstrating the overlapping of the dis-
tal humeral trochlea with the medial and lateral epicondyles and the
overlapping of the medial side of the radial head and the radial neck
with the proximal ulna (the hollow arrow denotes the humeral capitel-
lum, the dashed line arrow denotes the lateral lip of the trochlea, and the
solid line arrow denotes the trochlea). (b) Lateral X-ray image illustrat-
ing the radial head, humeral capitellum, and ulnar olecranon: the thin
dashed line denotes the coronoid process, the solid line arrow denotes
the radial head, the dashed line arrow denotes the radial neck, and the
–– Lateral oblique position:
The image is captured when the elbow is straight
and the forearm is rotated backward at an angle of
40° to the X-ray receiver.
The lateral oblique position of elbow can reduce
overlap between the ulnar and radial images.
H. Chen et al.
d
triangle denotes the radial tuberosity, and the bold dashed line denotes
the radial head axis passing through the lateral epicondyle in the lateral
position. (c) Medial oblique X-ray image illustrating the radial head,
humeral capitellum, and olecranon fossa and coronoid processes (the
hollow arrow denotes the coronoid process, the dashed line arrow
denotes the trochlear notch, and the solid line arrow denotes the medial
lip of the trochlea). (d) Lateral oblique X-ray image illustrating the
radial head, humeral capitellum, radioulnar notch, olecranon fossa, and
medial epicondyle (the solid line arrow denotes the radial head and the
hollow arrow denotes the radial neck)
–– Medial oblique position:
The image is captured when the elbow is straight
and the forearm is rotated forward at an angle of
40°-45° to the X-ray receiver.
The medial oblique position of elbow can clearly
show the olecranon and coronoid processes.
5 Fracture of the Distal Humerus
• CT assessment:
–– CT scan of the elbow can reveal occult fracture and the
details of the fracture fragments. In particular, 3D CT
reconstruction can stereoscopically show the size of
the fracture fragments and degree of displacement. CT
scans can provide more information, with guiding sig-
nificance for clinical decision-making. Routine CT
scan is recommended (Doornberg et al. 2006).
5.2 Surgical Treatment
5.2.1 Surgical Indications and Purpose
• Surgical indications: Conservative treatment can be
applied for type A1 supracondylar fractures with no dis-
placement, whereas surgery is needed for most other
metaphyseal fractures and intra-articular fractures.
• Surgical purpose and principles:
–– The overall goal of treatment is to restore a stable, potent,
and painless elbow with a good range of movement.
–– This requires the anatomical reduction of the articular
surface, the reconstruction of the distal structure of the
humerus, and strong fixation, as well as early func-
tional exercise in full range.
–– For all distal fractures of the humerus involving both the
medial and lateral columns, double-plate fixation includ-
ing the parallel plate and the vertical plate should be used
(Helfet and Schmeling 1993; Schemitsch et al. 1994).
• Biomechanical studies have shown that the mechanical
stability of a flat steel plate is superior, but our hospital
has achieved good results using either a parallel plate or
vertical plate in the treatment of distal humeral fractures
(Schemitsch et al. 1994).
a b
Fig. 5.17 The patient is in the lateral decubitus position on the unaffected side (a), with the upper limb of the affected limb placed on the holder
and the forearm suspended downward (b)
139
• Timing for surgery: For distal humeral fracture combined
with vascular injury or open injury, emergency surgery is
needed. Routine surgery should not be delayed for too
long because extension of the duration of distal humerus
fracture will increase the probability of heterotopic ossifi-
cation. If the soft tissue injury is severe and open surgery
is not allowed, cross-articular fixation with an external
frame should be used after proper reduction of the frac-
ture (Ilahi et al. 1998).
5.2.2 Surgical Techniques
5.2.2.1 Position and Preoperative Preparation
• General anesthesia or brachial plexus anesthesia.
• The patient is in the contralateral supine position, with a
pillow under the armpit to protect the nerves.
• The upper limb of the affected limb is placed on the holder,
and the forearm is suspended downward (Fig. 5.17).
5.2.2.2 Operative Incision According
to the Projection on the Body Surface
• The incision is created in the middle of the posterior elbow
(in the middle of the posterior elbow downward from
10 cm above the olecranon tip, by the lateral of the ulnar
olecranon and then extending to the distal by 5 cm; this
incision bends outward at the olecranon tip to avoid scar
formation in the load-bearing part of the elbow) (Fig. 5.18).
5.2.2.3 Surgical Approach
1. Surgical approach for distal humeral fractures: There are a
variety of surgical approaches for the surgical treatment of
distal humeral fractures, but the appropriate surgical
140
Fig. 5.18 The preoperative
incision marks by surface
projection: The incision is
created in the middle of the
posterior elbow downward
from 10 cm above the
olecranon tip, slightly curving
near the lateral ulnar
olecranon and then extending
distal by 5 cm
approach should be selected based on the type of fractures
to minimize damage while ensuring the effect of surgery.
2. According to the incision position, the surgical approaches
can be divided into the medial approach, the lateral
approach, and the posterior approach:
(a) The medial approach is used to treat type A1.2, A1.3,
B2.1, and B2.2 simple fractures involving the medial
epicondyle and medial condyle.
(b) The lateral approach is used to treat type A1.1 and B1
simple fractures involving the lateral epicondyle and
lateral condyle.
(c) The posterior approach is extensible, and the medial,
lateral, and articular surfaces of the elbow can be
exposed. Therefore, some scholars have proposed
that “the front door of elbow joint is in the rear.”
According to the different methods for addressing the
extensor device, the posterior approach is further
divided into the following surgical procedures:
• The triceps split approach (Campbell posterior
approach): This approach is suitable for extra-­
articular fractures or for intra-articular fractures
with simple fractures on the articular surfaces
(Campbell 1932) (Fig. 5.19).
–– According to the projection of the incision on
the body surface, the skin, subcutaneous, and
fascia are cut to separate toward both sides,
forming a full-thickness fascia flap and
retraction.
H. Chen et al.
–– The ulnar nerve in the elbow tube is exposed
and separated to the first motor branch domi-
nating the ulnar carpal flexor muscle.
–– The triceps and tendon are longitudinally split
from the proximal to the distal, and sharp sub-
periosteal stripping is performed for the attach-
ment of the triceps tendon on the ulnar
olecranon. Note that the continuity of the
medial ulnar flexor carpi and lateral ulnar
extensor carpi should be maintained, and the
distal humerus and trochlea can be exposed by
pulling to both sides.
• The triceps-on approach or Alonso-Llames
approach: This approach cannot directly expose the
articular surface, and thus it is applicable to extra-
articular supracondylar fractures or to intra-­articular
fractures with simple fractures on the articular sur-
faces (Alonso-Llames 1972) (Fig. 5.20).
–– After separating the ulnar nerve, the medial tri-
ceps space is dissociated to pull out the triceps
tendon and expose the medial condyle of the
humerus. This is the ulnar port.
–– The lateral triceps space is dissociated to pull
the triceps inward and expose the lateral epi-
condyle of the humerus. This is the radial port.
–– In the surgical process, the triceps is treated as
a whole unit, which can be pulled around to
show the surgery field.
5 Fracture of the Distal Humerus
a
common extensor tendon
ulnar carpal flexor muscle
(ulnar head)
ulnar carpal flexor muscle
(humeral head)
groove for ulnar nerve
triceps tendon
ulnar nerve (relaxed)
Fig. 5.19 The triceps split approach for the distal humeral fracture. (a)
The skin, subcutaneous tissue, and fascia are cut to separate toward
both sides, forming a full-thickness fascia flap that is then retracted. The
ulnar nerve in the elbow tube is exposed and separated to the first motor
branch dominating the ulnar carpal flexor muscle. (b) The triceps and
tendon are longitudinally split proximal to distal, and sharp subperios-
• The triceps flip-out approach (Bryan-Morrey
approach): This approach maintains the extensor
device as a whole unit to retract outward, with
superior exposure of the trochlea compared to the
triceps-on approach on both sides. It can be applied
to supracondylar fractures or to intra-­articular frac-
tures with simple fracture on the articular surface
(Bryan and Morrey 1982) (Fig. 5.21).
–– After the ulnar nerve is separated, the triceps is
stripped outward from the humerus along the
medial margin of the triceps under the perios-
teum, and the forearm fascia is cut along the
proximal medial ulna toward the distal end.
–– The attachment of the triceps in the ulnar olec-
ranon is disassociated using a periosteal strip-
per outward under the periosteum. The entire
elbow device can be pulled out to expose the
distal posterior humerus and olecranon.
141
humerus and
periosteum
anconeus capitellum
medialis
olecranon
teal stripping is performed for the attachment of the triceps tendon on
the ulnar olecranon. Note that the continuity of the medial ulnar flexor
carpi ulnaris and lateral extensor carpi ulnaris should be maintained,
and the distal humerus and trochlea can be exposed by pulling toward
both sides
• The triceps tongue-shaped flap approach
(Crenshaw 1987; Wadsworth 1979):
–– The view of the surgical exposure field is rela-
tively wide, leading to easy reduction for the
trochlea.
–– Tongue flap healing involves scar healing, with
a certain impact on the elbow device, causing
poor recovery of triceps muscle strength.
–– The elbow must be fixed for at least 3 weeks,
with a high incidence of postoperative joint
stiffness.
–– This approach is not commonly used currently
and is not recommended.
• Ulnar olecranon osteotomy approach (O’Driscoll
2000):
–– The articular surface is exposed clearly, which
has special advantages for complex fractures of
the articular surface, such as type C3 fractures:
142 H. Chen et al.

common extensor tendon

a b
lateral distal humerus

lateral intermuscular
septum

ulnar carpal
flexor muscle

humeroulnar
medial joint capsule
ulnar nerve
triceps tendon intermuscular
septum medial distal
humerus

Fig. 5.20 The triceps-on approach is initiated using the same proce- expose the lateral epicondyle of the humerus. (b) The medial triceps
dure as the triceps split approach to separate the ulnar nerve, and then space is dissociated to pull out the triceps tendon and expose the medial
(a) the lateral triceps space is dissociated to pull the triceps inward and condyle of the humerus

a b

lateral epicondyle
ulnar nerve

anconeus
medial epicondyle
triceps brachii

cubital tunnel olecranon triceps brachii

olecranon
retinaculum insertion

first motor branch

Fig. 5.21 The triceps flip-out approach: After the ulnar nerve is sepa- end. (b) The attachment of the triceps in the ulnar olecranon is disas-
rated, (a) the triceps is stripped outward from the humerus along the sociated using a periosteal stripper. The entire elbow mechanism is
medial margin of the triceps under the periosteum, and the forearm fas- pulled laterally
cia is cut along the proximal medial ulna (red line) toward the distal

It can fully expose the distal articular surface
of the humerus. The fracture fragment in the
olecranon is flipped up together with the tri-
ceps to avoid blockage of the ulnar olecra-
non, which may hinder the reduction in the
articular surface of the humeral trochlea.
It has little impact on the elbow device. The
healing after the “V” shaped osteotomy of
the olecranon involves bone healing but not
scar healing.
The fixation of the olecranon osteotomy
tension band allows patients to perform
5 Fracture of the Distal Humerus
radial tuberosity
ulnar tuberosity
coronoid
radial neck
process
annular
ligament
trochlear
notch
proximal radioulnar joint
olecranon
Fig. 5.22 In the semilunar notch of the ulna, near the midpoint of the
connection of the ulnar olecranon tip and the coronal protrusion, there
is an area with no articular cartilage coverage or a small amount of
articular cartilage coverage, which is known as the “bare area.”
Olecranon osteotomy should be performed in this area to reduce carti-
lage destruction
early elbow flexion and extension activities,
thus avoiding elbow stiffness.
–– The “bare zone” of the articular surface of the
ulnar olecranon: In the half-moon shaped notch
of the ulna, near the midpoint of the connection
of the ulnar olecranon tip and the coronal pro-
trusion, there is an area with no articular carti-
lage coverage or a small amount of articular
cartilage coverage, which is known as the “bare
zone.” Olecranon osteotomy should be in this
area to reduce cartilage destruction (Fig. 5.22).
–– Surgical procedures:
An incision is created in the middle of the
posterior, which is slightly curved outward
at the olecranon.
The skin, subcutaneous layer, and deep fas-
cia are cut to dissociate toward both sides
and form the fascia flap in full thickness,
with retraction toward both sides.
In the elbow tube, the ulnar nerve is exposed
and separated to the first motor branch con-
trolling the ulnar carpal flexor, which is
marked and protected with a rubber band.
Excessive retraction should be avoided in
the process of surgery to prevent traction
injury to the ulnar nerve.
The articular capsule in the rear of the
humeroulnar joint is exposed and cut to find
143
the “bare zone” in the half-moon shaped
notch for the osteotomy.
The tip of the ulnar olecranon “V”-shaped
osteotomy should be toward the distal of the
upper limbs. Due to the special shape of the
olecranon cross section, when a pawl saw is
used for the osteotomy, it should not exceed
3/4 of the depth of the olecranon, and the
middle part of the subchondral bone should
be operated with a narrow bone knife.
In the process of osteotomy, gauze through
the olecranon notch is used to lift the olecra-
non and protect the joint.
After osteotomy, the tip of the olecranon
with the triceps muscle is lifted toward the
proximal to expose the articular surface.
After surgery, the ulnar olecranon should be
fixed using a Kirschner wire tension band,
with parallel placement of 2 Kirschner wires
through the ulnar anterior cortex. Note that
the tension band wire should be buried
under the triceps tendon (the detailed fixa-
tion of the ulnar olecranon tension band is
described in the section on proximal ulna
fracture) (Fig. 5.23).
5.2.2.4 Reduction and Internal Fixation
of the Fracture
1. Application of reduction and internal fixation techniques
using a parallel steel plate (Helfet and Schmeling 1993;
Jupiter et al. 1985b; Self et al. 1995). In the application of
a parallel plate in the fixation of distal humeral fractures,
8 principles should be followed: (Fig. 5.24).
(a) All screws should be placed through the steel plate.
(b) All screws should be fixed to the opposite side of the
fracture fragment.
(c) All screws should be of sufficient length.
(d) All screws should be fixed in as many intra-articular
fracture fragments as possible.
(e) The distal fracture fragments should be fixed using as
many screws as possible.
(f) The screws to fix the distal fracture fragments should
be interlocking, thus achieving the angle fixation of
the medial and lateral columns to connect the 2
columns.
(g) The humeral supracondylar fracture should be fixed
using the bone plate with compression.
(h) Before healing of the condylar fracture, the bone
plate should provide adequate strength and stiffness,
with no fracture and bending.
(i) Reduction of the articular surface: First, the articular
surface for reduction is dissected, and the type C
fracture is converted into a type A fracture (Fig. 5.25).
144
a b
e f
Fig. 5.23 The ulnar olecranon osteotomy approach. (a) The posterior
humeroulnar joint capsule is cut open to identify the “bare area” of the
articular surface of the ulnar olecranon. (b) The tip of the ulnar olecra-
non “V”-shaped osteotomy should be performed toward the distal end
of the upper limbs. (c) Due to the special shape of the olecranon cross
section, when an oscillating saw is used for osteotomy, it should not
• With the proximal ulna and radial head as the tem-
plate, the articular surface for reduction is dissected.
• For severe comminuted fractures, a fine thread
guidewire can be used for fixation and will ulti-
mately be cut as the auxiliary final fixation.
• The order of the reduction and fixation is as fol-
lows: the bone fragments in the anterior trochlea
and the humeral capitellum, the medial trochlea
fragments, and the posterior bone fragments.
• The Kirschner wire for the temporary fixation of
the articular surface in the horizontal direction
should be as close to the subchondral cartilage as
possible; otherwise, it may block the placement of
the parallel steel plate.
• Note that this procedure is different from that for
the vertical plate: before placing the steel plate, do
H. Chen et al.
c
exceed 3/4 of the depth of the olecranon, and the middle part of the
subchondral bone should be operated with a narrow osteotome. (d)
After osteotomy, the tip of the olecranon with the triceps muscle is
lifted proximally to expose the articular surface. (e, f) After surgery, the
ulnar olecranon should be fixed using a Kirschner wire tension band,
and the tension band wire should be buried under the triceps tendon
not use screws for fixation; otherwise, the long
screw in the distal humerus will be blocked.
• In the direction of the long axis, 1–2 Kirschner
wire can be placed to temporarily fix the articular
surface with the humerus.
• If the intra-articular fracture is severely comminuted,
the anatomical reduction for the anterior articular
surface of the distal humerus, the humeral capitel-
lum, and the medial trochlea should first be ensured.
(j) Placement and temporary fixation of the bone plate:
• Selection of material for internal fixation: An ana-
tomical locking plate of the distal humerus or a
reconstructed plate after shaping in accordance with
the shape of the distal humerus can be used for inter-
nal fixation. The length of the bone plate should
ensure at least 3 screws in the metaphyseal fracture
5 Fracture of the Distal Humerus
Fig. 5.26 A non-locking screw is screwed into each of the most distal
nail holes on the medial and lateral stainless-steel plates
Fig. 5.24 Reduction of the articular surface: In the direction of the
long axis, Kirschner wire can be horizontally placed close to the sub-
chondral cartilage to temporarily fix the articular surface with the
humerus shaft
(k) Fixation of distal fracture fragments:
Fig. 5.25 Kirschner wires are used to temporarily fix the stainless-­
steel plate with the distal bone fragment, the position of the distal frag-
ment relative to the humeral shaft is adjusted, and a unicortical
non-locking screw is screwed into the sliding hole of each stainless-­
steel plate
line proximal, while the proximal ends of the bilat-
eral plates should be at different levels to avoid re-
fractures caused by stress concentration (Fig. 5.26).
• The bone plate is attached to the bone surface
with 2-mm Kirschner wire placed in the nail
145
holes of the medial and lateral epicondyle to tem-
porarily fix the steel plate. The positions of the
articular surface metaphysis in the distal humerus
and the humeral shaft are adjusted to ensure ana-
tomical reduction. Note that the distal humerus
has an anteversion of 40° to the long axis of the
humerus.
• A single cortical non-locking screw is screwed
into the sliding hole of each steel plate, without
tightening, to facilitate later adjustment of the
position.
• A non-locking screw is screwed in each of the
most distal nail holes of the inner and outer sides
of the steel plate (Fig. 5.27).
• The previously mentioned principles should be
followed: the screw should be as long as possible,
pass through as many fracture fragments as pos-
sible, and be fixed to the opposite side of the col-
umn to connect the 2 columns.
• For young people with normal bone quality, a 3.5-­
mm screw can be used. For patients with osteopo-
rosis, a 3.0-mm screw should be used to allow
more screws to be inserted with a greater
interval.
(l) Compression fixation of bilateral supracondylar frac-
ture (Fig. 5.28):
• After loosening the screw in the sliding hole on
1 side of the steel plate, a large resetting forceps
146
Fig. 5.27 After loosening the screw in the sliding hole on the lateral
stainless-steel plate, a large reduction clamp is used to clamp the cortex
in the ipsilateral distal and contralateral proximal shaft to achieve
eccentric compression. Subsequently, in the bone fragment proximal to
a b
Fig. 5.28 (a, b) In the second nail hole of the distal end of each of the medial and lateral stainless-steel plate, a locking screw is inserted after
drilling and tapping. (c) After screw placement on both sides
is used to clamp the cortex in the ipsilateral dis-
tal and contralateral proximal shaft to achieve
the eccentric compression. Note that the posi-
tion of the distal fracture should be maintained
during the compression process. In the proxi-
mal end of the fracture line, the non-locking
screw is screwed in with dynamic pressuriza-
tion, and then the screw in the sliding hole is
tightened.
• Compression is applied on the opposite side in the
same manner.
H. Chen et al.
the fracture line, the non-locking screw is screwed in with dynamic
pressurization. Similar to the above approach, compression is applied
on the medial column
c
Placement of the remaining locking screws
(Fig. 5.29):
• At the second nail hole of the distal end of both
sides, a locking screw is inserted after drilling and
tapping to complete the interlocking of the screw
in the distal joint.
• For patients with osteoporosis, a locking screw
can be placed in the third nail hole on both sides of
the distal end to achieve greater stability.
• The remaining locking screws are placed on both
sides of the humeral shaft to ensure at least 3
5 Fracture of the Distal Humerus
a b
d e
Fig. 5.29 Parallel plate fixation for a Type C1 fracture of the distal
humerus. (a) Postoperative anteroposterior and lateral X-ray images
illustrating the distal humeral fracture. (b) CT coronal-reconstructed
image illustrating a Type C1 fracture with a Y-shaped fracture line. (c)
screws at the distal of the fracture line on both
sides of the steel plate.
2. Reduction and internal fixation techniques using the vertical
steel plate (O’Driscoll 2005; Sanchez-Sotelo et al. 2007):
(a) Reconstructing the articular surface (Fig. 5.30):
• The articular surface is first reset, with temporary
fixation using hollow nail wire.
• All articular surface fragments should be reset as
much as possible. For those without soft tissue
attachment, fixation can be carried out using head-
less screws.
• The hollow nail is placed from the outside toward
the inside, or an ordinary screw is placed parallel
to the guidewire. The placement from the outside
toward the inside ensures that the tail of the screw
does not stimulate the ulnar nerve and does not
conflict with the position of the medial steel plate.
147
c
CT- scan-reconstructed 3D image. (d) Anteroposterior and lateral X-ray
images after parallel plate fixation using the olecranon osteotomy
approach. (e) Follow-up X-ray images illustrating good fracture healing
at 3 months after surgery
If space allows, 2 screws can be placed
simultaneously.
• Compression fixation with the lag screw technique
can be applied only for cases with good bone
quality and satisfactory anatomical reduction of
the joint. In cases with osteoporosis or bone
defect, fixation should be conducted with full-­
thread screws.
• For patients with bone defects, autologous bone
grafts or filling with residual fragments should be
used.
(b) Connecting the reconstructed articular surface with
the metaphysis:
• The reconstructed articular surface is temporarily
connected with the metaphysis using Kirschner wire.
• A reconstruction plate or anatomical locked steel
plate vertically placed in the distal humerus is
used for fixation:
148 H. Chen et al.

Fig. 5.30 (a) The articular

a b
facet is anatomically reset and
temporarily fixed with
Kirschner wires or hollow
nail guidewire. (b) The
hollow nail is placed from the
outside toward the inside, and
if space allows, two screws
can be placed in parallel. (c)
Defected bone can be repaired
by autogenous bone grafting
with fully threaded bone
screws used for fixation, in
which the width of the
trochlea must be restored. (d)
In cases with poor bone
quality, the lag screw
technique used to fix the
articular facet may cause c d
compression on the intra-­
articular bone fragment and a
resulting width decrease of
the trochlea, leading to a poor
prognosis due to contour
damage of the articular facet

–– A 3.5-mm steel reconstruction plate is used
(Fig. 5.31):
Shaping is needed to follow the anatomical
shape of the distal humerus.
For comminuted fractures that are difficult
to reset, an appropriate length steel plate
should be selected for bridging fixation.
If the fracture line is too close to the distal
end, the steel plate must be pre-bent fully
following the angle of the posterior part of
the lateral epicondyle of the humerus and
should be placed as far as possible. In this
case, the larger the coverage of the fracture
by the steel plate, the higher the stability.
However, collision of the distal plate with
the radial capitellum when the elbow is
straight should be avoided.
The steel plate is fixed with the bone frag-
ment of the distal articular surface using
Kirschner wire through the nail hole, with
compression at the metaphysis and the
screw placed at the proximal end of the
fracture.
The medial plate is placed in the medial epi-
condylar crest, with a straight angle to the
lateral steel plate, and the medial column is
fixed. The distal screw should be fixed with
the trochlea through the medial condyle as
far as possible.
–– An anatomical locking steel plate is used
(Figs. 5.32 and 5.33):
The location of the steel plate placement
should receive special attention. The distal
plate must be at least 3 mm from the distal
humerus to avoid limited elbow extension
caused by collision of the radial capitellum
with the distal edge of the plate when the
elbow is straight.
5 Fracture of the Distal Humerus
a b
c d
Fig. 5.31 (a) Two 3.5 mm reconstruction plates are used for medial
and lateral fixation, which are re-shaped according to the anatomical
shape of the distal humerus. (b) If the fracture line is too close to the
distal end, the stainless-steel plate must be pre-bent fully following the
angle of the posterior part of the lateral epicondyle of the humerus and
should be placed as far as possible. However, collision of the distal plate
The relationship between distal fracture
fragments and the humeral shaft is reset,
with temporary fixation by placing a screw
in the sliding hole.
In the lateral nail hole, at least 1 locking
screw is placed. A long screw is preferred,
with a general length of 40–60 mm.
In the distal nail hole, a screw is placed to
fix the humeral capitellum. Usually, 16–­24-­
mm screws are used. When monitoring
elbow activity by fluoroscopy, do not
149
90°
with the radial capitellum when the elbow is straight should be avoided.
(c) The stainless-steel plates are temporarily fixed with Kirschner wires
through the distal nail holes, with compression on the metaphysis and
the screws placed at the proximal end of the fracture. (d) The medial
plate is placed in the medial epicondylar crest at a right angle to the
lateral stainless-steel plate
destroy the articular surface of the humeral
capitellum.
The medial plate is placed in the medial epi-
condyle crest or slightly posterior. The distal
end of the steel plate is appropriately pre-
bent, with 1 edge 31 through the nail hole, to
insert a locking screw of sufficient length.
A screw is placed in the sliding hole to fix
the steel plate. A long locking screw is
placed in the distal end to reach the contra-
lateral trochlea. At least 1 screw is fixed to
150 H. Chen et al.

a b c

Fig. 5.32 (a) Preoperative X-ray image of Type C fracture of the distal Anteroposterior X-ray image of open reduction and fixation with
humerus. (b) Preoperative CT scan-reconstructed 3D image demon- medial and lateral anatomical locking plates using the olecranon oste-
strating the dislocation of the humeral articular surface. (c) otomy approach. (d) Posterior lateral X-ray image
5 Fracture of the Distal Humerus 151

Fig. 5.33 (a) The distal plate

a b
must be at least 3 mm from
the distal humerus to avoid
limited elbow extension
caused by collision of the
radial capitellum with the
distal edge of the plate when
the elbow is straight. (b) The
relationship between distal
fracture fragments and the
humeral shaft is reset, with
temporary fixation by placing
a screw in the sliding hole. (c)
In the lateral nail hole, at least
one locking screw is placed; a
long screw is preferred, with a 3 mm
general length of 40–60 mm.
(d) The medial plate is placed
in the medial epicondyle crest
or slightly posterior. (e) A
c d
screw is placed in the sliding
hole to fix the stainless-­steel
plate. A long locking screw is
placed in the distal end to
reach the trochlea on the
opposite side. At least one
screw is fixed to the bone
fragment on the opposite side
through the locking holes on
the medial and the lateral
distal plates. (f) The
remaining screws are inserted
to ensure that at least three
screws are present at both
ends of the fracture line in the
medial and lateral stainless-
steel plates

e f
152 H. Chen et al.

Fig. 5.34 Case example of

Type C3 fractures of the distal
a b
humerus. (a) Preoperative
X-ray image. (b) Preoperative
CT coronal- reconstructed
image demonstrating
comminuted fractures of the
humeral trochlea. (c)
Preoperative CT-scan-­
reconstructed 3D image
demonstrating remarkable
fracture dislocation. (d) Open
reduction and internal fixation
with vertical plate placement
using the olecranon
osteotomy approach

c d

the contralateral bone fragment through the
locking holes on the medial and the lateral
edges of the distal plate.
The remaining screws are inserted to ensure
at least 3 screws at both ends of the fracture
line in the medial and lateral steel plate.
3. Reduction and fixation techniques for fracture in the cor-
onal plane of the distal humerus (type B3) (Fig. 5.34):
(a) Approach selection:
• For types I-III in the Bryan & Morrey classification
and types I-IV in the David Ring classification, the
expansion of the lateral approach can be used.
• For type IV in the Bryan & Morrey Classification
and type V in the David Ring Classification, the
olecranon osteotomy approach can be selected
(Bryan and Morrey 1985).
(b) Fixation strategy:
• For simple fractures on the coronal plane of the
radial capitellum or humeral trochlear articular
surface (type I and type II in the David Ring clas-
sification), fixation with headless screws can be
applied (Fig. 5.35).
–– The blood clots in the fracture ends, the crushed
bone fragments, and embedded parts in the soft
tissue that cannot be reset are removed. The
joint with non-crushed bone residue should be
confirmed by fluoroscopy.
–– Reduction of the fracture fragments is per-
formed under direct vision. If the reduction
cannot be operated using the fingers due to the
limitation of the surgical incision, a Kirschner
wire can be temporarily placed in the bone as a
rocker to restore the location of the bone
fragments.
–– Temporary fixation of bone is performed with
a fine Kirschner wire, with the use of a guiding
device for sounding and drilling. After sound-
ing, the Kirschner wire can be properly inserted
deeper and even penetrate the contralateral cor-
tical bone. When the hollow drill is withdrawn
after drilling, care should be taken not to bring
out the Kirschner wire.
–– The headless compression screws of appropri-
ate length are screwed in.
5 Fracture of the Distal Humerus
• Coronary plane fractures involving internal and
external condylar fractures (type III and type V in
the David Ring classification) can be fixed with
headless screws and a steel plate (Mckee et al.
1996) (Fig. 5.36).
–– Complex coronal fractures of the articular sur-
face often involve the internal and external con-
dyle, that is, the medial or lateral column
structures. in these cases, in addition to headless
compression screws, a steel plate should also be
used to fix the medial or lateral columns.
–– Fracture fixation in this case is more complex,
and the olecranon osteotomy approach should
be used.
• For compressed fractures (type III and type IV in
the David Ring classification), an intraoperative
bone graft should be applied to maintain the
a b
c d
Fig. 5.35 Open reduction and internal fixation of the coronal fractures
of the humeral capitellum. (a) The blood clots, crushed bone fragments
that cannot be reset, and embedded parts in the soft tissue at the fracture
ends are removed. Fluoroscopy should be applied to confirm the
absence of crushed bone residue in the joint. (b) Reduction of the frac-
ture fragments is performed under direct visualization. If finger-assisted
reduction cannot be performed due to limitations of the surgical inci-
sion, a Kirschner wire can be temporarily placed in the bone as a rocker
to restore the location of the bone fragments. (c) Temporary fixation of
153
shapes of the humeral capitellum and the trochlea.
The bone graft can be collected from the iliac or
ulnar olecranon.
(c) Fixation technique (Elkowitz et al. 2002; Ruchelsman
et al. 2008):
• Biomechanical studies have shown that fixation
with headless screws from front to back is stron-
ger than fixation with lag screws from back to
front.
• Placement of screws from the front allows confir-
mation that the screw does not protrude the articu-
lar surface, and the integrity of the rear structure
of the joint can be protected, with reduced blood
supply damage.
• For relatively large bone fragments of the humeral
capitellum, the long screw can be obliquely placed
and fixed in the medial column.
bone is performed with fine Kirschner wires, with the use of a guiding
device for sounding and drilling. (d) The headless compression screws
of appropriate length are positioned. (e, g) A coronal fracture of the
humeral capitellum (Type B3.1). (e) Preoperative anteroposterior and
lateral X-ray images: Lateral X-ray image demonstrating a remarkable
dislocation of the articular surface of the humeral capitellum. (f)
Postoperative anteroposterior X-ray image: After open reduction, three
headless compression screws are placed to fix the articular surface. (g)
Postoperative lateral X-ray image
154 H. Chen et al.

f g

Fig. 5.35 (continued)

5 Fracture of the Distal Humerus 155

Fig. 5.36 A medial condylar

fracture passing through the
trochlea (Type B2.2)
complicated by a coronal
fracture of the humeral
trochlea (Type B3.2). (a)
Preoperative anteroposterior
and lateral X-ray images
demonstrating a partial
intra-articular fracture starting
from the trochlea of the distal
humerus. (b) Preoperative CT
plain scan and sagittal-­
reconstructed images
illustrating the articular
surface coronal fracture. (c)
Preoperative CT scan-­
reconstructed 3D image. (d)
Open reduction and internal
fixation, with headless screws
for coronal fracture fixation
and lag screws and locking
plates for medial column
a
fixation

b c

d
156
• At least 2 screws at different angles are required
to prevent rotation displacement of the bone
fragments.
Incision Closure
• The ulnar nerve can be moved forward to the subcutane-
ous area, or a new nerve fascia channel can be prepared.
Particularly for patients with preoperative ulnar nerve
symptoms, the sliding of the ulnar nerve to the rear of the
olecranon should be avoided, or numb discomfort will
occur when the elbow contacts hard objects (Fig. 5.37).
• After regular placement of drainage, the incision can be
closed.
Fig. 5.37 A new nerve-passing channel can be prepared using the
common flexor tendon fascia to avoid the backward slide of the ulnar
nerve
a b
Fig. 5.38 Case example of a 56-year-old female patient who received vertical dual-plate fixation for a Type C fracture of the distal humerus. (a)
Postoperative catheterization for subcutaneous brachial plexus block. (b) Functional exercise of the elbow was initiated on postoperative day 1
H. Chen et al.
Postoperative Treatment
• On the first day after surgery, the plaster cast can be removed.
Flexion and extension exercises of the elbow joint can be
performed once daily, with 1 each of extreme flexion and
extension (the exercise time must not exceed 20 min). The
elbow is then immobilized again with a plaster cast, with
long contraction exercise for the biceps and triceps.
• At 2 weeks after surgery, the immobilization is changed
to a hanging triangular bandage, with extreme flexion and
extension exercise at least once daily.
• At 6 weeks after surgery, based on the condition of frac-
ture healing, mild resistance functional exercise can start.
• If the pain is obvious, an appropriate dose of oral non-­
steroidal analgesics or subcutaneous indwelling brachial
plexus blocking analgesia can be provided.
Experience and Lessons
• Injury and hemorrhage of the elbow can easily lead to
heterotopic ossification; therefore, intraoperative hemor-
rhage must be reduced, and intra-articular hematoma
must be completely cleaned up.
• In general, non-steroidal anti-inflammatory drugs are not
used in our hospital to prevent heterotopic ossification.
However, for patients complicated with central nervous
system injury or high-risk patients with delayed surgery
and open fractures, oral indomethacin can be provided
after surgery for the prevention of heterotopic
ossification.
• In the second day after the fixation with osteotomy, func-
tional exercise of the elbow can be started, with catheter-
ization for subcutaneous brachial plexus block (Fig. 5.38).
• For elderly patients with distal humeral fractures
(>65 years), if the fracture was significantly displaced or
severely crushed and it is difficult to maintain stability
5 Fracture of the Distal Humerus 157

after surgery, 1-stage elbow replacement surgery can be
performed (Fig. 5.39).
• For some patients with type C3 fractures, 1-stage
elbow replacement should also be applied when the
articular surface cannot be reconstructed or stable
fixation is not available to meet the needs of early
functional exercise.
5.2.3 Postoperative Complications and Their
Prevention and Treatment
• After internal fixation for the distal humeral fracture,
the common complications include limited elbow
movement, non-healing fracture, deformity healing of

Fig. 5.39 Case example of a

a b
75-year-old female patient
who received the first-stage
elbow replacement surgery
for comminuted fractures of
the humeral condyle
complicated by a fracture of
the radial capitulum. (a, b)
Preoperative anteroposterior
and lateral X-ray images
illustrating comminuted
fractures of the humeral
condyle at a relatively low
position, complicated by a
radial capitulum fracture. (c,
d) Postoperative
anteroposterior and lateral
X-ray images after first-stage
elbow replacement surgery

c d
158
a b
Fig. 5.40 For patients with osteoporosis or supracondylar bone loss
caused by crushing fractures, stable connection of the metaphysis and
diaphysis can be achieved with appropriate bone shortening. (a)
Trimming of the distal fracture fragment of the humeral shaft. (b) After
bone shortening, the metaphyseal portion can be connected to the
humeral shaft through the parallel plate or vertical plates
the fracture, nerve injury, and damage of the elbow
extension device.
• Anatomical reduction of fracture:
–– Anatomical reduction (including articular surface
morphology and correct force line) can prevent insta-
bility of the elbow joint, restore the internal stability of
the elbow, and reduce the burden on the internal fixa-
tion, which allows early full functional exercise. It is
the core component for preventing postoperative lim-
ited elbow activity.
–– The integrity of the articular surface: For patients with
osteomalacia of the articular surface, the use of com-
pression screws in the horizontal direction is erroneous
and will cause a narrower width of the humeral troch-
lea, humeral capitellum, or both, resulting in limited
elbow movement and traumatic arthritis. The correct
approach is to attempt to restore the location of the
small bone fragments with fixation using a headless
screw or Kirschner wire, and then the fully threaded
screw in the horizontal direction can be used for
fixation.
• Fixation of the metaphysis and diaphysis: For patients
with osteoporosis or supracondylar bone loss caused by
crushing fractures, stable connection of the metaphysis
and the diaphysis can be achieved with appropriate short-
ening, and then the metaphyseal portion can be connected
to the humeral shaft through the parallel plate or vertical
plate (Fig. 5.40); The literature shows that metaphyseal
H. Chen et al.
shortening of 1 cm will only have a mild effect on triceps
strength (Hughes et al. 1997).
• The selection of the implant: An implant with adequate
strength should be selected for internal fixation to avoid
early internal fixation failure. The common choice is the
combination of a compression steel plate and steel recon-
struction or the application of parallel and vertical com-
pression plates or locking plate; the strength of 1/3 of the
pipe plate is insufficient and may lead to failure of the
internal fixation.
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 Fracture of the Proximal Ulna
Hua Chen, Zhe Zhao, and Wei Zhang
6.1 Basic Theory and Concepts
6.1.1 Overview
• Fractures in young patients are mostly caused by high-­
energy trauma, whereas those in elderly patients are
mostly due to falling injury.
• There are two basic types of proximal ulna fractures, and
surgery is needed in most cases:
–– Olecranon fracture, accounting for approximately 10%
of elbow injury (Karlsson et al. 2002).
–– Coronoid process fracture, accounting for 10–15% of
the elbow injury. Its combination with injury in other
parts often suggests elbow instability (Rommens et al.
2004).
• The half-moon shaped notch of the proximal ulna is the
most important stable bone structure of the elbow, so the
treatment goals for proximal ulna fractures are anatomical
reduction to restore the proximal ulnar articular surface
with the half-moon shaped notch, restore the length of the
half-moon notch, and strengthen the internal fixation,
thus allowing early postoperative functional exercise
(Terada et al. 2000).
6.1.2 Applied Anatomy
• Elbow extension device: The elbow extension-related
muscles are the triceps and elbow muscle, in which the
triceps plays a major role.
–– The proximal part of the triceps has 3 starting points.
The long head of the triceps originates from the infra-
glenoid tubercle of the scapula. The lateral head begins
H. Chen (*) · W. Zhang
Chinese PLA General Hospital, Beijing, China
e-mail: chenhua0270@131.com
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_6
6
at the lateral humeral shaft, and the medial head begins
at the bottom of the radial nerve.
–– The distal triceps converges into a common tendon and
terminates at the olecranon. The distance from the ten-
don attachment point to the rotation center is the arm
of the elbow extension device. Based on mechanical
fluoroscopy, in the partial resection of ulnar olecranon,
the triceps ending point should be reconstructed at the
posterior margin far from the articular surface, rather
than the articular margin close to the articular surface;
otherwise, the arm of the triceps will be shortened,
thus affecting the power of the elbow.
–– The efficiency of the triceps muscle is different for dif-
ferent elbow flexion positions (Fig. 6.1):
For complete extension, the force of the muscle can
be divided into the component in the elbow exten-
sion direction and the component pointing to the
dorsal side of the rotation center (this component
has no effect on the elbow extension movement).
For partial flexion: In flexion of 20–30°, all muscle
strength is used to complete the elbow flexion, and
the efficiency is highest at this time; in further
elbow flexion, the muscle strength can be divided
into the component in the elbow extension direction
and the component pointing to the rotation center
(this component has no effect on the elbow exten-
sion movement). As the angle of elbow flexion
increases, the proportion of this component gradu-
ally increases, while the efficiency of the triceps
muscle is reduced.
For complete flexion, the triceps tendon reflexes in
the posterior olecranon and distal humerus, and this
anatomical structure provides a sufficiently long
force arm to reduce the loss of the efficiency of the
triceps muscle.
• Anatomy of the coronoid process and the attachment of
the surrounding articular capsule, ligament, and muscle
(Fig. 6.2):
161
162 H. Chen et al.

Fig. 6.1 (a) In full elbow

a T b T
extension, the force of the
triceps can be divided into the
component in the elbow
extension direction and the
component pointing to the
dorsal side of the rotation
center. (b) In flexion of
20°–30°, all muscle strength
is used to complete the elbow C
flexion, reaching the highest
efficiency. (c) In further elbow
flexion, the muscle strength
can be divided into the
component in the elbow
extension direction and the
component pointing to the
rotation center. As the angle
of elbow flexion increases, the
efficiency of the triceps
muscle is reduced. (d) In full
elbow flexion, the triceps
tendon reversely folds at the
posterior olecranon and distal
humerus, and this anatomical
structure provides a c d
sufficiently long force arm to
reduce the loss of efficiency
of the triceps muscle
T

–– The partial anterior articular capsule is attached a
few millimeters below the tip of the coronal and thus
in coronoid process fracture, this bone may be
attached to the torn articular capsule and isolated in
the articular capsule. Surgical repair should be per-
formed in this case (Bucholz and Court-Brown
2010).
–– The anterior bundle of the medial collateral ligament is
attached to the medial side of the base of the coronoid
process and is one of the most important stable struc-
tures in the medial elbow joint. If the bone fragment in
the base of the coronal fracture is large or the fracture
involves the anteromedial surface of the coronoid pro-
cess, the anterior bundle of the medial collateral liga-
ment at this area will be damaged, resulting in elbow
instability caused by ligament failure. In this case, sur-
gery should be performed to fix the ligament attach-
ment and restore the stability of the elbow (Cage et al.
1995).
–– The brachial muscle ends at the front of the distal coro-
nal base, with a large range of ending points. Fracture
involving the base of the coronoid process will involve
this muscle ending point. However, regardless of how
large the bone fragment is, it is difficult to damage all
ending points of the brachial muscle. Part of the bra-
chial muscle will still be attached to the ulnar bone.
Thus, coronal fractures may not be avulsion fractures
caused by brachial contraction.
6 Fracture of the Proximal Ulna
a with a protrusion in the middle and depressions on the
b
attachment points anterior bundle of the medial
of the brachialis collateral ligament
• Comparison of several fixation methods for olecranon
Fig. 6.2 Anatomy of the coronoid process and attachment of the sur-
rounding joint capsule, ligament, and muscle. (a) Schematic diagram of
the medial proximal ulna illustrating the attachment points of the bra-
chialis and anterior bundle of the medial collateral ligament. (b)
Schematic diagram of the anterior proximal ulna illustrating the attach-
ment points of the brachialis and anterior joint capsule
• The correlation between the anatomical structure of the
semicircular notch of the proximal ulna and the stability
of the elbow:
–– The length of the semicircular notch of the proximal
ulna and the stability of the elbow (Fornalski et al.
2003) (Fig. 6.3).
When the olecranon fracture is severely commi-
nuted and cannot be reconstructed, elbow extension
function is usually restored by using the partially
resected olecranon to reconstruct the ending point
of the triceps. However, if the scope of olecranon
resection is greater than 50%, the length of the
semicircular notch will be too short, thus affecting
the stability of the elbow, and elbow dislocation
may easily occur in elbow flexion.
When the coronoid process fracture is >50%, the
ulnar angle of the opening should be measured (the
angle between the connecting line from the olecra-
non tip to the coronoid process and the long axis of
the ulnar shaft; the normal value is >30°). If this
angle is reduced to 0°, the stability of the elbow will
be seriously affected, easily leading to dislocation
of the elbow (Bucholz and Court-Brown 2010).
–– The anatomical morphology of the articular surface
with the semicircular notch in the proximal of the ulna
and the stability of the elbow: The section of the semi-
circular notch shows a unique anatomical morphology
163
2 sides that matches the notch of the humeral trochlea.
This specific anatomical structure provides internal
stability for the elbow joint against the internal and
external valgus. Studies have shown that resection of
1/4 of the olecranon will reduce elbow valgus resis-
tance stability by 50%; in elbow extension, the humer-
oulnar joint provides 55% of the varus resistance; in
90° flexion, it provides 75% of the varus resistance
(O'Driscoll et al. 2003).
–– The basic requirement for the treatment of proximal
ulna fractures is anatomical reduction of the articular
surface while restoring the length of the semicircular
notch of the ulna.
fractures: The specific features of the anatomical structure
and biomechanics of the ulnar olecranon determine the
diversity of surgical methods. At present, the most com-
mon surgical method is Kirschner wire tension band fixa-
tion and plate-screw internal fixation (Ring et al. 1998)
(Fig. 6.4).
–– Resection of olecranon bone: As mentioned above,
bone resection may affect the elbow extension force
and elbow stability, and thus resection of the olecranon
should be avoided if possible. This procedure should
not be considered unless internal fixation is not possi-
ble with severely comminuted bone (Fyfe et al. 1985).
–– Fixation technology with wire cerclage: Wire cerclage
fixation is an ancient fracture fixation technology. In
this surgical method for fracture fixation, holes are
punched in the proximal and distal ends of the fracture
for wire cerclage. Because this technique is not consis-
tent with the principle of the tension band, it cannot
effectively resist the tension of the brachialis and tri-
ceps, often resulting in fracture separation; conse-
quently, this method is no longer in use.
–– Non-interlocking intramedullary nail and intramedul-
lary lag screw technique: As for the wire fixation tech-
nology, these 2 methods are limited in their ability to
provide adequate stability, and gypsum-assisted fixation
is needed. The triceps tension often generates a gap on
the dorsal side of the fracture, resulting in fracture sepa-
ration, articular surface gap, and fracture re-­displacement
and eventually leading to fixation failure.
–– Kirschner wire tension band technique: The tension
band technique can be used to convert the tensile stress
caused by the triceps muscle contraction into compres-
sive stress, with reliable fixation and less soft tissue
damage in the surgical process, which is conducive to
bone healing. A disadvantage is that the soft tissue
around the olecranon is poorly covered, resulting in
complications of pain and exposure caused by the pro-
truding internal fixation (An et al. 1986).
164
a
b
Fig. 6.3 Schematic diagram illustrating the correlation between the
anatomical structure of the semicircular notch of the proximal ulna and
the stability of the elbow (red arrow: the flexion direction of the triceps;
blue arrow: the flexion direction of the brachialis; green arrow: the dis-
location direction of the elbow joint). (a) In the partial resection of the
olecranon and reconstruction of the ending point of the triceps for treat-
ing comminuted olecranon fracture, it is necessary to preserve the ulnar
–– Plate-screw internal fixation technique: When the
olecranon fracture is severely comminuted, especially
comminuted fracture involving the olecranon base, if
good support between the bone fragments cannot be
achieved, the gap between the bone fragments will fur-
ther decrease after fixation with the tension band,
resulting in a decrease in the length or opening angle
of the ulnar half-moon notch and affecting the flexion
and extension function of the elbow. Plate fixation can
effectively maintain the location of the bone fragment
and reduce the reduction loss caused by the decreased
length or opening angle of the ulnar half-moon notch.
A 1/3 tube plate was once commonly used for fixation,
but due to its weak fixation strength, complications
such as fatigue fracture of the plate and secondary
fracture may occur. In recent years, a proximal ulnar
H. Chen et al.
>30°
olecranon as long as possible because posterior dislocation of the elbow
may easily occur in elbow flexion if the olecranon is too short. (b) The
opening angle of the ulnar—the angle between the connecting line from
the olecranon tip to the tip of the coronoid process and the long axis of
the ulnar shaft, which should normally be>30°. (c) When the coronoid
process fracture is >50%, anterior dislocation of the elbow joint may
easily occur during elbow extension
anatomical locking plate has been developed. The
design of this plate includes an angle between the
screw and steel that allows the screw to pass through
and fix as many bone fragments as possible. The lock-
ing mechanism between the plate and screw enhances
the overall holding force among the bone fragment,
screw, and steel. Plate fixation can obtain satisfactory
results even in some olecranon fractures with serious
comminution (Heim 1991).
–– A biomechanical study by Wilson et al. (2011) showed
that, in the fixation of transverse ulnar olecranon frac-
ture, compared with the steel plate tension band, the
Kirschner wire tension band generated significantly
lower pressure on the fracture ends under both static
and dynamic conditions. In the dynamic test, the
Kirschner wire tension band could not convert the ten-
6 Fracture of the Proximal Ulna
a b
Fig. 6.4 (a) Kirschner wire tension band fixation for ulnar olecranon
fracture: This method is suitable for simple fractures, through which the
fracture fragments can support each other and are compressed by the
tension band. (b) Plate-screw internal fixation technique for ulnar olec-
ranon fracture: This method is suitable for severe olecranon commi-
nuted fractures, especially comminuted fractures involving the base of
the olecranon. Regular plate fixation with screws passing through frac-
ture fragments can avoid the decrease in length or opening angle of the
ulnar semilunar notch caused by piling and compression among frag-
sion into pressure; instead, the pressure on the articular
surface of the fracture ends was further reduced, in
opposition to the traditional principle of the Kirschner
wire tension band (Closkey et al. 2000).
6.1.3 Mechanisms of Injury
• Direct violence:
–– External force acting directly on the elbow, causing
olecranon fracture and dislocation (Fig. 6.5):
The elbow hits the ground to receive the direct vio-
lence, and the stress passes from the olecranon to
the distal humeral trochlea. The reaction force gen-
erated in the distal humerus directly hits the olecra-
165
ments, thus effectively maintaining the location of the bone fragment.
(c) Proximal ulnar anatomical locking plate technique: This method is
suitable for internal fixation for treating severe olecranon comminuted
fractures. The design of this plate includes an angle between the screw
and plate that allows the screws to pass through and fix as many bone
fragments as possible. The locking mechanism between the plate and
screws enhances the overall holding force among the bone fragments,
screws, and plate
non as a pile driver, resulting in ulnar olecranon
fracture and elbow dislocation. Different positions
of the elbow joint in the violent injury may result in
different types of fractures of the olecranon, as well
as associated injuries, such as coronoid process and
radial head fractures (Rommens et al. 2004;
Nowinski et al. 2000).
When the elbow receives direct violence in flexion,
the distal humeral trochlea will strike the olecranon
body, resulting in simple olecranon fracture, as
indicated by a shift of the forearm to the palm side.
The injury often involves the humeroulnar joint and
rarely involves the radial structure, including
injuries in the proximal radioulnar joint, radial
­
head, and radial collateral ligament.
166
a b
Fig. 6.5 Olecranon fracture and dislocation. (a) When the elbow
receives a violent impact during flexion, the distal humeral trochlea will
strike the body of the ulnar trochlear notch, resulting in olecranon frac-
ture, as indicated by a shift of the forearm to the volar side. The injury
rarely involves the ulnoradial joint, radial head, and radial collateral
ligament. (b) When the elbow receives a violent impact during full
When the elbow receives direct violence in exten-
sion, the distal humeral trochlea will directly hit the
intersection of the olecranon and the base of the cor-
onoid process, resulting in double fractures in the
olecranon and the coronoid process. Collision of the
humeral capitellum with the radial head can also lead
to radial head fracture. The specific direction of vio-
lence often leads to fracture collapse on the articular
surface. In surgery, the olecranon, coronoid process,
and radial head fracture should be fixed, and the col-
lapse of the articular surface should be restored. The
operation is difficult, and the prognosis is poor.
Some olecranon fractures may extend to the ulnar
shaft, that is, proximal ulnar comminuted fractures,
and will require steel plate fixation and other spe-
cial solutions.
• Indirect violence:
–– The hand hits the ground when falling, and thus the
violence is transmitted from the forearm to the elbow
to cause indirect injury instead of directly acting on the
elbow. At the moment of injury, depending on the for-
ward or backward rotation of the forearm, the flexion
or extension position of the elbow joint, and the flexion
angle of the elbow, different anatomical parts of the
elbow joint will receive different degrees and nature of
mechanical load, resulting in various types of injury
and dislocation in the elbow, such as coronoid process
fracture, radial head fracture, posterolateral rotation
injury, and posteromedial rotation injury.
H. Chen et al.
extension, the distal humeral trochlea will directly hit the intersection of
the olecranon and the base of the coronoid process, resulting in double
fractures in the olecranon and the coronoid process. Collision of the
humeral capitellum with the radial head can also lead to radial head
fracture
–– When the hand hits the ground with an elbow flexion
angle of <20°, the axial load passes to the elbow
through the forearm, and thus the coronoid process
bears greater stress, which can lead to simple coronal
fracture (Horne and Tanzer 1981). When the hand hits
the ground with an elbow flexion angle >30°, the
humeroradial joint will bear a greater load, leading to
radial head fracture.
–– Posterolateral rotation injury can cause elbow disloca-
tion and injury of the surrounding soft tissue. If the
elbow bears the stress at the valgus position, radial
head fracture and coronal fracture may occur, resulting
in instability in posterolateral rotation (refer to the
related sections for radial head dislocation and triad of
the elbow).
O’Driscoll et al. have described the mechanism of
posteromedial rotation injury (Bucholz and Court-­
Brown 2010).
The arm is extended when falling, and the forearm
is in the forward rotation position. Consequently,
the forces of axial direction, varus, and forward
rotation are all on the elbow, causing a series of
injuries.
This type of injury can cause subluxation of the
elbow. The stress on the lateral coronoid process
can lead to compression fracture of the anterome-
dial coronoid process. The tension and stress on the
lateral elbow can also be combined with lateral col-
lateral ligament injury (Fig. 6.6).
6 Fracture of the Proximal Ulna 167

Fig. 6.6 (a) Schematic

a
diagram illustrating a
posteromedial rotation injury:
When falling with the arm
extended and the forearm in
the forward rotation position,
the forces of the axial
direction, varus deformity,
and forward rotation are all on b
the elbow. Consequently, the
stress on the medial coronoid
process can lead to
compression fracture, and the
tension and stress on the
flexion
lateral elbow result in lateral
collateral ligament injury,
which can further cause
posteromedial rotation flexion
instability of the elbow. (b) varus
CT scan of posteromedial
rotation injury of the elbow
joint demonstrating an axial load pronation
anteromedial compression
fracture of the coronoid
process and avulsion of the
lateral collateral ligament
ending point. (c) A mini
supporting plate is used to
internally fix the coronoid
process fracture, and suture
rivets are used to repair the c
tear in the lateral collateral
ligament

olecranon avulsion fracture caused by sudden contrac-

6.1.4 Classification of Fractures
• Schatzker classification of ulnar olecranon fractures
(Fig. 6.7): This classification method is relatively simple
and can guide the operation of the ulnar olecranon frac-
ture and the selection of internal fixation. According to
the fracture morphology, ulnar olecranon fractures are
divided into 6 types:
–– Type A: Transverse fracture generally occurs in the
deepest half-shaped notch. This fracture can be ulnar
tion of the triceps muscle or by direct hit of the olecra-
non to the ground when falling.
–– Type B: Complex transverse fracture, transverse frac-
ture associated with comminution or compression of
the articular surface.
–– Type C: Oblique fracture, mostly caused by elbow
excessive flexion. The fracture extends from the coro-
noid process of the half-moon shaped notch distally.
–– Type D: Comminuted fracture, often caused by high
violence directly on the elbow. In addition to commi-
168 H. Chen et al.

a b c

d e

Fig. 6.7 Schatzker classification of ulnar olecranon fractures. Type
(a): transverse fractures that generally occur in the apex of the semilu-
nar notch; Type (b): complex transverse fractures, which refer to trans-
verse fractures complicated by comminution or compression of the
articular surface; Type (c): oblique fractures, which are mostly caused
by elbow excessive flexion and extend distally from the coronoid pro-
cess of the semilunar notch; Type (d): comminuted fractures of the
olecranon with or without coronal fractures; Type (e): oblique fractures
of the distal ulnar olecranon, which involve the distal part after the
middle point of the semilunar notch; Type (f): ulnar olecranon fractures
complicated by radial head fracture and elbow dislocation

nuted fracture of the olecranon, it can also be com-

bined with coronal fracture.
–– Type E: Oblique fracture of the distal ulnar olecranon.
This fracture involves the coronoid process of the half-­
moon shaped notch extending to the ulnar shaft. In
contrast to the C-type fracture, this type of fracture
bears greater stress on the fracture ends.
–– Type F: Radial head fracture with elbow dislocation,
often accompanied by rupture injury of the medial col-
lateral ligament. The olecranon, radial head, and I

medial collateral ligament must be reconstructed. II

• Regan and Morrey classification of coronal fractures III
(Fig. 6.8): The classification is based on the extent of cor-
onoid process involvement of the fracture. The larger the
involved coronoid process, the greater its impact on the
stability of the elbow (Schatzker 2005).
–– Type I: Avulsion fracture in the tip of the ulnar coro-
noid process.
–– Type II: Single or comminuted fracture involving no Fig. 6.8 Regan and Morrey classification of ulnar coronoid fractures.
more than 50% of the coronoid process. Type I: avulsion fractures in the tip of the ulnar coronoid process. Type
II: single or comminuted fractures involving no more than 50% of the
–– Type III: Single or comminuted fracture involving coronoid process. Type III: single or comminuted fracture involving
more than 50% of the coronoid process. more than 50% of the coronoid process
6 Fracture of the Proximal Ulna
tip
anteromedial
basal
Fig. 6.9 O’Driscoll classification of ulnar coronoid fractures (view of
the proximal ulnar from the distal side, the marked fracture lines denote
the fracture sites of each fracture type). Type I fractures involve only the
tip of the coronoid process, Type II fractures involve the anteromedial
coronoid process with or without affecting the tip of the coronoid pro-
cess, and Type III fractures involve the base of the coronoid process
• O’Driscoll classification of coronal fractures (Fig. 6.9): In
2003, on the basis of the Regan and Morrey classification,
O’Driscoll et al. emphasized the importance of the ante-
rior medial side of the coronoid process and divided coro-
nal fractures into 3 types (Bucholz and Court-Brown
2010):
–– Type I: Fracture in the tip of the coronoid process.
–– Type II: Fractures in the anterior medial of the coro-
noid process.
–– Type III: Fracture in the basement of the coronoid
process.
–– The subtyping of this classification is not described
in detail here, but it should be noted that the anterior
medial side of the coronoid process is the attach-
ment point of the medial collateral ligament, and
fractures at this location often cause failure of the
medial collateral ligament and thus warrant particu-
lar attention.
6.1.5 Assessment of Proximal Ulna Fractures
6.1.5.1 Clinical Assessment
• Typical manifestations: The affected elbow is often in
flexion position, commonly held by the hand on the con-
tralateral healthy side. The area around the elbow is swell-
169
ing, and the swelling is often more obvious in the rear of
the elbow. Subcutaneous bleeding or bruising can be
observed in the affected area.
• While examining the elbow, an empty feeling, abnormal
activities, and elbow flexion and extension dysfunction
suggest fracture or dislocation.
• Examining elbow stability: For patients with no fracture
shown in X-ray, a stress test should be performed with the
varus and valgus of the elbow. Pain and instability suggest
damage in the ligament and other soft tissue.
• For patients with pain in the forearm and wrist, tenderness
between the ulna and radius and the presence of instabil-
ity in the distal radioulnar joint should be further assessed
to prevent misdiagnosis of combined injury of the radio-
ulnar interosseous membrane (Essex-Lopresti fracture)
and the distal radioulnar joint.
• Neurological function: The sensory function of the ulnar
nerve innervation and motor function should be checked
for early detection of ulnar nerve injury (Regan and
Morrey 1989).
6.1.5.2 Imaging Assessment
• X-ray examination:
–– A conventional scan of the elbow joint at the antero-
posterior, lateral, and oblique positions can basically
reveal the scope of the fracture, the degree of commi-
nution, and the involvement of the articular surface.
The scope of the radiograph should be the X-ray of the
full-length forearm including the elbow to clarify the
dislocation of the radial head and injury in the distal
radioulnar joint.
–– In fracture of the medial coronoid process, the frac-
ture fragments are often small, and thus missed diag-
nosis might occur in regular X-ray scanning.
Observation of the double cortical line sign in the
coronoid process during scanning in the lateral posi-
tion suggests possible avulsion fracture in the antero-
lateral coronoid process caused by posteromedial
rotation injury.
• CT examination:
–– Patients with suspected intra-articular fractures
should receive CT scan and 3-dimensional recon-
struction of the elbow joint to clarify the intra-articu-
lar fracture.
–– In particular, anterolateral fracture of the coronoid pro-
cess is not easy to identify by conventional X-ray
examination. CT scan and 3-dimensional reconstruc-
tion can reveal occult fractures, thus reducing the rate
of missed diagnosis (Fig. 6.10).
170
a b
Fig. 6.10 A fracture of the medial ulnar coronoid process. (a) In the
anteroposterior radiographic image of the elbow joint, the cortex of the
anteromedial coronoid process appears slightly rough, and the presence
of fractures is uncertain, leading to a high risk of a missed diagnosis.
(b) The lateral radiographic image demonstrates the coronoid process
with dual cortical patterns, indicating an anteromedial fracture of the
6.2 Surgical Treatment
6.2.1 Ulnar Olecranon Fracture
Surgical Indications
• For ulnar olecranon fracture with small displacement,
articular surface step or separation <2 mm, and minor
injury of the surrounding soft tissue, function after frac-
ture healing is good, and thus external fixation and other
conservative treatment can be applied.
• In general, the tension of the triceps can cause obvious
displacement of the proximal fracture fragment, and most
olecranon fractures involve the articular surface, often
with articular surface step and fracture separation dis-
placement of greater than 2 mm. Consequently, open
reduction or internal fixation is needed in this case.
Purpose of Surgery
• To restore the anatomical morphology of the articular sur-
face with the semicircular notch in the proximal ulna, to
restore the length of the olecranon, to implement strong
internal fixation, and to allow early postoperative func-
tional exercise.
H. Chen et al.
c
coronoid process. (c) The CT scan-reconstructed 3D image of the
elbow joint clearly demonstrates the size and dislocation of the fracture
fragments of the anteromedial coronoid process
Position and Preoperative Preparation
• Brachial plexus anesthesia or general anesthesia.
• The hemostatic belt is placed in the upper arm. The loca-
tion of the belt should be as high as possible to fully
expose the surgical area and facilitate the operation.
• The patient is supine on the surgical bed, and the forearm
is placed on the arm holding plate by the chest (Fig. 6.11).
• C-arm fluoroscopy is used to monitor the reduction and
fixation of the fracture.
Operative Incision According to the Projection on the
Body Surface
• An incision is created in the middle of the posterior elbow,
and the length of the incision is determined according to
the required exposure scope of the surgery. The incision
extends from the proximal end of the forearm along the
ulna to the proximal end, passing the tip of the ulnar olec-
ranon and ending at 3 cm above the olecranon (Fig. 6.12).
Under normal circumstances, the incision often passes the
olecranon by the lateral ulna to facilitate exposure of the
ulnar nerve when necessary. The incision avoiding the
olecranon tip can reduce the formation of scar tissue, thus
reducing postoperative discomfort due to the surgical
6 Fracture of the Proximal Ulna
b
Fig. 6.11 Position during surgery for ulnar olecranon fracture: The
patient is supine on the surgical bed, and the forearm is placed on the
arm holding plate in front of the chest. (a) Longitudinal view. (b)
Sideview
incision (Bucholz and Heckman 2001; Gartsman et al.
1981).
Surgical Approach
• The skin and subcutaneous tissue are cut along the projec-
tion of the incision on the body surface to expose the elbow
muscles, extensor carpi ulnaris, and flexor carpi ulnaris.
• The deep fascia between the elbow muscle, the extensor
carpi ulnaris muscle, and flexor carpi ulnaris is cut to sep-
arate the underlying periosteum to expose the olecranon.
• The fracture line is usually separated after elbow flexion.
The proximal fracture fragment can be flipped to observe
the fracture displacement and collapse of the articular sur-
face (Fig. 6.13).
• Incarcerated soft tissue and blood clots in the fracture
ends are cleared.
Reduction and Fixation
• The appropriate reduction and fixation technique is
selected according to the Schatzker classification of the
ulnar olecranon fracture (Dowdy et al. 1995):
171
triceps tendon
over olecranon
Fig. 6.12 The incision extends longitudinally along the medial subcu-
taneous margin of the ulna toward the proximal end, passing around the
tip of the ulnar olecranon and ending 3 cm above the olecranon
–– Type A: The fixation technique of the standard
Kirschner wire and tension band is usually used.
–– Type B: The reduction and fixation of the articular sur-
face with collapse is the key component of the surgery.
To avoid further damage to the blood supply of the
fracture fragment, the bone fragment in the articular
surface for reduction should be lifted together with the
cancellous bone below the fracture using a periosteal
stripper. Bone graft should be performed for the bone
defect remaining below to prevent recurrence of col-
lapse of the articular surface. A slight over-reset can
also be done to compensate the reduction loss when
the joint is running in. If the bone fragments cannot be
stabilized, the Kirschner wire for temporary fixation
can also be left in place.
–– Type C: Compression between the fracture fragments
is applied by a lag screw, and a tension band or plate is
needed for auxiliary fixation; otherwise, the fixation
strength will not be sufficient to meet the needs of
early functional exercise (Fig. 6.14).
–– Type D: For proximal ulnar comminuted fracture,
some patients can achieve stability after fracture reduc-
tion, allowing axial compression and stabilization, and
thus tension band technology or a steel plate can be
172
extensor digliorum communis extensor digiti minimi
a
extensor carpi radialis brevis
common extensor origin
extensor carpi radialis longus
brachioradialis
lateral intermuscular septum
brachialis
posterior antebrachial
cutaneous n.
anconeus
ulnar n.
medial epicondyle
triceps tendon
medial head of triceps
long head of triceps
Fig. 6.13 (a) After the skin and subcutaneous tissue are cut, the exten-
sor carpi ulnaris and flexor carpi ulnaris are identified, and the subperi-
osteal stripping is made from the space between the two muscles to
used for fixation. In other patients, it is difficult to
obtain stability by fracture reduction, and thus steel
plate fixation is recommended to better maintain the
reduction of bone, thereby reducing reduction loss
caused by shortening of the gap between bone frag-
ments. The reduction order should be from the distal
end to the proximal end. For coronal fractures, lag
screws can be used for fixation, followed by reduction
for the olecranon and distal ulna. If the fracture frag-
ment of the coronoid process is large, auxiliary reduc-
tion forceps can also be used for the reduction.
Kirschner wire can be used for temporary fixation, and
then a lag screw can be used for fixation from the back
of the ulna by the plate.
–– Type E: In contrast to type C fracture, the fracture line
extends by the coronoid process to the ulnar shaft and
rarely involves the medial and lateral collateral liga-
ment. The elbow and olecranon bone thus become 1
piece, and the fracture ends are consequently subject to
greater rotation and varus and valgus stress. Tension
band technology can only provide 1-way stability for
pulling of the triceps, which is not sufficient to resist
against a large rotational stress. Thus, steel plate screw
fixation technology should be used.
H. Chen et al.
extensor carpi ulneris
aponeurosis over flexor
digitorum protundus
flexor carpi ulnaris
b
expose the olecranon. (b) Along the separated fracture line, the proxi-
mal fracture fragment can be flipped to observe the fracture displace-
ment and collapse of the articular surface
–– Type F: The fracture is characterized by radial head
fracture with elbow dislocation, which may be associ-
ated with medial collateral ligament injury.
Reconstruction of the olecranon fracture and radial
head fracture is needed, and repair of the medial col-
lateral ligament injury should be considered.
• Kirschner wire and tension band fixation for olecranon
fractures (Stanley and Trail 2012) (Fig. 6.15):
–– A hole with a diameter of 2 mm is drilled 40 mm from
the fracture site and 5 mm from the posterior cortex for
insertion of the tension band steel wire. The position of
the hole and its distance to the fracture line are contro-
versial. The above is the AO technology. In addition,
J. Schatzker et al. suggested that the hole can be drilled
at roughly the same distance as the distance from the
fracture line to the tip of the olecranon, so that an
8-shaped intersection is located near the fracture line
to maximize stability after fixation of the fracture.
–– A pointed reduction forceps can be used to maintain
the reduction of the fracture fragment.
–– From the ending point of the triceps, 2 1.6.mm
Kirschner wires are placed in parallel from the back of
the ulna toward the lateral palm side of the ulna. The
Kirschner wire should attach to the articular surface as
6 Fracture of the Proximal Ulna
close as possible, so that the Kirschner wire passes
through the fracture line near the half-moon notch,
thus increasing the holding force of the tension band.
After the Kirschner wire passes through the palm side
of the cortex, the length of the Kirschner wire should
be adjusted under fluoroscopy to maintain a distance
of 1 cm from the tip of the wire to the piercing point of
the cortex at the palm side of the ulna. This is the dis-
tance for final fixation by the Kirschner wire.
–– Fixation with an 8-shaped tension band is usually per-
formed by tightening and compression on both sides
simultaneously to ensure pressure balance on both sides.
a b
c
Fig. 6.14 Kirschner wire and tension band fixation for olecranon
fractures (a) A 2 mm-diameter hole is drilled 40 mm distal to the frac-
ture line and 5 mm from the posterior cortex. A pointed reduction
clamp is used for fracture reduction. Next, a 1.6 mm Kirschner wire is
inserted from the back of the ulna toward the volar side of the ulna and
positioned as close as possible to the articular surface, so that the
Kirschner wire passes through the fracture line near the semilunar
notch. After the Kirschner wire passes through the volar bone cortex, it
is pulled back by 1 cm. (b) A 1.0 mm-diameter wire with a pre-twisted
ring at approximately 1/3 is inserted through the distal bone tunnel.
The second Kirschner wire is inserted in parallel to the first one. (c) On
the proximal side, a trocar is used to assist the stainless-steel wire pass-
ing through the deep layer of the triceps tendon on the proximal side of
173
Two steel wires with a diameter of 1.0 mm are usually
used for the compression fixation. If a wire with a diam-
eter of 1.0 mm is used, it is necessary to pre-twist a ring
at approximately 1/3 of the proximal end for simultane-
ous tightening and compression on both sides.
–– The tension band steel wire must pass through the
deep layer of the triceps tendon for fixation to reduce
stimulation and damage of the triceps tendon. Upon
completion of this operation, a thick trocar can be
passed through the triceps tendon. After first passing
the trocar through the triceps tendon, a guidewire can
be passed through after pulling out the core needle.
d
the Kirschner wires, and the wire is twisted into an “8” shape. (d, e) A
thick needle is used as a guide trocar to assist the passage of the wire
through the triceps tendon. (f) Both sides of the wire are simultane-
ously twisted and tightened with pliers for compression. (g) The two
wire knots are cut to shorten the tail and then bent to reduce the soft
tissue stimulation. (h) The two Kirschner wires are cut until only a
length of 2 cm is left outside the bone cortex and folded 180° from the
middle point (1 cm away from the bone cortex). Finally, the tails of the
Kirschner wires are hammered into the proximal cortex of the olecra-
non to prevent withdrawal of the wires and reduce stimulation of the
surrounding soft tissue. (i) The incision in the triceps tendon above the
tails of the Kirschner wires is sutured to avoid soft tissue disturbance
caused by wire withdrawal
174
e f
g
Fig. 6.14 (continued)
–– The tension band wire should pass the fracture line in
an 8-shaped cross and then through the distal preset
bone channel. Simultaneous tightening of the double-­
stranded wire will complete the compression fixation
at the fracture end.
–– The Kirschner wire is cut with a 2-cm tail, which is
bent at 1 cm. A small incision is created in the triceps
tendon, and the tail of the Kirschner wire is hammered
H. Chen et al.
h
in the proximal cortex of the olecranon through this
incision. The incision of the triceps tendon is sutured,
and stimulation of the tendon and other soft tissue by
the nail tip should be reduced.
–– The position of the Kirschner wire is confirmed under
fluoroscopy. The length of the tip of the Kirschner wire
is observed in the lateral position to avoid soft tissue
injury caused by excessive protrusion of the tip to the
6 Fracture of the Proximal Ulna 175

Fig. 6.15 The Kirschner

wire and tension band
technique for fixation of a
Schatzker Type C fracture of
the ulnar olecranon. (a)
Preoperative anteroposterior
and lateral X-ray images
illustrating a fracture in the
middle segment of the
olecranon. (b) A CT
scan-reconstructed 3D image
showing a transverse fracture
in the middle of the semilunar
notch of the olecranon, with a
visible bone fragment on the
ulnar side. (c) Anteroposterior
and lateral X-ray images after
open reduction and fixation a b
with a Kirschner wire and
tension band. (d) Follow-up
X-ray image at 5 month
postoperatively showing
fracture healing. (e)
Anteroposterior X-ray image
after removal of internal
fixators

cortex on the palm side of the ulna; the forearm is
placed on the C-arm receiver with backward rotation
to observe whether the tip of the Kirschner wire acci-
dently enter the proximal radioulnar joint.
–– Experience and lessons:
In the Kirschner wire tension band technique, the
Kirschner wire plays the role of scaffolding. The wire
prevents rotation displacement of the fracture end
while also fixing the fracture end with compression
along its direction following the tension band princi-
ple. Thus, 2 Kirschner wires must be placed in paral-
lel without crossing; the tension band is placed close
to the articular surface to improve conversion of the
compressive stress on the palm side of the ulna.
Different methods of tightening the wire have been
reported. Some authors believe that unilateral pres-
sure is sufficient, but to obtain bilateral symmetri-
cal pressure, tightening is generally conducted at
176
both sides simultaneously. When tightening the
wire, the force should be balanced, so that the 2
wires intertwined with each other can be tightened
simultaneously. If 1 of the wires is tightened while
wrapping the other wire, the wrapped wire will eas-
ily slip after the wire is cut, causing failure of the
tension band fixation (Fig. 6.16).
The common complications in the Kirschner wire
tension band technique include premature with-
drawal of the internal fixation caused by backward
movement of the Kirschner wire and pain caused by
stimulation of the soft tissue by the implant. The
following measures can reduce the occurrence of
these complications:
The tip of the Kirschner wire can pass through
the contralateral cortical bone to enhance the
fixation strength and reduce the backward move-
ment of the wire.
The end of the Kirschner wire can be bent and
inserted in the proximal cortical bone to reduce
the backward movement of the wire and stimula-
tion of the soft tissue.
For fixation, the steel wire should pass through
the deep layer of the triceps tendon rather than
directly across the surface of the triceps tendons
to reduce stimulation and injury of the triceps
tendons and other soft tissues by the wire and
nail tail.
After cutting the wire, the end should be bent
and attached to the cortex on both sides of the
ulnar shaft, whose surface is covered by the
extensor carpi ulnaris and flexor carpi ulnaris, to
Fig. 6.16 When tightening the wire, the force should be balanced to
allow the two wires intertwined with each other; if one of the wires
wraps the other wire, the wrapped wire will easily slip after the wire is
cut, causing failure of the tension band fixation
H. Chen et al.
reduce stimulation of the skin and other soft
tissues.
The triceps tendon at the tail of the Kirschner
wire is sutured to prevent withdrawal of the
wire, increase soft tissue coverage, and reduce
stimulation of the skin and other superficial
tissues.
For elderly patients with osteoporosis, the holding
force of the internal fixation is insufficient, and
thus, it is difficult to obtain strong fixation and start
early exercises. Because the functional require-
ments of the elderly are relatively low, resection of
the proximal olecranon fracture fragment and
reconstruction of the triceps tendon end point can
be applied. When performing this procedure, the
length of the olecranon should be retained as much
as possible. In terms of biomechanics, the recon-
structed ending point of the triceps should not be
too close to the articular surface to provide suffi-
cient force arm for the elbow extension device and
prevent weakness in elbow extension (Heim 1991)
(Fig. 6.17).
• Steel plate and screw fixation technology for ulnar olecra-
non fracture:
–– For type C or E fractures in the Schatzker classifica-
tion, steel plate fixation using the following procedure
is recommended:
A pointed reduction forceps is used for reduction
and temporary fixation of the fracture.
In accordance with the shape of the dorsal proximal
ulna, the DCP is shaped, or the anatomical plate of
ulnar olecranon is used for the fixation.
According to the standard lag screw fixation technique,
the 3.5-mm screw through the plate should be perpen-
dicular to the fracture plane to fix the fracture fragment
with compression. Three cortical bone screws should
be used to fix each of the fracture ends (Fig. 6.18).
–– For type D fractures in the Schatzker classification, if
the fracture fragment is butterfly-shaped, the main
bone fragments can be stabilized by contacting each
other after the reduction. Steel plates can be used for
compression fixation (Fig. 6.19). The procedure is as
follows:
After reduction of the fracture, 2 intercrossing
Kirschner wires are used for temporary fixation to
pre-set sufficient space for the placement of the
steel plate.
In accordance with the shape of the proximal ulna,
the DCP is shaped.
The proximal fracture fragment is fixed with the
plate to convert the butterfly-shaped fracture into a
simple fracture.
6 Fracture of the Proximal Ulna
a b
Fig. 6.17 Resection of the proximal fracture fragment of the olecranon
and reconstruction of the ending point of the triceps tendon. (a) The
reconstruction that fixes the triceps at the site away from the articular
surface can provide a longer lever arm when the triceps contract, thus
In the distal eccentric position, the plate is fixed
with screws, and pressure is applied to the fracture
end.
The screws are screwed into the neutral position of
the remaining nail holes for fixation.
If there is a large butterfly-shaped bone fragment,
compression fixation can be performed using a steel
plate with lag screw technology.
For fractures of the coronoid process, if the fracture
fragments are small, a lag screw can be used first
for fixation, followed by plate screw fixation. If the
fracture fragments are large, Kirschner wire fixa-
tion can be used first for temporary fixation, fol-
lowed by fixation of the coronoid process fracture
with a steel plate. In fixation, the screws should be
as perpendicular to the fracture line as possible.
Fine screws can be used in the fixation to avoid fur-
ther comminution in the bone fragments.
–– For type D fractures in the Schatzker classification, if
the bone is crushed and good support after reduction
cannot be achieved, compression fixation cannot be per-
formed on the fracture ends. Otherwise, the length of the
ulnar notch and the opening angle will be reduced.
This fracture fixation method is roughly the same as
that above, except that the distal screw should be
screwed in the neutral position, and no pressure is
applied on the fracture.
For fractures with collapse of the articular surface, a
bone graft can be performed in the resultant gap after
reduction with the cancellous bone using a blunt
stripper, followed by fixation (Figs. 6.20 and 6.21).
177
minimizing the risk of weak extension of the elbow after surgery. (b)
The reconstruction that fixes the triceps at the site close to the articular
surface would cause a significant decrease in muscle strength during
elbow extension
Incision Closure
• Conventional incision closure is performed with drainage
placement and temporary fixation using a 90° elbow flex-
ion brace.
Postoperative Treatment
• Drainage is withdrawn at 24–36 h postoperative.
• Postoperative movement should be temporarily prohib-
ited. The fixed time is based on the stability of the fracture
after the fixation. Usually, the brace can be removed in
2–3 days. If no complication of the wound occurs at this
time, functional exercise can be started (range of motion,
ROM).
• The duration of bracing should not exceed 3 weeks, or
elbow stiffness and other complications will occur.
• When conditions allow, a CPM machine can be used for
full functional exercise under pain control (full ROM).
• Patients are encouraged to self-perform functional exer-
cises of pronation and supination.
• After 6.8 weeks, gradual healing of the fracture is con-
firmed by imaging, and the intensity of functional exer-
cise can be appropriately increased.
6.2.2 Coronoid Process Fracture
6.2.2.1 Principle of Treatment
• Regan & Morrey type I coronal fracture:
–– Most simple type I fractures can be treated with con-
servative treatment, and after short-term bracing, early
functional exercise can start.
178 H. Chen et al.

a b

c d

Fig. 6.18 Schematic diagram and case example of plate-screw fixation
for proximal ulnar fractures. (a) A pointed reduction clamp is used for
reduction and temporary fixation of the fracture. (b) In accordance with
the shape of the dorsal proximal ulna, the stainless-steel plate is
reshaped. (c) According to the standard lag screw fixation technique,
3.5 mm screws are placed through the plate and perpendicular to the
fracture line to fix the fracture fragments with compression. First, a
3.5 mm guiding device with a 3.5 mm drilling head is used to drill
through the medial cortex; then, a 2.5 mm guiding device with a 2.5 mm
drilling head is used to drill through the cortex at the opposite site;
finally, the screw is inserted and tied after sounding. (d) Three screws
are used for fixation at each of the proximal and distal ends. (e)
Preoperative anteroposterior and lateral X-ray images demonstrating an
olecranon fracture complicated by a radial head fracture. (f) Sagittal
view of the preoperative CT scan and 3D-reconstructed image: The
fracture involves the proximal ulnar olecranon, with a fracture line
extending to the ulnar shaft after passing through the coronoid process,
and the olecranon fracture is complicated by a radial head fracture; this
type of fracture is extremely unstable. (g) Open reduction and anatomi-
cal locking plate fixation of the olecranon fracture: The medial fracture
fragment is fixed with lag screws, followed by open reduction and inter-
nal fixation of the radial head
6 Fracture of the Proximal Ulna
f g
Fig. 6.18 (continued)
–– When a type I fracture includes a bone fragment in the
joint cavity, the bone fragment as an isolated body can
cause pain, traumatic arthritis, and other complications
and thus can be fixed by suture.
–– Type I fracture associated with radial head fracture
will seriously affect the stability of the elbow, and thus
fractures in the radial head and coronoid process
should be stabilized at the same time.
179
• Regan & Morrey type II coronal fracture:
–– This type is an intermediate type. The study of I. H.
Jeon et al. showed that, when the radial head and the
ligament are intact, fracture involving less than 40% of
the coronoid process is still stable (Ring et al. 1998).
–– Fracture combined with ligament injury or radial head
fracture should be treated with open reduction and
internal fixation.
180 H. Chen et al.

a b

c d

e f

Fig. 6.19 Tension band and plate fixation of butterfly-shaped bone
fragments: This fixation method is suitable for patients whose main
bone fragments can be stabilized by contacting each other after reduc-
tion. (a) After reduction of the fracture, Kirschner wires are used for
temporary fixation, and the plate is re-shaped. (b) The proximal fracture
fragment is fixed with the plate to convert the butterfly-shaped fracture
into a simple fracture. (c) The plate is fixed using eccentric screw place-
ment, and pressure is applied to the fracture site. (d) The screws are
inserted into the neutral position of the remaining nail holes. (e) Large
butterfly-shaped bone fragments can be fixed using plate. (f) The plate
technology is used to fix the fracture of the coronoid process, for which
the screws should be as perpendicular to the fracture plane as possible.
Fine screws can be used for fixation to avoid further comminution of the
bone fragments

–– The intact bone fragment can be fixed with screws,
while the crushed bone should be fixed by suture or
steel plate.
• Regan & Morrey type III coronal fracture:
–– This type of fracture requires open reduction and inter-
nal fixation. Fixation can be performed with screw or
steel plate. A hinge external fixator can be applied
postoperatively for auxiliary fixation to avoid loss of
reduction. Early functional exercise should be per-
formed to avoid elbow stiffness.
• O’Driscoll type II fracture involving the medial side of
the coronoid:
6 Fracture of the Proximal Ulna
a b
c d
Fig. 6.20 Bridging plate fixation for comminuted fractures. (a) The
ulnar olecranon trochlea is reduced with the humeral trochlea as a tem-
plate and temporarily fixed with Kirschner wires. (b) The plate is re-­
shaped, and screws are placed in a neutral position passing through the
–– This type of fracture is often associated with elbow
subluxation or even complete dislocation and should
be treated with open reduction and internal fixation.
Conservative treatment can be applied only if the frac-
ture fragment is very small, with no elbow joint sub-
luxation, and the distance of the humeroulnar joint is
not significantly enlarged based on radiography under
varus stress (Jeon et al. 2012).
6.2.2.2 Surgical Approach
• Anterior elbow approach:
–– Suitable for comminuted or non-comminuted type II
and type III fractures.
–– The anterior approach can more clearly reveal the frac-
tures to allow reduction and fixation under direct
vision.
• Medial elbow approach:
–– Suitable for non-comminuted fractures with large and
complete bone fragments and type IV fractures.
–– For type III fractures with large fracture fragments, the
medial elbow approach is recommended for n­ eurovascular
reasons and the fracture line bias to the dorsal ulna.
181
plate to fix the fracture fragments. (c) After removal of the Kirschner
wires, bone grafting is applied to repair the remaining bone defect. (d)
The plate is fixed with screws placed perpendicular to the bone surface
from the proximal ulna to the coronoid process
–– For simple coronal osteophyte removal, the medial
elbow approach can also be used.
• Lateral elbow approach:
–– This approach is suitable for the patients with ulnar
coronal fractures combined with radial head or
radial neck fracture who require internal fixation or
radial head resection and coronal osteophyte
removal.
–– Before reduction and fixation of a radial head fracture
or before radial head replacement following radial
head removal, the coronoid process should be fixed to
avoid affecting the exposure and fixation of the coro-
noid process.
–– The lateral elbow approach is not suitable for the
reduction and fixation of simple coronal fracture.
• Posterior elbow approach:
–– This approach is suitable for coronal fracture with
olecranon fracture and is similar to the ulnar olecranon
osteotomy approach for distal humerus fractures. The
coronal fracture can be reset under direct vision
through the olecranon fracture in the elbow flexion
position.
182 H. Chen et al.

Fig. 6.21 Schatzker Type D a b

fractures of the ulnar
olecranon. (a, b) Preoperative
anteroposterior and lateral
X-ray images illustrating
comminuted fractures of the
middle segment of the ulnar
olecranon combined with
anterior dislocation of the
elbow. (c) Preoperative CT
scan-reconstructed 3D image:
The ulnar olecranon has
comminuted fractures in its
middle segment, and a portion
of the fracture fragments have
a small size. (d and e) Open c
reduction and internal fixation
of the ulnar olecranon with an
anatomical locking plate
without compression of the
fracture ends

d e
6 Fracture of the Proximal Ulna
6.2.2.3 Ulnar Olecranon Fracture with Coronal
Fracture (Proximal Ulnar Posterolateral
Approach)
Position and preoperative preparation, incision with body
surface projection, surgical approach:
• See the section on olecranon fracture.
Fracture Reduction and Internal Fixation
• After the skin and subcutaneous tissue are cut, in the
elbow flexion position, the olecranon fracture proxi-
mal (similar to the olecranon V-shaped osteotomy to
expose the elbow) is lifted together with the triceps to
expose the elbow joint cavity and the coronoid
process.
• The reduction of the coronoid process is performed under
direct vision, and Kirschner wire is used for temporary
maintenance of the reduction.
• The olecranon fracture is then reset and temporarily fixed
using Kirschner wire and point-type reduction clamps.
The fracture reduction is confirmed under fluoroscopy
(Fig. 6.22).
• The appropriate anatomical locking plate is selected for
the fixation of the coronoid process bone fragments
through the steel plate.
• The incision is closed layer by layer.
Experience and Techniques
• If the ulnar olecranon fracture is combined with coronoid
fracture:
–– The typical coronoid process bone is triangular and
involves 50%–100% of the coronoid process. The
reduction and fixation of coronal fracture is very
important in restoring support stability in the anterior
elbow.
–– Ulna fractures can be separated to fully expose the
coronal fracture, that is, the coronal fracture is first
reset with temporary fixation, and then the olecranon
fracture is reset and fixed. Once the ulna fracture is
reset, the exposure and repair of the coronal fracture
will be very difficult.
–– After the reduction of coronal fracture, a lag screw can
be used for fixation, or Kirschner wire can be used for
temporary fixation. After stable reduction of the ulnar
olecranon fracture, fixation with a steel plate and screw
can be performed.
• Deformity healing of the proximal ulna fracture should be
avoided to reduce elbow joint complications caused by
elbow flexion and extension dysfunction, humeroradial
dislocation, or subluxation.
183
6.2.2.4 Medial Coronal Compression Fractures
with Rupture at the Starting Point
of the Lateral Collateral Ligament (Elbow
Medial and Lateral Joint Approach)
Position and Preoperative Preparation
• The patient is in the supine position, with the forearm on
the side table.
Operative Incision According to the Projection on the
Body Surface
• An arc incision in the medial elbow joint is combined
with a lateral incision.
Surgical Techniques
• The skin and subcutaneous tissue are cut to expose the
ulnar nerve, which is retracted with a rubber band for
protection.
• The flexor and anterior pronator teres muscle are stripped
from the medial collateral ligament and ulnar coronoid.
• Under direct vision, the coronoid can be reset and fixed
with screws or a micro-supporting plate. For some com-
minuted fractures for which steel plate and screw fixation
cannot be implemented, suture fixation can also be applied
(Fig. 6.23).
• Through the incision in the lateral elbow, the starting
point of the lateral collateral ligament is sutured and fixed
on the lateral epicondyle with rivets, or the lateral collat-
eral ligament is reconstructed using other surgical meth-
ods (see the related sections on radial head fracture)
(Fig. 6.24).
• Conventional incision closure is performed.
Experience and Techniques
• Coronoid anteromedial fracture is a very unique type of
injury that includes elbow varus injury, coronal medial
compression fracture, and injury caused by the tension on
the lateral collateral ligament.
–– The appropriate surgical incision is selected according
to the degree of lateral collateral ligament injury and
whether repair is needed. Medial and lateral joint inci-
sion is often selected, with simultaneous fracture fixa-
tion and repair of the ligament injury.
–– Most coronal fractures are biased to the ulnar side.
Based on the size of the bone fragment and the degree
of comminution, fixation can be performed with a
screw, steel plate, or suture. Fixation using a micro-­
steel plate designed according to the anatomy of the
operating site can effectively prevent further collapse
and displacement of the bone fragments.
184 H. Chen et al.

a b

c d

Fig. 6.22 Example of an ulnar olecranon fracture complicated by frac-
ture of the coronoid process. (a) CT sagittal-reconstructed image illus-
trating the fracture at the base of the coronoid process and comminuted
fractures from the middle to the distal ulnar olecranon. (b) CT scan-­
reconstructed 3D image demonstrating comminuted fractures of the
ulnar olecranon complicated by a fracture of the coronoid process. (c)
Through the posterior elbow approach, the fracture end of the olecranon
was cleaned up, and the coronoid process was exposed through the frac-
ture line in the elbow flexion position. (d) Using the posterior elbow
approach, the coronoid process was reduced under direct vision and
temporarily fixed. (e) The olecranon fracture was then reset and main-
tained using Kirschner wires and pointed reduction clamps. (f)
Postoperative anteroposterior and lateral X-ray images demonstrated
anatomical reduction of the fracture. (g) Follow-up lateral X-ray image
demonstrating fracture healing at 13 months postoperatively. (h) Lateral
X-ray image after removal of internal fixators
6 Fracture of the Proximal Ulna
g h
Fig. 6.22 (continued)
–– An internal fixation device with a rivet is an effective
method for the fixation of the starting point of the lat-
eral collateral ligament.
6.2.2.5 Postoperative Complications
and Prevention Strategies
• Complications of ulnar olecranon fractures:
–– Kirschner wire and tension band:
The most common complication is pain stimulation
caused by postoperative nail tail withdrawal, and
most patients therefore request removal of the inter-
nal fixation.
Studies have shown that (Job et al. 2006), in the
application of Kirschner wire and tension band for
the fixation of olecranon fractures, fixation of the
anterior cortex using Kirschner wire has a lower
rate of tail withdrawal than fixation along the long
axis using Kirschner wire.
185
Other complications are related to the depth and
direction of Kirschner wire placement. Excessive
front protrusion of the Kirschner wire may damage
the vascular nerves in the front.
Errors in the direction and depth of the Kirschner
wire may cause it to stray into the proximal radioul-
nar joint or block its rotation around the proximal
ulna in front of the radial head, thus affecting the
forward rotation movement of the forearm.
Surgical methods to reduce the above complica-
tions: In fixation using Kirschner wire and tension
band, the direction and depth of the Kirschner wire
should be well adjusted under fluoroscopy so that
the tip of the Kirschner wire is located in the ante-
rior cortex of the ulna. The wire should be fixed
under the triceps tendon rather than fixed with
direct contact with the Kirschner wire tail after
crossing the surface of the triceps tendon.
186
a b
d e
Fig. 6.23 Plate-screw internal fixation for anteromedial fractures of
the ulnar coronoid process. (a) First, the fracture of the ulnar coronoid
process is reset through an anteromedial incision and temporarily fixed
with Kirschner wires that are inserted from the dorsal position, fol-
lowed by pulling back the Kirschner wires to the ensure the wire tips
embedded within the bone cortex. (b) After being placed and adjusted
to an appropriate position, the anatomical plate of the coronoid process
is temporarily fixed to the proximal ulna with Kirschner wires; next, a
screw with a proper length is inserted through the middle nonlocking
hole for temporary fixation. (c) Two non-locking screws are inserted in
• Intramedullary nail:
As the proximal ulnar medullary cavity is slightly bent
instead of a straight line, the nail tail will swing when
the nail is placed into the medullary cavity, which may
cause varus or valgus displacement of the ulnar olecra-
non (Fig. 6.25).
• Complications of ulnar coronal fractures:
• Continuous elbow instability:
This instability is common in the complex injury of the
elbow, such as Regan & Morrey type III coronal
­fracture (van der Linden et al. 2012; Schneeberger
et al. 2004).
After backward, inner backward or outer backward
dislocation of the elbow, friction between the humeral
trochlea and the sharp part of the fracture end may
occur, resulting in cartilage injury and even secondary
traumatic arthritis in severe cases.
To prevent the occurrence of this complication, the sta-
bility of the elbow should be checked after fixation of
H. Chen et al.
c
the proximal plate to fix the fracture fragment at the tip of the coronoid
process, and the decision regarding whether non-locking screws should
be placed anteromedially is made according to the shape of the fracture.
(d) After removal of the Kirschner wires used for temporary fixation,
two locking screws are inserted through the distal plate to complete the
fixation. (e) For a Type I fracture of the coronoid process with small
fragments, suture fixation is an applicable way. The suture passing
through the holes drilled on the proximal ulna is used to suture the coro-
noid process and then knotted for fixation after it passes through the
bone canal
the coronary process, and the stability of the elbow
under varus or valgus stress can be observed.
For patients with coronal fracture with lateral collat-
eral ligament injury or radial head fracture, all dam-
aged structures should be repaired by surgery to restore
the stability of the elbow (Fig. 6.26).
• Heterotopic ossification (Fig. 6.27):
The reported incidences of heterotopic ossification
of Regan & Morrey type II and type III fractures are
as high as 20% and 80%, respectively (Schatzker
2005).
Iatrogenic injury caused by high-energy damage and
surgical operation may increase the degree of hetero-
topic ossification.
For high-risk patients with severe coronal fracture
associated with brain injury, oral administration of
non-steroidal anti-inflammatory drugs can prevent the
occurrence of heterotopic ossification.
6 Fracture of the Proximal Ulna
a b
d e
Fig. 6.24 Radiographic images of a patient who was treated for an
anteromedial fracture of the right ulnar coronoid process. (a)
Preoperative anteroposterior X-ray image illustrating an anteromedial
fracture of the right ulnar coronoid process near the medial collateral
ligament. (b) Preoperative lateral X-ray image: The fracture of the ulnar
coronoid process was a Regan &Morrey Type I fracture. (c) Preoperative
CT scan and 3D-reconstructed image demonstrating the fractures at the
Fig. 6.25 (a) The proximal ulnar medullary cavity is
a b
slightly bent rather than lying in a straight line. (b, c)
When an intramedullary compression nail is used to
fix the proximal ulnar fracture, the nail tail
accommodates to the shape the medullary cavity,
which may cause varus or valgus displacement of the
ulnar olecranon
187
c
f
tip and anteromedial of the coronoid process. (d) Intraoperative fluoros-
copy image at the stress position showing that the lateral side is unsta-
ble, requiring repair of the lateral collateral ligament. (e, f) Plate-screw
fixation was applied to fix the anteromedial fracture of the coronoid
process through the medial elbow approach; through both medial and
lateral elbow approaches, rivets were used to repair the rupture at the
starting point of the lateral collateral ligament
c
188
a b
d e
Fig. 6.26 Example of elbow complex fractures complicated by com-
minution fractures of the coronoid process and radial head that seri-
ously affect the varus or valgus stability of the elbow. (a) Preoperative
X-ray image demonstrating the fractures of the radial neck and ulnar
coronoid process. (b) Preoperative CT sagittal-reconstructed image
illustrating a coronoid fracture that involves more than 50% of the coro-
noid process. (c) Preoperative CT sagittal-reconstructed image illustrat-
H. Chen et al.
f
ing the fracture line of the radial neck. (d) Preoperative CT
coronal-reconstructed image illustrating a fracture that involves the
anteromedial surface of the coronoid process. (e, f) Postoperative
anteroposterior X-ray image: Open reduction and internal fixation was
conducted with headless screws and Kirschner wires for fixation of the
coronoid process bone fragments; a stainless-steel plate was used to fix
the radial neck fracture
6 Fracture of the Proximal Ulna 189

Fig. 6.27 Heterotopic

a
ossification after surgical
treatment for comminution
fractures of the ulnar
olecranon and coronoid
process. (a) Preoperative
anteroposterior and lateral
X-ray images illustrating
ulnar olecranon comminuted
fractures complicated by a
coronoid process fracture. (b)
A lag screw was used to fix
the coronoid process and a eft
Kirschner wire—stainless-­
steel wire—tension band
technique was used to fix the
olecranon fracture. However,
the reduction outcome was
poor, and an X-ray image
taken at postoperative month
four showed signs of
heterotopic ossification. (c) At
9 months after surgery, the
X-ray image showed a large
amount of heterotopic
ossification surrounding the
elbow and cross-healing of b c
the ulna and radius

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 Fracture of the Radial Head and Terrible
Triad Injury of the Elbow
Hua Chen, Zhe Zhao, and Jiantao Li
7.1 Basic Theory and Concepts
7.1.1 Overview
• Radial head fracture accounts for approximately 20% of
fractures of the elbow joint (van Riet et al. 2009).
• The radial head was previously considered an unimport-
ant structure and often removed at will. The radial head
is now considered the second most important structure
for the stability of the elbow joint (Morrey et al. 1991).
With increasing awareness of its importance, the treat-
ment of radial head fractures has undergone tremendous
change.
• Before choosing a treatment method for radial head frac-
tures, the stability of the elbow should be carefully evalu-
ated, including comprehensive assessment of injuries in
the proximal ulna, distal humerus, medial collateral liga-
ment, and interosseous membrane of the forearm (van
Riet et al. 2005).
• Regardless of the treatment methods, the purposes of ana-
tomical reduction, strong fixation, early functional exer-
cise should be achieved, and elbow stiffness caused by
delayed exercise should be avoided.
• Triad injury of the elbow refers to dislocation of the elbow
associated with fracture of the radial head and coronoid
process, which is a severe acute trauma of the elbow.
Because the treatment is difficult and the prognosis is
poor, it is also known as the “terrible triad injury”
(Josefsson et al. 1987; Ring et al. 2002a).
H. Chen (*) · J. Li
Chinese PLA General Hospital, Beijing, China
e-mail: chenhua0270@132.com
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_7
7
7.1.2 Applied Anatomy
• Morphology of the proximal radius:
–– The shape of the radial head (Fig. 7.1):
The radial head is close to a cylinder, but the intui-
tive surface is an oval rather than a regular circle.
Consequently, in the pronation of the forearm,
when the long axis of the radial head cross section
contacts the ulna, the proximal radius will move
outward. Kapandji et al. showed that in the process
of forearm pronation, this outward movement
increases the distance between the radius and the
ulna and leaves space for the radial tuberosity to
facilitate forearm rotation (Kapandiji 2011).
The upper surface of the radial head has a round
recess matching the humeral head similar to a cup
that contacts and slides with the humeral capitellum
during forearm rotation and the flexion and exten-
sion process of the elbow.
The medial upper surface of the radial head has a
notch to adapt to the adjacent relationship of the
humeral capitellum and trochlea. In forearm rota-
tion and elbow flexion, this structure allows close
contact of the radial head and humeral trochlea with
the radial head notch.
–– Radial proximal collodiaphysial angle: The normal
proximal radius has a valgus angle of approximately
15° known as the collodiaphysial angle. The surgical
repair of radial neck fracture should restore the collo-
diaphysial angle.
–– The impact of proximal radius morphology on the
radial head prosthesis: Due to the complexity of the
anatomical shape of the proximal radius, the irregu-
larity of the radial medullary cavity, and individual
differences in the anatomy of the proximal radius, it
is difficult to achieve perfect bionic design of the
radial head prosthesis. Silicone prostheses, monopo-
lar prostheses, anatomical modular prostheses, and
bipolar prostheses have been successively used in
191
192
a condyle, which is divided into the anterior bundle, the
b
15°
Fig. 7.1 (a) The articular surface of the radial head is an oval with a
notch on its medial margin, allowing close contact of the radial head
and humeral trochlea during the pronation and supination processes of
the forearm. The importance of this anatomical structure is considered
in designing radial head prostheses, and most of the currently available
prostheses have adopted the bionic design. (b) The normal proximal
radius has a neck-shaft angle of approximately 15°
clinical replacement of the radial head. Currently,
the anatomical modular prosthesis is widely used
(Grewal et al. 2006). The bionic design of the oval-
shaped columnar articular surface and the recessed
articular surface on the top of this prosthesis
increases its similarity to the natural anatomical
morphology of the radius. The size of the radial head
and the length of the radial neck can be arbitrarily
assembled intraoperatively to match the size of the
prosthesis and facilitate the operation.
• Safe zone of radial head surgery (Fig. 7.2):
–– The proximal radius is connected to the ulna through
the radioulnar joint. The bony articular surface is the
radial notch of the ulna, which covers approximately
1/4 of the circumference, and the rest is surrounded by
the annular ligament to form a complete annular
structure.
–– In the forearm medial position, the area of the arc area
at approximately 90° of the anterolateral radial head
does not enter the bone space of the proximal radioul-
nar joint in the pronation and supination process of the
forearm. This area is known as the “safe zone”
(Harrington and Tountas 1980), which is the area for
internal fixation placement of the steel plate in radial
head fracture. Before placing the steel plate, this safe
zone should be defined by the pronation and supina-
tion process of the forearm (Smith and Hotchkiss
1996).
• Ligament structure in the elbow joint (Fig. 7.3):
–– Medial collateral ligament: This ligament starts from
the anterior lower margin of the medial humeral epi-
H. Chen et al.
posterior bundle, and the transverse bundle. The ante-
rior bundle is the strongest and is the most important
structure for maintaining the stability of the elbow
joint. The integrity of the anterior bundle is an impor-
tant assessment indicator to determine the surgical
approach for radial head fracture. The posterior bundle
mainly restricts the excessive flexion of the elbow
joint; the transverse bundle has no obvious effect on
the stability of the elbow joint.
–– Lateral collateral ligament complex: The lateral col-
lateral ligament complex starts from the lateral humeral
epicondyle and consists of the annular ligament, the
bundle on the radial side, and the bundle on the ulnar
side. The annular ligament is attached to the anterior
and posterior of the radial notch of the ulna and forms
a complete loop around the radial neck together with
the ulnar notch. The bundle on the radial side is fan-­
shaped, ending in the annular ligament, as the impor-
tant structure to maintain the stability of the radial
head together with the annular ligament. The bundle
on the ulnar side ends in the ulnar supinator crest, as an
important structure to limit the elbow varus and poste-
rior lateral dislocation. In radial head fracture surgery,
the bundle on the ulnar side should be carefully pro-
tected. If it is already damaged, it should be recon-
structed and repaired.
• Protection of the radial nerve deep branch in radial head
surgery:
–– At the level of the humeroradial joint in front of the
elbow, the radial nerve deep branch (interosseous dor-
sal nerve) is derived from the radial nerve and enters
and runs along the supinator through the supinator
arch.
–– In the process of exposing the radial head by the
Kocher approach, the forearm should be pronated as
much as possible when making the incision for the
articular capsule to allow the posterior interosseous
nerve to be moved forward far from the incision
(Fig. 7.4).
–– The articular capsule should be cut close to the ulna
rather than the radius to reduce the risk of injury.
–– For the incision of the annular ligament to expose
the radial head, the extension from the radial head to
the distal should not exceed 2 transverse fingers;
otherwise, it may damage the interosseous dorsal
nerve.
• The stable structure of the valgus of the elbow joint:
–– Trochlea and ulnar half-moon shaped notch: the ulnar
half-moon shaped notch matches the humeral trochlea,
providing a certain degree of internal stability, but the
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow 193

Fig. 7.2 A fan-shaped area of

approximately 90° of the
radial head does not enter the
bony zone of the proximal
radioulnar joint during either
pronation or supination
processes of the forearm;
therefore, this area is known
as the “safe zone” for
plate-screw fixation in radial
head surgery

pronation neutral position supination

a b

humerus
humerus
supracondylar ridge

lateral supracondylar
tubercle of annular
radial bundle of radial ligament
radius radius
collateral ligament
radius anterior bundle of ulnar
collateral ligament
medial supracondylar of
humerus
posterior bundle of ulnar
collateral ligament
transverse bundle of ulnar
collateral ligament

olecranon ulnar bundle of annular radial ulna ulna coronoid olecranon

radial collateral ligament neck process
ligament

c
radial notch
radial collateral
ligament

wynoviun

coronoid
annular
ligament

Fig. 7.3 Schematic diagram of the elbow ligamentous stabilization into the anterior bundle, the posterior bundle, and the transverse bundle.
structure for the elbow joint. (a) The lateral collateral ligament complex (c) The annular ligament is attached to the anterior and posterior of the
consists of the annular ligament, the bundle on the radial side, and the radial notch of the ulna and forms a complete loop around the radial
bundle on the ulnar side. (b) The medial collateral ligament is divided neck together with the ulnar notch
194 H. Chen et al.

flexor carpi ulnaris

supinator
supinator

posterior
interosseous nerve

anconeus pronation

radial nerve

Frohse arch

Fig. 7.4 During the process of exposing the radial head by the Kocher approach, the forearm should be pronated as much as possible when making
the incision for the joint capsule to allow the posterior interosseous nerve to be moved medially away from the incision

auxiliary functions of other stability structures of the a b

elbow joint are still needed.
–– Medial collateral ligament: The medial collateral liga-
ment is the most important anti-valgus stability struc-
ture. With the elbow at 90°, the medial collateral
ligament provides more than 50% of valgus stability.
Excision of the anterior bundle can lead to severe
instability of the elbow (Soyer et al. 1998).
–– Radial head: Contact of the humeral head and the
radial capitellum is the second most important anti-­
valgus stability structure of the elbow joint (Fig. 7.5).
When the radial capitellum is missing, the anti-valgus
stability of the elbow depends on the medial collateral m m
ligament. If the medial collateral ligament is broken at F
F
this time, the elbow will be unstable (Fig. 7.6).
Therefore, for radial head fracture associated with
medial collateral ligament rupture, radial head resec-
tion is not an option, and radial head prosthesis
replacement should be performed (Morrey 2009).
• Radial conductance of the forearm axial force and Essex-­
Lopresti injury (Fig. 7.7):
–– When the forearm is intact, the distal radius bears most
Fig. 7.5 Contact of the humeral head and the radial capitellum is an
of the stress of the wrist. Of this stress, 60% is transduced important anti-valgus stabilization structural mechanism for the elbow
through the radius, and 40% is transduced to the ulna joint. (a) When the radial head is intact, its lateral side serves as the pivot
through the distal radioulnar joint and the interosseous point for the anti-valgus lever structure of the forearm. (b) When the radial
head is resected, the lever pivot point moves medially to the lateral ulnar
membrane. Hotchkiss indicated that in fractures or resec-
olecranon, thus shortening the force arm. Consequently, under the same
tion of the radial head, the central bundle of the interos- stress, the strain on the medial collateral ligament increases several fold
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow
a b
d e
Fig. 7.6 (a) Under normal conditions, an eccentric axial force on the
forearm results in compression stress on both the radial head and ulnar
semilunar notch. (b) When the radial capitellum is missing and the
interosseous membrane is intact, the same force on the forearm results
in compression stress on the semilunar notch and strain on the medial
collateral ligament. (c) When the radial capitellum is missing and the
medial collateral ligament and the ulnar bundle of the lateral collateral
ligament are ruptured but the interosseous membrane remains intact,
the axial load on the forearm results in compression stress perpendicu-
seous membrane (interosseous ligament) provides 71%
of forearm axial stability, with the rest provided by the
distal radioulnar joint (Taylor and O’Connor 1964).
–– Essex-Lopresti injury can be defined as longitudinal
radioulnar dissociation caused by radial head
195
c
lar to the lateral semilunar notch, leading to elbow instability. (d) When
the radial head is missing and the medial collateral ligament is ruptured
but the ulnar bundle of the lateral collateral ligament and the interosse-
ous membrane remain intact, the eccentric axial load on the forearm
results in compression stress perpendicular to the medial semilunar
notch, which will also lead to elbow instability. (e) Absence of the
radial head in combination with rupture of the interosseous membrane
can cause a longitudinal separation of the ulna and radius, namely,
Essex-Lopresti injury
c­ omminuted fracture or resection combined with inter-
osseous membrane injury. The interosseous membrane
injury can be acute injury caused at the time of fracture
or chronic injury caused by surgical resection of the
radial head (Hotchkiss 1996).
196
a b
resection of
radial head
Fig. 7.7 (a) When the forearm structure is intact, the distal radius bears
most of the stress on the wrist. Of this stress, 60% is transduced through
the radius and 40% is transduced to the ulna through the distal radioul-
nar joint and interosseous membrane. When the radial head is fractured
or resected, the central bundle of the interosseous membrane (interosse-
ous ligament) provides 71% of forearm axial stability, with the rest pro-
7.1.3 Mechanisms of Injury
• Injury due to direct violence is rare, and most fractures
are caused by indirect violence.
• Most radial head fractures are caused by falling with the
upper limb straightened, the forearm in the pronation
position, and the palm hitting the ground. The violence is
transmitted along the forearm, causing valgus of the
elbow and leading to injury due to collision of the radial
head and the humeral capitellum.
• Posterolateral rotation mechanism of injury in elbow dis-
location (Smith et al. 2002; Mehta and Bain 2004)
(Fig. 7.8):
–– The arm is stretched while falling, and the elbow is
slightly curved while hitting the ground. Consequently,
the axial, valgus, and backward rotation stress all act
on the elbow simultaneously, causing a series of
injuries.
–– The ligament and articular capsule of the elbow joint
can be considered an annular structure. The damage is
from the outside to the inside and can be divided into 3
stages according to order of occurrence:
Stage I: Injury of the lateral ulnar collateral liga-
ment (LUCL) occurs first and may be combined
with injury of the lateral ligament ligation bundle
on the radial side and the lateral articular capsule;
H. Chen et al.
vided by the distal radioulnar joint. (b) Acute Essex-Lopresti fracture
dislocation: If the forearm hits the ground and causes comminuted frac-
tures of the radial head during a fall from a high place, the longitudinal
stress from the wrist to the elbow can cause rupture of the interosseous
membrane, leading to elbow instability
injury at the site will lead to lateral rotation
instability.
Stage II: The external force further tears the ante-
rior and posterior articular capsule, and the elbow
enters a state of incomplete dislocation, with the tip
of the coronoid process located in the humeral
trochlea. Because the medial collateral ligament is
intact, the elbow after reduction has anti-valgus
stability.
Stage IIIa: All ligaments and articular capsules
except the medial collateral ligament are injured.
The elbow further rotates outward with the anterior
bundle of the uninjured medial collateral ligament
as the center, and the elbow shows further disloca-
tion with the ulnar coronoid process located behind
the humeral trochlea. Because the medial collateral
ligament remains intact, the elbow after reduction
still has some valgus stability.
Stage IIIb: All ligaments in the anterior bundle of
the medial collateral ligament and articular capsule
are injured. The varus, valgus, and rotation stability
after reduction are damaged.
• Mechanism of injury of the triad of the elbow (O’Driscoll
et al. 1991):
–– Triad injury is mostly caused by falling with å straight
elbow and hitting the ground in the wrist dorsiflexion
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow
valgus
axial compression
(1)
supination
axial compression
1 3
LUCL MUCL
Fig. 7.8 Posterolateral rotation injury mechanism and stages of elbow
dislocation. (a) During a fall in which the arm is stretched and the
elbow is slightly bent when hitting the ground, axial, valgus, and supi-
nation stress all act on the elbow simultaneously, causing a series of
injuries. (b, c) The ligaments and capsule of the elbow joint can be
considered an annular structure. The damage occurs sequentially from
the outside to the inside structure and can be divided into three stages:
(1) shows the normal position relationship of the elbow; (2) shows stage
I dislocation where the injury of the ulnar bundle of the lateral collateral
ligament results in posterolateral rotation instability of the elbow; stage
II injury includes further tearing of the anterior and posterior joint cap-
sule, and the elbow enters a state of backward semi-dislocation, with
197
supination
(4)
(3)
valgus
(2)
the ulnar coronoid process located above the humeral trochlea; stage III
injury (3) refers to the state in which all elbow ligaments and joint
capsules are injured, and the elbow shows further backward dislocation.
(d, f) Example of elbow dislocation (female, 16 years old) (4) showing
stage III b elbow dislocation with an intact annular ligament and a
medial radioulnar joint in the normal position, but all other elbow liga-
ments and the joint capsule damaged (d). The joint is unstable after
reduction, with avulsion fractures at the ligament attachment points on
the medial and lateral epicondyles of the humerus and a radial head
fracture (e). The post-reduction lateral X-ray image demonstrates dis-
sociated bone fragments and an extremely unstable elbow joint showing
a trend toward dislocation (f)
198 H. Chen et al.

position. The axial stress and backward stress are
transmitted to the elbow through the forearm, and the
axial shear force causes fractures of the radial head and
coronoid process.
–– In the posterolateral rotation mechanism of injury
described above, the elbow dislocation can also cause
fractures of the radial head and coronoid process
simultaneously.
• Radial head fractures: Radial head fractures can be com-
plicated with not only coronal fractures but also fracture
and dislocation of the elbow and forearm, such as ulnar
olecranon, humeral capitellum fracture, and Essex-­
Lopresti injury, suggesting that the stability of the elbow
is severely damaged.
7.1.4 Classification of Fractures
• Mason classification of radial head fractures (Mathew et al.
2009): The classification criteria based on the changes in
X-ray proposed by Mason in 1954 are as follows.
–– Type I: Fractures with no displacement.
–– Type II: Fractures at the margin with compression,
depression, and angular displacement.
–– Type III: Comminuted fractures involving the entire
radial head.
• On the basis of the Mason classification (Mason 1954),
Morrey added radial neck fracture and defined the quanti-
fication standard of displacement: a fracture fragment
involving more than 30% of the articular surface or frac-
ture displacement >2 mm.
• Johnston (Morrey 1985) proposed various types of radial
head fractures described above. A radial head fracture is
classified as type IV (Fig. 7.9) when combined with dislo-
cation of the elbow or Essex-Lopresti injury.
7.1.5 Assessment of Radial Head Fractures
7.1.5.1 Clinical Assessment
• Typical manifestations:
–– The flexion and rotation of the elbow and forearm are
limited, especially for rotation.
–– The radial head in the lateral elbow is swelling, with
tenderness.
–– If active and passive activity of the elbow are limited,
radial head fracture should be suspected.
• The position of the radial head can be pressed with the
fingers while the forearm in the position of pronation. The
occurrence of bony crepitus may indicate radial head
fracture.
• Acute pain and swelling may complicate the assessment
of surgical indications. In this case, elbow joint puncture
should be performed to aspirate the hemorrhage inside the
joint. Local anesthetic can be injected at the same time to
check the rotation of the forearm. Radial head fracture is

Fig. 7.9 Mason classification type I type II

of radial head fractures
(modified): Type I: Fractures
with no displacement. Type
II: Fractures at the margin
with compression, depression,
and angular displacement of
the radial head. Type III:
Comminuted fractures
involving the entire radial
head. Type IV: Fractures
combined with dislocation of
the elbow and injury of the
forearm interosseous
membrane
type III type IV
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow
a b
Fig. 7.10 (a) The elbow puncture point is located near the center of the
approximate isosceles triangle formed by the medial epicondyle, lateral
epicondyle of the humerus, and the ulnar olecranon. (b) The patient lies
on the examination bed with the affected limb on the top of the head so
that outward rotation of the humerus can be restricted. The examiner
holds the upper arm of the patient with the one hand and the patient’s
wrist or forearm with the other hand to obtain extreme backward rota-
tion. Simultaneously, axial stress and valgus force are applied to the
indirectly determined mainly through mechanical block-
age accompanied by forearm rotation activity (Fig. 7.10a).
• Axial stress test: With axial stretch of the forearm, proxi-
mal radius displacement greater than 5 mm is defined as
positive, and injury of the interosseous membrane and
distal radioulnar joint and acute Essex-Lopresti injury
should be considered.
• Wrist dorsal pain and elbow pain that is particularly
obvious in the posterior rotation position, a limited
activity range in forearm supination and wrist dorsal
extension, significant protrusion of the distal ulna to the
199
valgus
axial compression
supination
forearm of the affected limb. When the elbow moves from full exten-
sion to flexion of approximately 40°, the humeroradial joint is dislo-
cated, the radial head protrudes backward, and a depression appears on
the skin proximal to the radial head. (c) Evaluation of posterolateral
rotation instability: When axial, supination, and valgus forces are
applied to the forearm of the affected limb, the radial head dislocation
and the depression of the surrounding skin become visible
dorsal side, and elbow valgus instability suggest chronic
Essex-­Lopresti injury after resection of the radius head.
• The valgus stress test is performed to check the tender-
ness and dislocation of the medial elbow to exclude lat-
eral and medial collateral ligament injury.
• Evaluation of lateral rotation instability: The patient lies
on the examination bed with the limb on the head so that
the outward rotation of the humerus can be restricted. The
examiner holds the upper arm of the patient in 1 hand and
holds the patient’s wrist or forearm in the other hand to
obtain extreme backward rotation. Simultaneously, axial
200 H. Chen et al.

a b

olecranon
staxis
bursa

fat pad fat pad

Fig. 7.11 (a) Under normal conditions, there is very little fluid in the
articular cavity. (b) Lateral view: The fat pad is lifted upward when
intra-articular hemorrhage occurs. (c) Lateral radiographic image of the
elbow: The red dashed line denotes the axis of the radial neck, and the
red circle denotes the line connecting the centers of the humeral medial
and lateral epicondyles; the red dashed line normally should cross the
red circle, and a deviation between them indicates rupture of the ulna
bundle of the medial collateral ligament and dislocation of the radial
head; an increase in distance between the two blue dashed lines indi-
cates injury of the collateral ligaments

stress and valgus force are applied to the forearm of the In the lateral image of the elbow joint, the axis of
affected limb. From full extension of the elbow to flexion the radial neck should cross the connection line of
of approximately 40°, radial dislocation, backward radial the humeral entepicondyle and epicondyle centers.
head protrusion, and the depressed skin in the proximal A significant bias between them suggests injury at
radial head should be observed, in addition to self-­ the lateral ulnar side of the lateral collateral liga-
resetting of the humeroradial joint with flexion of the ment; in addition, an increase in the distance
elbow (Fig. 7.10). between the half-moon notch of the ulnar olecranon
• If the last 2 examinations are difficult to perform due to and the humeral trochlea also suggests injury of the
patient pain, they can be performed intraoperatively under collateral ligament (Fig. 7.11).
anesthesia. The examination should be repeated after the –– Greenspan image: The image of the radial head can be
completion of fixation to determine the stability of the obtained by standard lateral X-ray with the bulb tilted
elbow. 45° toward the shoulder joint (Bohrer 1970).
–– Imaging of the wrist joint at the anteroposterior posi-
7.1.5.2 Imaging Assessment tion is captured to exclude Essex-Lopresti injury
• X-ray: (Fig. 7.12).
–– X-ray scanning of the elbow at the anteroposterior and • CT and 3-dimensional reconstruction: For peripheral
lateral position can reveal the general fracture but can- joint fractures, CT scan should be performed to carefully
not provide the exact type of each fracture. assess the joint fractures in the sagittal, coronal, and
Sail (fat pad) sign: Uplift of the anterior and poste- 3-dimensional reconstruction to characterize the bone
rior fat pad in the lateral image indicates intra-­ displacement for preoperative planning (Fig. 7.13).
articular hemorrhage, which is the only clue for the • MRI examination: MRI examination of the elbow aids
presence of radial head fracture with displacement judgment of the integrity of the ligament structures around
(Johnston 1952). the complex elbow joint injury or elbow dislocation.
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow
a
45°
Fig. 7.12 Example of a radial head fracture patient with luxation of the
distal ulnoradial joint caused by shortening of the radius. (a) Body posi-
tion and projection angle for Greenspan oblique radiography: The fore-
arm is placed in the lateral position, with the radiation beam tilted 45°
toward the shoulder joint. (b) Greenspan oblique image of the elbow:
The solid arrow denotes the humeral capitellum, and the hollow arrow
201
b
denotes the radial head. (c) While capturing the lateral image for the
elbow, the X-ray image of the wrist should simultaneously be acquired
to determine the stability of the distal ulnoradial joint, excluding Essex-­
Lopresti injury [Figure (c) was from K. Wegmann, et al.: The Essex-­
Lopresti lesion. Strat Traum Limb Recon (2012) 7: 131-139]
202
a b
c d
Fig. 7.13 (a, b) Preoperative anteroposterior and lateral X-ray images
of terrible triad of the elbow, demonstrating fractures of the ulnar olec-
ranon, radial head, and coronoid process. (c, d) Preoperative multipla-
nar CT-reconstructed images that can be used to thoroughly evaluate
7.2 Surgical Treatment
7.2.1 Surgical Indications and Purpose
7.2.1.1 Surgical Indications
• Mason type I fracture: After intra-articular injection of local
anesthetic, non-surgical treatment can be administered if
there is no mechanical obstruction in the forearm. One week
after bracing with hanging fixation, early functional exer-
cise can start. The displacement of the fracture is monitored
in weekly follow-up (Greenspan and Norman 1982).
• Mason type II fracture: Fracture with displacement
>2 mm and involving >30% of the articular surface can
cause mechanical obstruction of the rotation of the fore-
arm or poor matching of the articular face affecting fore-
H. Chen et al.
the fractures on the sagittal and coronal planes shows fractures at the
anteromedial coronoid process, the tip of the coronoid process, and the
ulnar olecranon, accompanied by backward dislocation of the elbow
arm rotation function, and surgical treatment should be
provided in this case (Herbertsson et al. 2005).
–– The factors affecting the results of internal fixation
include the number of fracture fragments, the degree
of comminution, and the presence of osteoporosis.
Usually, cases with ≤3 fracture fragments of the radial
head and no osteoporosis can be repaired through open
reduction and internal fixation surgery.
–– For fractures in the margin of the radial head, open
reduction with lag screw fixation is often performed.
–– For radial neck fracture, open reduction with plate and
screw fixation is often performed.
–– If the fracture fragments are crushed, located on the
margin, do not enter the bone joint space in the rota-
tion of the forearm, and involve <1/3 of the articular
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow 203

a b

Fig. 7.14 For surgical treatment of a radial capitellum fracture, the patient is placed in the lateral decubitus position (a) with the affected limb on
a soft pad in the neutral position (b)

surface, the fracture fragments can be removed.

However, radial subluxation may occur after sur-
gery, and the procedure should be carefully applied.
• Mason type III fracture: Injury of the medial collateral
ligament should be assessed (Ring et al. 2002b).
–– If the medial collateral ligament is intact, simple radial
head resection can be provided.
–– If the medial collateral ligament is injured, 1-stage
radial head replacement can be provided.
• Mason type IV fracture: Because this type of fracture is
associated with other injuries, the stability of the elbow
joint is damaged, and radial head replacement surgery humeral
ectocondyle
should be performed to restore radial mechanical conduc-
tion and anti-valgus capability.
• Other surgical indications:
–– Open fractures should receive early emergency treat- radial head
ment (Pomianowski et al. 2001).
–– Cases with blood vessel and nerve injuries should Fig. 7.15 The black dashed line denotes the preoperative incision
receive fixation of the radial head fracture with simulta- mark by surface projection for the Kocher approach, and the red dash
neous exploration and repair of the blood vessel and line denotes the preoperative incision mark by surface projection for the
Boyd approach
nerve injuries.

7.2.1.2 Purpose of Surgery
• To restore the normal anatomy and biomechanical rela-
tionship of the elbow joint and to reconstruct elbow
stability.
• Regardless of the method, anatomical reduction, recon-
struction of joint stability, and early functional exercise
should be achieved, and elbow stiffness should be
avoided.
7.2.2 Surgical Techniques
7.2.2.1 Radial Head Fracture
Position and Preoperative Preparation
• General anesthesia or brachial anesthesia.
• For simple radial head fractures, the patient can be in the
supine position, with the affected limb placed on a radio-
lucent holder.
• For cases with other elbow injuries to be repaired at the
same time, the patient can be in the lateral position with
the affected limb on a soft pad at the chest (Fig. 7.14).
Operative Incision According to the Projection on the
Body Surface (Fig. 7.15)
• Kocher approach (Van Glabbeek et al. 2001): starting
from the rear of the lateral epicondyle of the humerus,
with oblique distal extension to 3 cm from the ulnar
olecranon.
• Boyd approach (Kocher 1911): an arc-shaped incision
starting 3 cm from the elbow along the lateral margin of
204 H. Chen et al.

the triceps downward to the lateral of the ulnar olecranon a

and then along the subcutaneous margin of the junction at
the middle-proximal 1/3 of the ulna.

Surgical Approach
• The Kocher approach is commonly used for simple radial
head fractures (Fig. 7.16):
–– The skin and subcutaneous tissue are cut along the pro-
jection of the incision to the fascia layer. The white
line of the intermuscular septum between the extensor
carpi ulnaris muscle and the elbow muscle should be
identified in the fascia layer, and an incision can be
created along this intermuscular septum.
b
–– The extensor carpi ulnaris muscle and the elbow mus-
cle are retracted to both sides to expose the articular
capsule, lateral collateral ligament complex, and supi-
nator muscle.
–– The forearm is rotated forward to move the posterior
interosseous nerve away from the incision, and the
articular capsule is cut in front of the ulnar side of the
lateral collateral ligament.
white line of
–– If further exposure is needed, the annular ligament can intermuscular
be cut, but the distance of the downward incision space
should not exceed 2 fingers from the articular surface
of the radial head to avoid the damage to the posterior
interosseous nerve.
c
• Boyd approach: For complex elbow fracture and disloca-
tion, the ulna and proximal radius can also be exposed
(Fig. 7.17).
–– The skin and subcutaneous tissue are cut along projec- supinator
tion of the incision and retracted to both sides to expose
the olecranon, elbow muscles, extensor carpi ulnaris
muscle, and medial flexor carpi ulnaris muscle.
–– An incision is created along the proximal lateral margin
of the triceps and the distal ulna and deep fascia between
the elbow muscles and extensor carpi ulnaris muscle.
The incision in the dorsal ulnar periosteum is created for
subperiosteal detachment in the deep surface of the
elbow muscle and the extensor carpi ulnaris muscle.
–– The elbow muscles and the extensor carpi ulnaris mus- Fig. 7.16 Kocher approach. (a) An incision is made from the rear of
cle are pulled outward to expose 1/3 of the ulna and the the lateral epicondyle of the humerus, with oblique distal extension to
supinator attached to the ulna. 3 cm from the distal ulnar olecranon. (b) After the skin and subcutane-
ous tissue are cut and pulled toward two sides, the white line of the
–– The forearm is rotated forward to gain access to the intermuscular septum between the extensor carpi ulnaris muscle and
ulna, and the supinator is cut, with careful protection the elbow muscle should be identified. (c) An incision can be created
of the posterior interosseous nerve of the supinator. along the white line in the intermuscular gap, and the muscles are
–– The supinator is cut and pulled outward together with retracted to both sides to expose the joint capsule and supinator muscle.
(d) The forearm is pronated to move the posterior interosseous nerve
the posterior muscle and the extensor carpi ulnaris away from the incision, and the joint capsule is cut at the site near the
muscle to expose the proximal radius at 1/4. ulna. (e, f) After the supinator muscle is pulled aside and the joint cap-
sule is cut open, the disassociated edge of the joint capsule is marked by
Fracture Reduction and Internal Fixation a suture, and the radial capitellum fracture is exposed. (g) Special atten-
tion should be paid to avoid damaging the ulnar bundle of the lateral
• Mason type II fracture not involving the radial neck: collateral ligament when cutting the annular ligament (Figure (d) repli-
–– Hematoma between bones and crushed small pieces of cates a previous figure)
cartilage are cleared.
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow 205

flexor carpi ulnaris

supinator
supinator

posterior
interosseous
nerve

anconeus pronation

radial nerve

frohse arch

fracture line

capsular incision

radial collateral
ligament
f

lateral collateral ligament

flexor carpi
ulnaris
anconeus

radial head

humeroradial capsule

Fig. 7.16 (continued)

206
a
b
triceps tendon
olecranon
anconeus
incision line
flexor carpi ulnaris
extensor carpi ulnaris
Fig. 7.17 Boyd approach. (a) After the skin and subcutaneous tissue
are cut, an incision is made along the proximal lateral margin of the
triceps and downward through the space between the ulna with the
elbow muscle and extensor carpi ulnaris muscle. (b) After subperiosteal
detachment, the elbow muscle and extensor carpi ulnaris muscle are
–– For a bone fragment with a small collapse on the mar-
gin, a periosteal stripper can be used for support for the
reduction.
–– If the bone quality is good and the bone is large, a
small pointed reduction clamp can also be used for
clamp reduction, and further comminution of the bone
fragments should be avoided.
–– A Kirschner wire is obliquely placed for temporary
fixation.
–– Lag screws are applied to fix the bone fragments with
1.5-mm or 2.0-mm headless screws. The screw head
can be buried in the cortical bone with the countersink
technique.
–– Note that the lag screw should be inserted from the safe
zone. If the position of the fracture fragment does not
allow, the screw can be placed and fixed from the safe
zone on the contralateral side of the bone. One screw
can be used for small bone fragments. Larger bone frag-
ments should be fixed by 2 screws to effectively prevent
rotation displacement of the bone fragments (Fig. 7.18).
–– After the screw is fixed, gently rotate the forearm for-
ward and backward to confirm that the internal fixation
is in the safe zone and does not obstruct movement
(Fig. 7.19).
H. Chen et al.
pulled outward to expose the supinator muscle, which is then severed at
the site close to the ulna with careful protection of the underlying radial
nerve. Subsequently, forward separation of the elbow muscle, extensor
carpi ulnaris muscle, and supinator muscle continues until the proximal
radius and ulna are exposed
• Mason type II fracture involving the radial neck (Figs. 7.20
and 7.21):
–– The radial head is exposed as described above. After
clearing the hematoma and soft tissue, significant dis-
placement of the radial head should be observed.
–– All bone fragments of the radial head are reset and
temporarily fixed with Kirschner wire, followed by the
reduction with the radial head as a whole unit. The
neck-shaft angle of the radial neck should be restored
while observing the existence of bone defects. If
autogenous bone graft is needed, a small amount of
autogenous bone can be obtained from the lateral epi-
condyle of the humerus.
–– A 1.5-mm or 2.0-mm T-shaped steel plate or a spe-
cially designed radial head anatomical locking plate
can be used for fixation of the radial head and radial
neck. If an ordinary T-shaped steel plate is used, it
should be shaped in accordance with the shape of the
radial head to avoid excessive stimulation and wear of
the annular ligament.
–– The steel plate should be placed in the safe zone; oth-
erwise, the plate will collide the proximal radioulnar
joint during pronation and supination, resulting in a
reduced range of forearm rotation.
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow 207

a b

fracture line

c
d

Fig. 7.18 (a) A periosteal stripper is used to push and hold the radial fragments that are separate from the main fragment. (d) If the position
head for reduction. (b) After reduction, a screw should be inserted per- of the fracture fragment does not allow a screw to be placed directly in
pendicular to the fracture plane to fix the fracture fragment within the the safe zone, the screw can be screwed into the fragment on the oppo-
safe zone. (c) Kirschner wires are placed for temporary fixation of large site side for fixation from the safe zone

a b c

Fig. 7.19 To confirm that the screws are in the safe zone, the relationship between the screws and the medial ulnoradial joint must be examined
radiographically while the forearm is rotated maximally. (a) Pronation position. (b) Neutral position. (c) Supination position
208 H. Chen et al.

a b

c d

e f

Fig. 7.20 (a) The bone fragments are reset and temporarily fixed. (b)
An appropriate stainless-steel plate is selected and used to fix the radius
fracture fragment through plate lag screws, which together are reduced
and fixed with the radial neck as a whole. (c) The 2.0 mm T-type regular
plate. (d, e) Various types of radial head anatomical locking plates. (f)
Screw fixation for a Mason Type II fracture involving the radial neck: In
addition to horizontal screw fixation of the bone fragment of the radial
head, an axial screw is placed from the margin of the radial cartilage
along the long axis of the radius to restore the connection of the radial
head and the radial neck
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow 209

Fig. 7.21 Radiography

during treatment for a Mason
a b
Type II fracture of the radial
head. (a, b) Preoperative
anteroposterior and lateral
X-ray images demonstrating a
radial neck fracture with
remarkable angulation
deformity. (c, d)
Anteroposterior and lateral
X-ray images after open
reduction and internal fixation
of the radial head locking
plate

c d

–– An anatomical locking steel plate is used with screws
at the radial head side to form an angle for s­ tabilization,
and multiple screws are allowed to pass through the
bone fragments to fix the fracture lines in different
directions.
–– Some scholars have reported the application of hollow
screws in the fixation of Mason type II fracture (Boyd
1940) involving the radial neck. In addition to horizontal
screw fixation of the bone fragment of the radial head, an
axial screw is placed from the margin of the radial carti-
lage along the long axis of the radius to restore the con-
nection of the radial head and the radial neck.
• Mason type III and type IV radial neck fractures
(Figs. 7.22, 7.23, and 7.24):
210 H. Chen et al.

a b

c d

e f

Fig. 7.22 Implantation of the anatomical assembled radial head
prosthesis. (a) After exposure of the radial head via the Kocher
approach, bone debris is thoroughly removed. (b) During radial head
osteotomy, the radial neck remnant should be as long as possible. (c)
The fracture ends of the radial neck are flattened with a flat head file
to ensure that at least 60% of the bone is in contact with the flat head
file. (d) The prosthesis stem gauge and radial head gauge are assem-
bled and then inserted into the bone shaft. Beginning with 0 mm,
neck gauges of different heights are inserted between the radial shaft
gauge and the radial head gauge until the radial head gauge reaches
the humeral capitellum. (e) The trial radial head prosthesis is assem-
bled and placed, and then the humeroradial, distal ulnoradial, and
humeroulnar joints are carefully examined to determine whether the
radial head prosthesis has an appropriate size. (f) The radial head
prosthesis is assembled. (g) The prosthesis is inserted with the
marker line aligned with Lister’s tubercle or laterally when the fore-
arm is in the neutral position. (h) Schematic diagram of the implanted
prosthesis
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow
g h
Fig. 7.22 (continued)
–– For Mason type III and type IV radial head fractures
that can be repaired by open reduction and fixation,
radial head resection or radial head replacement should
be selected based on the conditions of the individual
case (Smith et al. 2007; Doornberg et al. 2007).
For elderly patients with low functional recovery
requirements, radial head resection can be per-
formed, but the injury of the medial ligament and
forearm interosseous membrane should be moni-
tored during surgery.
For patients with higher requirements of functional
recovery and Mason type IV fractures associated
with other injuries, radial head replacement is
recommended.
The occurrence of Essex-Lopresti injury can be
assessed using the radial traction test proposed by
Rabinowitz (Moro et al. 2001): after surgical
resection of the radial head, with the forearm in
neutral position, traction of 9.1 kg is applied to
the proximal radius; proximal radial displacement
of greater than 3 mm suggests an interosseous
membrane tear, whereas displacement of more
than 6 mm suggests associated injury of the distal
radioulnar joint.
The valgus stress test should be performed at the
same time to check the anti-valgus stability of the
elbow and assess the integrity of the medial collat-
eral ligament.
–– All broken bone fragments of the radial capitellum
should be removed first, and thorough clearance of the
bone fragments should be confirmed under
fluoroscopy.
–– The size of the radial head prosthesis is determined:
The prosthesis trial implants are used to compare
and confirm.
After the radial bone fragments are spliced, the
diameter of the radial head is measured with the
211
mold, and a prosthesis 2 mm smaller than the actual
measurement is selected.
If the radial head has been removed, a secondary
operation can be performed to place the prosthesis.
An image of the contralateral radial head can be
captured to measure its size as a reference before
the surgery.
–– At the rear of the proximal radial neck, the radial neck
is pried with a Hohmann retractor (the Hohmann
retractor should not be placed from the front to avoid
damaging the dorsal nerve).
–– Osteotomy: A pendulum saw is used for medullary
osteotomy perpendicular to the radial neck. The scope
of excision should be minimized to avoid excessive
osteotomy, which will result in a prosthesis of insuffi-
cient length.
–– Reaming: After opening with the spine, starting from
6 mm, the diameter of reaming is gradually increased
every 0.5 mm until it is in close contact with the corti-
cal bone.
–– The fracture ends of the radial neck are flattened with
a flat head file to ensure that at least 60% of the bone is
in contact with the flat head file.
–– The prosthesis stem gauge and radial head gauge are
assembled and then inserted into the bone shaft.
Beginning with 0 mm, neck gauges of different heights
are inserted between the radial shaft gauge and the
radial head gauge until the radial head gauge reaches
the humeral capitellum.
–– The following signs can help determine whether the
height of the prosthesis is appropriate:
Separation of the coronoid process and the trochlea
suggests that the prosthesis is too high.
The radial head prosthesis should match the height
of the ulnar radial notch, and the prosthesis articular
surface should be located approximately 1 mm
from the coronoid process.
212 H. Chen et al.

b c

Fig. 7.23 Radial head fracture complicated by fracture of the medial
humeral epicondyle. (a) Preoperative anteroposterior and lateral X-ray
images demonstrating a fracture at the attachment point of the medial
collateral ligament of the medial humeral epicondyle and a Mason Type
III radial head fracture. (b) Motion function evaluation of the radial
head at different positions during elbow flexion and extension after
prosthesis implantation. (c) Intraoperative fluoroscopy image to exam-
ine the position of the radial head prosthesis to avoid a prosthesis that is
too long, and radiographic image showing a normal position relation-
ship between the humeral trochlea and coronoid process with no notice-
able separation of the coronoid process. (d) Anteroposterior and lateral
X-ray images after rivet fixation of the medial humeral epicondyle frag-
ment and reconstruction of the attachment point of the medial collateral
ligament
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow 213

Fig. 7.24 A radial capitulum

fracture complicated by
a b
fracture of the medial humeral
epicondyle. (a) Preoperative
anteroposterior X-ray image
demonstrating an avulsion
fracture at the attachment
point of the medial collateral
ligament of the medial
humeral epicondyle and a
Mason Type III radial head
fracture. (b) Preoperative
lateral X-ray image. (c)
Radial head replacement: The
proximal radial medullary
cavity is not linear but instead
has a remarkable curve.
Because the early version of
monopolar radial head
prosthesis has a straight
handle, it is important to
ensure that the handle length
is appropriate. In this patient,
the excessive length of the
handle caused an iatrogenic
fracture at the tip of the
prosthesis. The rivet was used
to repair the avulsion fracture
of the medial epicondyle of
the distal humerus
c
214
The medial and lateral spaces of the distal radioul-
nar joint and the humeroulnar joint should be
checked under fluoroscopy and compared with the
contralateral side.
–– The radial head prosthesis should be assembled and
inserted as a trial implant. Note that the anatomical
radial head prosthesis has orientation requirements
that vary for different products. In general, the prosthe-
sis should be inserted with the marker line aligned with
Lister’s tubercle or toward the outside when the fore-
arm is in the neutral position.
–– After insertion of the trial implant, the interaction of the
radial head prosthesis with the humeral capitellum and
ulnar radial notch and whether the relationship between
the coronary process and the humeral trochlea is normal
should be assessed. With gentle pronation and supina-
tion, smooth forearm movement should be observed.
–– The trial implant is removed, and the radial head pros-
thesis is assembled and inserted with the same orienta-
tion. The appropriate height of the prosthesis should be
confirmed again.
Incision Closure
• Regardless of the technique used to repair the radial head
fracture, after fixation, the annular ligament must be
sutured and repaired (Fig. 7.25).
• The stability of the elbow valgus should be re-checked. If
the medial ligament is ruptured, repair should also be per-
formed at the same time (for the repair technique, refer to
the following section on the surgical treatment of elbow
triad injury).
• If the lateral ligament bundle on the ulnar side is intraop-
eratively found to have ruptured, the rupture usually
occurs near the epicondylar ending point, and repair
should be carried out in this case; if the injury is severe
and cannot be repaired, the bundle on the ulnar side can
be reconstructed using the palmaris longus muscle (for
the repair technique, refer to the following section on the
surgical treatment of elbow triad injury).
• Conventional closure of the wound is performed, with
placement of a drainage tube.
Postoperative Treatment
• According to intraoperative injury in the medial collateral
ligament, lateral collateral ligament or both, the forearm
is temporarily fixed in backward rotation, forward rota-
tion or neutral position. The forearm should not be fixed
for longer than 3 weeks.
• Early postoperative functional exercise is emphasized. If
the postoperative elbow is stable, with no ligament repair,
reconstruction or other surgical operations, elbow flexion
H. Chen et al.
Fig. 7.25 After radial head fracture fixation, the annular ligament is
repaired with a non-absorbable suture
and extension exercises in a safe scope can be started
from the second postoperative day.
• To prevent heterotopic ossification, oral indomethacin
25 mg 3 times daily can be provided within 3 weeks after
surgery. Ulcers and gastrointestinal bleeding should also
be prevented.
7.2.2.2 Terrible Triad Injury of the Elbow
• Position and preoperative preparation: Same as radial
head fracture.
• Operative incision according to the projection on the body
surface: the posterior elbow middle approach is used (see
the section on proximal ulna fracture).
• Surgical approach:
–– Superficial dissection of the posterior elbow should be
performed with the middle approach to dissociate the
full thickness of the flap toward both sides.
–– Deep dissection follows the Kocher approach to enter
along the gap between the elbow muscle and the exten-
sor carpi ulnaris muscle.
• Fracture reduction and internal fixation:
–– Order of fracture reduction and fixation: Entering from
the lateral elbow incision, the repair should be per-
formed from the inside to the outside in the order of
coronal fracture, radial head fracture, and finally the
lateral collateral ligament.
–– Strategy for the repair of the coronoid process (the spe-
cific surgical approach is described in the section on
proximal ulna fracture):
For Regan & Morrey type I coronal fractures, an
absorbable suture can be used to suture the fracture
fragments and the articular capsule. Percutaneous
drilling is performed from the ulnar posterior mar-
gin forward to the fracture fragments, and a knot of
the suture through the bone channel is made at the
ulnar posterior margin.
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow
a b
repair anterior
suture origin joint capsule
ligament using lateral radial collateral
Bunnell stitch ligament
lateral ulnar collateral
ligament
suture the joint capsule
c d
3 mm
1 cm
equidistant point
(totational axis)
Fig. 7.26 (a, b) The lateral collateral ligament and the joint capsule are
repaired by suture: The tear in the anterior joint capsule at the proximal
humeroradial joint and in the posterior joint capsule at the rear of the
humeroradial joint are sutured without tightening. Using the Bunnell
suture technique, the ulnar and radial bundles of the lateral ligament are
sutured, and a hole is drilled at the attachment point of the lateral col-
lateral ligament on the lateral epicondyle of the humerus to fix the lat-
eral collateral ligament through the bone tunnel. (c, d) Reconstruction
of the ulna bundle of the lateral collateral ligament with autologous
Most Regan & Morrey type II and type III coronal
fractures can be fixed by a screw in the front or a
reverse plate screw in the rear of the ulna.
The fracture on the medial side of the coronoid pro-
cess should be fixed with a plate and screw through
a medial incision.
–– Strategy for radial head repair:
For radial head fracture combined with elbow triad
injury, the requirement for stability of the fixation is
higher than that for simple radial head fracture.
For non-comminuted radial head fractures, the
method of open reduction and internal fixation can
215
repair anterior
joint capsule
lateral radial collateral
ligament
lateral ulnar collateral
ligament
suture the joint capsule
tendon grafting: The distal bone tunnel for tendon insertion is drilled in
the rear of the crest nodules of the ulnar supinator muscle, with a dis-
tance between the two tunnel entrances of approximately 1 cm. A tem-
porary suture through the distal bone channel is used to identify the
equidistant point of the lateral humeral epicondyle through the elbow
during flexion and extension. A bone tunnel is created in each of the
upper and lower rears of the equidistant point, and the tendon through
the bone channel is sutured and fixed at the other end of the distal bone
tunnel
be applied for internal fixation using a lag screw or
plate screw.
For radial head fractures with 3 or more fracture
fragments, radial head prosthesis replacement sur-
gery should be performed.
• Repair or reconstruction of ligaments (Fig. 7.26):
–– In the case of elbow joint dislocation, damage occurs
from outside to inside under valgus stress. It is usu-
ally accompanied by lateral collateral ligament rup-
ture, which must be repaired by surgery. Rupture of
the lateral collateral ligament bundle on the ulnar side
often occurs near the outer epicondyle starting point.
216
–– Ligament in situ repair: If the lateral collateral liga-
ment, especially the bundle on the ulnar side, ruptures
from its starting point and the ligament condition is
still good, in situ repair is an option:
Fixation with rivet and suture: A rivet is screwed in
the humeral capitellum on the outer side of the
rotation center, and the other end is sutured with
the lateral ligament ligation bundle on the ulnar
side.
The lateral collateral ligament and the articular cap-
sule are repaired by suture: With flexion and exten-
sion of the elbow, tearing of the anterior articular
capsule at the proximal humeroradial joint and tear-
ing of the posterior articular capsule at the rear of
the humeroradial joint should be observed. The
tears are sutured without tightening. Using the
Bunnell suture technique, the lateral ligament bun-
dles on the ulnar side and the radial side are sutured,
and a hole is drilled at the attachment point of the
lateral collateral ligament on the lateral epicondyle
of humerus to fix the lateral collateral ligament
through the bone channel.
–– Reconstruction of the lateral collateral ligament bundle
on the ulnar side: For patients with poor ligament con-
dition, the tendon palmaris longus or the lateral part of
the ipsilateral triceps tendon can be reconstructed:
Autologous tendon distal fixation: The tendon dis-
tal should be fixed in the rear of the crest nodules of
the ulnar supinator muscle, with a distance between
the 2 entrances of the bone channel of approxi-
mately 1 cm.
Autologous tendon proximal fixation: The equi-
distant point of the tendon is first located, and a
temporary suture through the distal bone channel
is used to identify the equidistant point of the lat-
eral humeral epicondyle through the elbow at
flexion and extension. A bone channel is created
in the upper and lower rear of the equidistant
point, and the tendon through the bone channel is
sutured and fixed at the other end of the distal
bone channel.
If the strength of the autologous tendon is insuffi-
cient, an artificial substitute can be used for fixa-
tion. Note that the lateral collateral ligament bundle
on the ulnar side cannot be reconstructed using a
synthetic substitute alone.
With the elbow in 30° flexion and the forearm in
pronation, all sutures are tightened, and the postop-
erative stability of the affected limb in posterolat-
eral rotation is checked.
–– After repairing the lateral collateral ligament, the val-
gus stability of the elbow is checked. If the medial
H. Chen et al.
ligament is damaged, 1-stage repair can be performed
(Fig. 7.27).
–– Application of hinged external fixation (Figs. 7.28 and
7.29):
After completion of the above reduction and
internal fixation, if the elbow remains unstable or
the strength of the fixation is poor, a hinged exter-
nal fixator can be used for auxiliary fixation. The
external fixator can protect the lateral and medial
ligament while allowing early functional
exercise.
There are various models of hinged external fixator,
which should be installed in accordance with the
operating manual.
The key in installation is to accurately identify the
elbow flexion axis. Under lateral fluoroscopy, this
axis should pass through the projection center of the
2 humeral condyles. A guidewire can be drilled first
to aid positioning.
• Postoperative treatment:
–– Postoperative functional exercise should be planned
according to the preset intensity.
–– If the fixed stability cannot achieve the purpose of
early functional exercise, auxiliary fixation with a
hinged external fixator should be applied as much as
possible.
–– Early functional exercise should be emphasized.
Active flexion and extension activities can be started
2-5 days postoperatively.
–– To prevent heterotopic ossification, oral administration
of indomethacin 25 mg 3 times daily can be provided
within 3 weeks after surgery, and ulcer and gastroin-
testinal bleeding should be prevented.
7.2.3 Prevention and Treatment of Surgical
Complications (Bucholz and Court-­
Brown 2010)
• Blockage of forearm rotation by the internal fixation for
radial head and neck fracture.
–– The scope of the safe zone of the radial head should be
identified and intraoperatively confirmed by the
extreme pronation and supination of the affected limb.
The internal fixation should be strictly controlled in
the safe zone.
–– In the fixation of the radial head and radial neck frac-
tures, appropriate materials for the internal fixation
should be selected, including headless screws (or
countersunk hollow screws), micro-steel plates, and
anatomical locking steel plates. Thick and heavy mate-
rials should be avoided for internal fixation.
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow 217

Fig. 7.27 Surgical treatment

posterior median skin incision
strategic workflow for terrible
triad injury of the elbow
deep Kocher approach

internal fixation for radial head

yes no

radial head resection

fixation of coronoid process fractures through lateral approach

yes no

fixation of coronoid process fractures; fixation of coronoid process fractures through

fixation of replacement of radial head; medial approach;
repairment of radial collateral ligament fixation of replacement of radial head;
repairment of radial and ulnar collateral ligament

elbow joint is stable or not

yes no

operation ending repairment of ulnar elbow joint is stable or not

collateral ligament

yes no

operation fixation with

ending external fixator

a b c

Fig. 7.28 (a) Two Schanz screws are inserted into each of the medial
humerus and ulna and connected to the external fixator frame. The rota-
tion center of the elbow is identified. Under lateral fluoroscopy, a guide-
wire is inserted at the projection center of the two humeral epicondyles
to aid positioning. (b) The rotation shaft of the hinged external fixator
frame is assembled with the guidewire as an axis to ensure that the rota-
tion shaft overlaps with the elbow rotation center. (c) After all frame
joints are tied and the guidewire is pulled out, fluoroscopy is again con-
ducted to confirm that the external fixator frame and elbow share the
same rotation axis
218
a b
Fig. 7.29 Elbow dislocation complicated by fractures of the ulnar
olecranon, coronoid process, and radial head. (a, b) Preoperative
anteroposterior and lateral X-ray images demonstrating the fractures in
the middle segment of the ulnar olecranon and coronoid process and a
Mason Type III fracture of the radial head. (c, d) Open reduction and
–– In anatomical reduction, the angle of the radial neck
should be restored to facilitate postoperative recovery
of forearm rotation function.
• Complications after radial head replacement:
–– The diameter of the radial head prosthesis is too large:
In this case, the proximal radioulnar joint may be too
tight, and dislocation of the radial head and humeral
capitellum may even occur, thus affecting the rotation
function of the forearm.
H. Chen et al.
c
internal fixation of the radial head and ulnar olecranon are conducted
using an anatomical locking plate, headless screws are used to fix the
ulnar coronoid process, and the hinged external fixator frame is used for
early functional exercises to avoid elbow stiffness
–– The thickness of the radial head prosthesis is too large:
The resultant excessive joint support in the radial head
and humeral capitellum can cause disorders of elbow
flexion and extension and forearm rotation. This prob-
lem may occur if the longest part of the radial head is
measured to determine the length of the radial head for
excision without using a good “head flattening” treat-
ment. To prevent this mistake, the thickness of the
radial head prosthesis should be determined under flu-
oroscopy as described above.
7 Fracture of the Radial Head and Terrible Triad Injury of the Elbow
–– Orientation for the installation of the anatomical radial
head prosthesis: The anatomical radial head prosthesis
is not a perfect circle, and thus the radial head prosthe-
sis should be installed with an appropriate orientation
based on the requirements of the operating manual.
• Comparison of the long-term efficacy of open reduction
and internal fixation, radial head prosthesis replacement,
and radial head resection for radial head and radial neck
fractures:
–– Some retrospective studies have shown that, for Mason
type III fractures, especially radial head fracture asso-
ciated with elbow dislocation, the incidence of arthritis
and functional rehabilitation of the radial head resec-
tion group were worse than those of the open reduction
and internal fixation group.
–– The functional rehabilitation of the radial head replace-
ment group was better than that of the open reduction
and internal fixation group (Rabinowitz et al. 1994;
Heim 1992; Ring et al. 2002c).
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1970;21:90–4.
Boyd HB. Surgical exposure of the ulna and proximal third of the radius
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Bucholz RW, Court-Brown CM. Rockwood and Green’s fractures in
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Doornberg JN, Parisien R, van Duijn PJ, et al. Radial head arthroplasty
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Harrington IJ, Tountas AA. Replacement of the radial head in the treat-
ment of unstable elbow fractures. Injury. 1980;12:405–12.
Heim U. Surgical treatment of radial head fracture. Z Unfallchir
Versicherungsmed. 1992;85:3–11.
Herbertsson P, Josefsson PO, Hasserius R, et al. Displaced Mason
type I fractures of the radial head and neck in adults: a fif-
teen-to thirty three-year follow-up study. J Shoulder Elb Surg.
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Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood
CA, Green DP, Bucholz RW, et al., editors. Rockwood and Green’s
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Johnston GW. A follow-up of 100 cases of fracture of the head of the
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Josefsson PO, Gentz CF, Johnell O, et al. Surgical versus nonsurgical
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Kapandiji, AI, 著. 骨关节功能解剖学: 上肢. 第6版. 顾冬云, 戴尅戎,
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radial head for unreconstructable fractures of the radial head. J Bone
Joint Surg Am. 2001;83A:1201–11.
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 Fractures of the Ulnar and Radial Shaft
Hua Chen, Zhe Zhao, and Ming Li
8.1 Basic Theory and Concepts
8.1.1 Overview
• The incidence of ulnar and radial shaft fractures is rela-
tively low, accounting for approximately 0.9% of frac-
tures, with a male to female ratio of approximately 2.7:1
(Zhang 2009).
• The incidence of open fractures at the ulna and radius is
very high (approximately 11.7%), second only to tibial
shaft fractures (Koval 2006).
• The ulna and radius function as a unit. In recent years, the
connection between them has tended to be considered as
a joint, and thus forearm fracture should be treated as an
intra-articular fracture (Jupiter and Kellam 2009; Perez
2013).
• The purpose of treatment is to achieve anatomical reduc-
tion (restoring the shortening, angulation, rotation defor-
mity, and radial arch), strong internal fixation, and early
functional exercise; plate-screw treatment is the preferred
strategy (Perez 2013; Jupiter 2008).
• Simple ulnar and radius fractures are often associated
with ligament injury and joint dislocation, such as
Galeazzi fracture (Faierman and Jupiter 1998; Moore
et al. 1985a, b; Galeazzi 1934; Sarmiento et al. 1975)
(accounting for 3–7% of forearm fractures), Monteggia
fracture (Bruce et al. 1974; Burwell and Charnley 1964;
Caden 1961; Reckling and Cordell 1968; Reckling 1982;
Schatzker and Tile 1987) (accounting for 1–2% of fore-
arm fractures), and Essex-Lopresti fracture and disloca-
tion (Chow and Leung 2010).
H. Chen (*) · M. Li
Chinese PLA General Hospital, Beijing, China
e-mail: chenhua0270@133.com
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_8
8
8.1.2 Applied Anatomy
• Range of pronation and supination of the forearm and
minimum goal of postoperative recovery (Morrey et al.
1981):
–– The pronation and supination of the forearm should be
measured when the elbow is in 90° flexion; otherwise,
involvement of the inward and outward rotation of the
humerus may affect the measurement results.
–– Under normal circumstances, the forearm can pronate
by 75° and supinate by 85°.
–– After fracture of the forearm, recovery with a prona-
tion and supination range of 50° for each does not
notably affect daily life (Fig. 8.1).
• The morphological characteristics of the ulna and radius:
–– Anatomical characteristics of the ulna:
The ulna is a nearly linear long bone. The lateral
view shows a slight backward protrusion of the
ulna, and the anterior view shows a slight outward
protrusion of the ulna. This shape matches the radial
arch, thus enhancing the rotation function of the
ulna and radius.
–– Anatomical characteristics of the radius:
The radius is an irregular long bone. The lateral
view in supination shows backward protrusion of
the radius, and the anterior view shows outward
protrusion of the radius. The arch shape permits
rotation of the radius around the ulna, and the radial
arc is opposite to the ulna.
To accurately restore the shape of the radial arch in
surgery, the following measurement method for the
maximum arc of the radius is proposed. In the
anteroposterior X-ray, a straight line from the radial
tuberosity to the distal radius on the most distal
ulnar side is made, and a vertical line from the most
distal point of the radial margin of the ulnar side is
made to the above connecting line. The length of
this vertical line (a) is the maximum arc of the
radius and has an average value of 15 mm. The
221
222
0° (neutral)
50° 50°
75°
85°
supination pronation
Fig. 8.1 The forearm can normally pronate by 75° and supinate by
85°. After surgical treatment for fracture of the forearm, a restoration
recovery for both pronation and supination range to 50° does not nota-
bly affect daily life
a
x The annular ligament is attached to the front and
y back ends of the radial notch of the ulna, accounting
maximum radial bow a (mm)
x radial head. It is an important stable structure in the
lication of maximum radial bow (%) ×100%
y
Fig. 8.2 Measurement method for the maximum arc of the radius. In
the anteroposterior X-ray image, a straight line from the radial tuberos-
ity to the distal radius on the most distal ulnar side is made, and a verti-
cal line from the most distal point of the radial margin of the ulnar side
is made to the above connecting line. The length of this vertical line (a)
reflects the maximum curvature of the radius and has an average value
of 15 mm. The measurement method for the fixed-point value of the
maximum radial arc: the distance (x) from the radial tuberosity to the
point of the above maximum radial arch is divided by the full length (y)
of the radial arch to obtain a percentage
fixed-point value of the maximum radial arc is mea-
sured from the distance (x) from the radial tuberos-
ity to the point of the above maximum radial arch
and is divided by the full length (y) of the radial
arch to obtain a percentage (Fig. 8.2), which is usu-
ally 60% (Schemitsch and Richards 1992).
The anatomical morphology of the radius and its
rotation function around the ulna demand that its
fixation be performed using steel screws instead of
H. Chen et al.
annular quadrate
ligament ligament
supination
oblique or
Weitbrecht
ligament
pronation
Fig. 8.3 The ligaments relevant to the proximal ulnar and radial joints
include the annular ligament and quadrate ligament, and the quadrate
ligament is attached to the lower edge of the radial notch of the ulna and
the base of the medial radial head
intramedullary nail fixation. It is difficult to restore
the shape of the radial arch by intramedullary nail
fixation, and the anti-rotation ability is poor.
• Rotation mechanism of the forearm:
–– Proximal ulna and radial joint:
The radial notch of the ulna is located in the proxi-
mal ulna on the radial side, is covered with carti-
lage, and accounts for 1/5–1/4 of the
circumference.
for 3/4–4/5 of the circumference, and around the
proximal ulna and radial joint.
The quadrate ligament is attached to the lower edge
of the radial notch of the ulna and the base of the
medial radial head as one of the structures limiting
forearm pronation and the supination angle; in pro-
nation, its posterior fiber is in tension, while in supi-
nation, its anterior fiber is in tension (Fig. 8.3).
–– Anatomy and function of the interosseous membrane
and oblique cord:
The interosseous membrane connects between the
ulnar and radial shafts. The fiber obliquely travels
below the radial tuberosity direction down to the
lateral surface of the ulna, with a thickened middle
part known as the interosseous ligament. When the
wrist joint is under axial stress, 80% of the mechan-
ical load is on the radial wrist joint, and the remain-
ing 20% is transmitted to the forearm by the
triangular fibrocartilage complex (TFCC) and ulnar
head. The interosseous membrane plays an impor-
tant role in the process of forearm mechanical
8 Fractures of the Ulnar and Radial Shaft
radius ulna
–– The anatomical structure and stabilization mechanism
of the distal radioulnar joint:
radiocarpel ulnocarpal
joint space
compression
force
Fig. 8.4 When the wrist joint is under axial stress, 80% of the mechan-
ical load is on the radial wrist joint, and the remaining 20% is transmit-
ted to the forearm by the triangular fibrocartilage complex (TFCC) and
ulnar head. The mechanical load on the radius is transmitted to the ulna
through the interosseous membrane, of which 60% will eventually be
transmitted along the humeroradial joint and 40% through the humer-
oulnar joint
t­ransmission. The mechanical load on the radius is
transmitted to the ulna through the interosseous
membrane. Finally, 60% of the mechanical load is
transmitted along the humeroradial joint and 40%
through the humeroulnar joint (Fig. 8.4). It has been
reported that the axial stability of the forearm is
reduced by 71% after resection of the interosseous
ligament (Morrey et al. 1988; Palmer and Werner
1984; Pfaeffle et al. 2000).
The oblique cord is located in the proximal interos-
seous membrane in the shape of a flat band starting
from the lateral margin of the ulnar tuberosity and
ending slightly below the radial tuberosity. When
the forearm is in tensile tension because there is no
skeletal resistance, the oblique cord is in tension
and provides part of the anti-dislocation resistance
together with the annular ligament. In addition, the
contraction of the brachioradialis muscle also pro-
223
vides power to prevent radial dislocation (Neumann
2010a).
For extreme supination of the forearm, the interos-
seous membrane is in tension, and the oblique cord
is in relaxation, whereas for extreme pronation, the
interosseous membrane is in relaxation, and the
oblique cord is in tension. When the forearm is in
the neutral position, the distance between the 2
bones is greatest, the tensions of the interosseous
membrane and oblique cord are even, and the mus-
cles around the bone are relatively relaxed; thus, the
forearm should be fixed in the neutral position.
Ossification and poor arrangement of the interosse-
ous membrane and oblique cord will cause limited
pronation and supination of the forearm. To avoid
interlocking fracture healing of the forearm caused
by ossification, early functional exercise should be
performed after internal fixation.
Articular surface: The ulnar head is a conical expan-
sion structure, and 3/4 of its circumference is cov-
ered by articular cartilage. The articular surface is
flatter on the radial side than on the ulnar side.
When the forearm is in the neutral position, the
articular surface of the distal radioulnar joint shows
the largest contact area. In the position of extreme
rotation, the contact of the radioulnar articular sur-
face is only 10%. Therefore, in the fracture reduc-
tion process of the distal radius, the forearm should
be placed in the neutral position to obtain the larg-
est contact area of the radioulnar joint in the role of
ulnar head support and template, which is condu-
cive to fracture reduction and fixation.
The TFCC is an important structure for stabilizing
the distal radioulnar joint and the wrist joint on the
ulnar side. The cartilage disc has a double-concave
shape and is located between the ulnar head and the
carpal bone. The thickness varies with the relative
length of the ulna during the rotation of the fore-
arm. The palmar and dorsal cartilage fibers are
thickened and attached to the edge of the radial
head on the ulnar side, ending at the depth of the
ulnar head concave and the superficial layer of the
base of the ulnar styloid process (Murray et al.
1995; Wald et al. 2000; Watanabe et al. 2004)
(Fig. 8.5).
The superficial fiber bundle plays a role in stabiliz-
ing the cartilage disc and jointly conducting the
load. The deep fiber is the main structure to main-
tain the stability of the distal radioulnar joint. In
forearm pronation, the superficial dorsal fiber and
the deep palmar fiber are both in tension. By
224 H. Chen et al.

drul (superficial)

drul (deep)
ulnar styloid c

a
prul (deep)
prul (superdicial)
volar fivea
fovea

dorsal ulnar styloid

drul drul
(superficial) (deep)
radius ulna
radial shaft fracture
b

disruption of distal
radioulnar joint

axial loading result in

shortening of radius

Fig. 8.5 (a) Top view and front view of the triangular fibrocartilage
complex (TFCC). The volar and dorsal fiber bundles have two layers,
the deep layer ending at the depression of the ulnar head and the super-
ficial layer ending at the base of the ulnar styloid process. (b) The sta-
tuses of the superficial fiber bundle and cartilaginous disk in forearm
pronation and supination: the volar fiber of the superficial fiber bundle
is in tension during forearm supination, and the dorsal fiber is in tension
during forearm pronation. The deep fiber bundle shows the opposite
status, namely its dorsal fiber is in tension during forearm supination,
and its volar fiber is intension during forearm pronation (not shown in
the figure). (c) The fracture dislocation in the middle and distal radial
shaft is associated with injury of the distal radioulnar joint

c­ ontrast, in forearm supination, the superficial pal-
mar fiber and the deep dorsal fiber are both in
tension.
The probability of fracture in the middle and distal
radial shaft associated with injury of the distal
radioulnar joint is relatively high. Rettig et al.
showed that few fractures 7.5 cm or farther from the
articular surface of the distal radius are associated
with distal radioulnar fractures (Rettig and Raskin
2001).
Radius fractures often involve the distal radioulnar
joint. In surgery, the stability of the distal radioulnar
joint should be routinely checked to reveal the
injury of the distal radioulnar joint and provide
timely treatment.
–– Forearm fractures are considered intra-articular
fractures:
The proximal and distal radioulnar joints and the
ulna and radius forming the forearm can be consid-
ered an annular structure. Fracture displacement at
any of these sites may cause injury in the proximal
and distal radioulnar joints or even dislocation,
such as Monteggia fracture and Galeazzi fracture.
Therefore, the reduction requirements for forearm
fracture are high to avoid affecting its rotation
function.
Forearm fractures should be treated as intra-­
articular fractures according to the principles of
intra-articular fractures: anatomical reduction,
strong fixation, early exercise, and maximum func-
tional recovery of the affected limb.
Studies have shown that for both single and double
forearm fractures, an angle >15° can cause a signifi-
cant loss of forearm rotation function, as can
8 Fractures of the Ulnar and Radial Shaft
f­ orearm fracture deformity healing. Fracture at 1/3
of the forearm has the most significant impact on
rotation function.
–– The driving mechanism involving forearm pronation
(Neumann 2010a) (Fig. 8.6):
The shape of the radius is like a crankshaft in which
the attachment point of the brachial biceps on the
radial tuberosity and the attachment point of the
musculus pronator teres are the 2 bending points of
the crankshaft.
The muscles for pronation and supination are
divided into 2 groups: short flat muscles and long
muscles. The pronation motor muscles include the
pronator quadratus muscle (short flat muscle) and
musculus pronator teres (long muscle). The supina-
tion motor muscles include the supinator muscle
(short flat muscle) and biceps (long muscle).
The 2 muscles for executing pronation are domi-
nated by the median nerve. Of the 2 muscles for
executing supination, the supinator is dominated by
the radial nerve, and the biceps is dominated by the
musculocutaneous nerve. Thus, in cases featuring
nerve damage, pronation movement is more
susceptible.
The relationship between the site of radius fracture
and the displacement of muscle retraction: for frac-
ture in the proximal 1/3 of the radius, the fracture
a b
x
1
x
x´
S P
Fig. 8.6 (a) The shape of the radius is like a crankshaft, and its rotation
involves two group of muscles, short flat muscles and long muscles. (b)
In a fracture in the proximal 1/3 of the radius with the fracture line
located at the proximal end of the pronator teres, pulling force from the
supinator muscles causes a supination dislocation of the proximal frag-
ment and that of the pronator muscles causes a pronation dislocation of
225
line is located at the proximal ending of the prona-
tor teres, and both fracture ends are affected by the
antagonized muscles, with distal supination and
proximal pronation. For fracture at the middle of
the radius, the fracture line is located at the distal
end of the pronator teres, and the fracture displace-
ment caused by antagonism of the pronator teres is
small.
–– The axis of forearm rotation (Neumann 2010b)
(Fig. 8.7):
The axis of the radius in rotational movement is
the connecting line from the center of the radial
head to the center of the ulna. When the radius
rotates around this axis, its trajectory is in a coni-
cal shape.
The actual movement is more complex than the
above theoretical model, including the ulnar swing.
In the supination position, the distal ulna is shorter
than the distal radius by 1.5–2.0 mm, and this is the
normal length for the ulnar bias and radial styloid
process. In the pronation position, the radius tilts
compared to the position of the ulna, and thus the
relative length of the ulna is increased, and the dis-
tal ulna exceeds the distal radius by 2.0 mm. Due to
the change in the relative length of the ulna, the
length of the radius in forearm fracture should be
restored to ensure normal length of the ulna and
the distal fragment, both fracture ends show significant dislocation. In a
fracture in the middle 1/3 of the radius with the fracture line located at
the distal end of the pronator teres, the proximal fragment has a rela-
tively slight dislocation due to antagonism between the supinator mus-
cles and the pronator teres, while the pronator quadratus causes a
pronation dislocation of the distal fragment
226 H. Chen et al.

Fig. 8.7 (a) The axis of the a b

radius in rotational
movements is the connecting
line from the center of the
radial head to the center of the
ulna. (b) When the radius
rotates around this axis, its
trajectory exhibits a conical
shape. (c) In the supination
position, the distal ulna is
shorter than the distal radius
by 1.5–2.0 mm, and in the
pronation position, the distal
ulna exceeds the distal radius
by 2.0 mm

radial styloid; otherwise, forearm pronation will
cause wrist discomfort or pain.
• The Henry muscle group (Fig. 8.8) includes the extensor
carpi radialis brevis, extensor carpi radialis longus mus-
cle, and brachioradialis muscle, starting from the lateral
humeral epicondyle and downward along the lateral fore-
arm. When the radius is revealed, it is called the “moving
extensor bundle.” The bone surface of the radius can be
easily exposed between the lateral muscle group and the
musculus extensor digitorum (Thompson approach)
(Thompson 1918) or between the medial and radial flexor
carpi (Henry’s approach) (Henry 1973).
• Arcade of Frohse (Fig. 8.9): Shortly after the interosseous
dorsal nerve begins, it enters the fibrous structure of the
supinator in an upward arch bridge shape known as the
arcade of Frohse or supinator arch. The arch can show
mixed features of tendon, muscle, and membrane. In fore-
arm rotation, the posterior interosseous nerve in the supi-
nator will move with this movement. Accordingly, the
posterior interosseous nerve can be indirectly protected
during surgery based on the rotation position of the fore-
arm. For the anterior Henry approach, while creating the
incision at the ending point of the supinator, the forearm
should be rotated backward to move the posterior interos-
seous nerve away from the surgical operation site.
8.1.3 Mechanisms of Injury
• Direct violence:
–– High-energy injury can be caused by car accidents and
is often accompanied by soft tissue injury and open
fractures.
–– Most fractures of the ulnar shaft are caused by direct
violence and are commonly known as baton fractures
(Chow and Leung 2010).
8 Fractures of the Ulnar and Radial Shaft 227

a b –– Gunshot damage is a high-energy injury and is often

accompanied by bone defects and injury of soft tissue,
nerves, and vessels.
• Indirect violence:
–– Indirect effects of crashes, falling, and sport injuries
and conduction of longitudinal stress can cause
fractures.
–– The axial load on the forearm when the arm is stretched
may lead to Galeazzi fracture. With the forearm in the
supination position, the fracture end at the distal radius
is toward the palm side; with the forearm in the prona-
tion position, the fracture end at the distal radius is
toward the dorsal side (Fig. 8.10).

8.1.4 Classification of Fractures

• AO classification of forearm fractures (Fig. 8.11): The

Fig. 8.8 (a) Rearview of forearm muscles. The three muscles on the
radial side of the blue dashed line are the extensor carpi radialis brevis,
extensor carpi radialis longus muscle, and brachioradialis muscle, con-
stituting the Henry muscle group. (b) Volar view of forearm muscles:
the muscles on the radial side of the blue dash line are the brachioradia-
lis muscle, extensor carpi radialis longus muscle, and extensor carpi
radialis brevis
AO/OTA classification is commonly used for forearm
fractures (Muller 1990) and is important for the epidemi-
ological statistics and scientific research. However, it
should be noted that the AO classification does not include
all injuries associated with ulnar and radius fractures, and
thus some traditional classification methods are still
widely used in clinical practice.
–– Type A is simple fracture (Fig. 8.11a):
Type A1 involves the ulna only: type A1.1 is oblique
ulna fracture; type A1.2 is the transverse ulna frac-

Fig. 8.9 Arcade of Frohse is

radial n.
a fibrous structure of the arcade of frohse
supinator with an upward arch
bridge shape. In the supinator
supination position of the
forearm, the posterior
interosseous nerve is in supination
positioned away from the
proximal radius

biceps tendon
biceps tubercle

in pronation
228
Fig. 8.10 When the arm is a b
stretched to support the body
while falling, the force that
longitudinally transmits along
the forearm will cause a
Galeazzi fracture. (a) If the
forearm is in the supination
position, then the distal
fracture end is toward the
palm side. (b) If the forearm
is in the pronation position,
then the distal fracture is
toward the dorsal side
ture; type A1.3 is simple ulna fracture with radial
head dislocation (Monteggia fracture).
Type A2 involves the radius only: type A2.1 is
oblique radius fracture; type A2.2 is transverse
radius fracture; type A2.3 is radius fracture with
distal radioulnar joint dislocation (Galeazzi
fracture).
Type A3 is fracture of both bones, which may be
combined with proximal and distal radioulnar joint
dislocation. According to the plane involved in the
radius fracture, that is, the upper, middle, and lower
1/3 segments, it is divided into types A3.1–3.
–– Type B is wedge fracture (Fig. 8.11b):
Type B1 involves the ulna only: type B1.1 is ulna
fracture associated with an intact butterfly-shaped
bone fragment; type B1.2 is ulna fracture with a
crushed butterfly-shaped bone fragment; type B1.3
is ulnar wedge fracture with radial head dislocation
(Monteggia fracture).
Type B2 involves the radius only: type B2.1 is
radius fracture associated with an intact butterfly-­
shaped bone fragment, and the bone fragment is
intact; type B2.2 is radius fracture with a crushed
butterfly-shaped bone fragment; type B2.3 is radial
wedge fracture with distal radioulnar joint disloca-
tion (Galeazzi fracture).
Type B3 is fracture involving both bones: type B3.1
is ulnar wedge fracture with simple radius fracture,
type B3.2 is ulnar simple fracture with radial wedge
fracture; type B3.3 is ulnar wedge fracture with
radial wedge fracture.
–– Type C fracture is complex fracture (Fig. 8.11c):
Type C1 is complex ulna fracture: type C1.1 is ulna
fractures at 2 sites, while the radius is intact, and
may be combined with radial head dislocation
(Monteggia fracture); type C1.2 is ulna fractures at
H. Chen et al.
2 sites, while the radius has a simple fracture or
wedge fracture; type C1.3 is irregular ulna fracture,
while the radius has a simple fracture or wedge
fracture.
Type C2 is complex radius fracture: type C2.1 is
radius fracture at 2 sites, while the ulna is intact,
and may be combined with distal radioulnar joint
dislocation (Galeazzi fracture); type C2.2 is radius
fracture at 2 sites, while the ulna has a simple frac-
ture or wedge fracture; type C2.3 is irregular radius
fracture, while the ulna has a simple fracture or
wedge fracture.
Type C3 is complex fracture of both the ulna and
radius: type C3.1 is fracture at 2 sites including both
the ulna and the radius; type C3.2 is 2-site fracture
of either the ulna or radius, with irregular fracture in
the other bone; type C3.3 is irregular fracture in
both the ulna and radius.
• Bado classification of Monteggia fractures (Fig. 8.12):
Initially, Monteggia only described the fracture between
the proximal 1/3 of the ulna and the base of the olecranon,
combined with proximal radioulnar anterior dislocation.
Bado subsequently extended this description to include
ulna fractures with radial head dislocation at any level
(Bado 1967). Monteggia fractures account for 1–2% of
forearm fractures. Monteggia fractures are divided into 4
types. Type II accounts for 59–79% of fractures in adult
patients, type I accounts for 15–30% (Konrad et al. 2007;
Ring et al. 1998; Jupiter et al. 1991), and the other 2 types
are rare.
–– Type I: Ulna fracture with a forward angle at the frac-
ture site and associated with radial head dislocation.
–– Type II: Ulna fracture with a backward angle at the
fracture site and associated with radial head disloca-
tion; Jupiter further divided it into 4 subtypes accord-
ing to the site of the ulna fracture:
8 Fractures of the Ulnar and Radial Shaft
A1.1
A2.1
A3.1
Fig. 8.11 (a) Type A is a simple fracture. Type A1 involves the ulna
only, including Type A1.1 (oblique ulna fracture), Type A1.2 (trans-
verse ulna fracture), and Type A1.3 (simple ulna fracture with radial
head dislocation (Monteggia fracture). Type A2 involves the radius
only, including Type A2.1 (oblique radius fracture), Type A2.2 (trans-
verse radius fracture), and Type A2.3 (radius fracture with distal radio-
ulnar joint dislocation (Galeazzi fracture)). Type A3 is a fracture of both
bones, which may be combined with proximal and distal radioulnar
joint dislocation. According to the plane involved in the radius fracture,
that is, the upper, middle, and lower 1/3 segments, type 3 fractures are
divided into types A3.1, A3.2, and A3.3, respectively. (b) Type B is a
wedge fracture. Type B1 involves the ulna only, including Type B1.1
(ulna fracture with an intact butterfly-shaped bone fragment), Type
B1.2 (ulna fracture with a crushed butterfly-shaped bone fragment), and
Type B1.3 (ulnar wedge fracture with radial head dislocation
(Monteggia fracture)). Type B2 involves the radius only, including Type
B2.1 (radius fracture with an intact butterfly-shaped bone fragment),
Type B2.2 (radius fracture with a crushed butterfly-shaped bone frag-
ment), and Type B2.3 (radial wedge fracture with distal radioulnar joint
dislocation (Galeazzi fracture)). Type B3 is a fracture involving both
229
A1.2 A1.3
A2.2 A2.3
A3.2 A3.3
bones, including Type B3.1 (ulnar wedge fracture with simple radius
fracture), Type B3.2 (ulnar simple fracture with radial wedge fracture),
and Type B3.3 (ulnar wedge fracture with radial wedge fracture). (c)
Type C is a complex fracture. Type C1 is complex ulna fracture: Type
C1.1 is an ulna fracture at two sites, while the radius is intact, and it
may be combined with radial head dislocation (Monteggia fracture);
Type C1.2 is an ulna fracture at two sites, while the radius has a simple
fracture or wedge fracture; and Type C1.3 is an irregular ulna fracture,
while the radius has a simple fracture or wedge fracture. Type C2 is a
complex radius fracture: Type C2.1 is radius fracture at two sites, while
the ulna is intact, and may be combined with distal radioulnar joint
dislocation (Galeazzi fracture); Type C2.2 is radius fracture at two sites,
while the ulna has a simple fracture or wedge fracture; and Type C2.3 is
an irregular radius fracture, while the ulna has a simple fracture or
wedge fracture. Type C3 is a complex fracture of both the ulna and
radius: Type C3.1 is a fracture at two sites, including both the ulna and
the radius; Type C3.2 is a two-site fracture of either the ulna or radius,
with an irregular fracture in other bone; and Type C3.3 is an irregular
fracture in both the ulna and radius
230
b c
B1.1 B1.2 B1.3
B2.1 B2.2 B2.3
B3.1 B3.2 B3.3
Fig. 8.11 (continued)
Type IIa: Fracture in the olecranon and coronoid
processes.
Type IIb: Fracture in the metaphysis and the transi-
tion zone of the shaft.
Type IIc: Fracture in the ulnar shaft.
Type IId: Fracture in the proximal 1/2 of the ulna.
–– Type III: Ulnar metaphyseal fracture with lateral or
anterolateral displacement of the radial head.
–– Type IV: Fracture of the ulna and the proximal 1/3 of
the radius at the same level with radial head
dislocation.
• Galeazzi fracture is radial shaft fracture combined with
ulnar joint dislocation. According to the distance of the
fracture line from the distal articular surface of the dis-
tal radius, it is divided into 2 types: the probabilities of
distal radioulnar joint instability for type I and type II
are 55% and 60% (Rettig and Raskin 2001),
respectively.
–– Type I: The fracture is in the distal 1/3 of the radius,
with a distance of the fracture line from the articular
surface of the distal radius of less than 7.5 cm.
H. Chen et al.
C1.1 C1.2 C1.3
C2.1 C2.2 C2.3
C3.1 C3.2 C3.3
–– Type II: The fracture is located in the middle 1/3 of the
radius, with a distance of the fracture line from the artic-
ular surface of the distal radius of greater than 7.5 cm.
8.1.5 Assessment of Ulnar and Radius
Fracture
8.1.5.1 Clinical Assessment
• Typical manifestations: The forearm of the affected limb
shows malformations, pain, and swelling, with hand and
forearm dysfunction.
• Check the blood supply of the forearm, with palpation of
the pulse for the radial artery and ulnar artery.
• Check the sensory and motor functions of the median
nerve, radial nerve, and ulnar nerve.
• Check the skin, except for open fractures; because the
ulna is in the subcutaneous area, a very superficial wound
can cause open fractures.
• Check the soft tissue tension of the forearm. Unbearable
and persistent pain, especially pain induced by the passive
8 Fractures of the Ulnar and Radial Shaft
I
II
IV
III
Fig. 8.12 Bado classification of Monteggia fractures. Type I: Ulnar
shaft fracture with a forward angle at the fracture site complicated by
forward dislocation of the radial head. Type II: Ulnar shaft fracture with
a backward angle at the fracture site complicated by backward disloca-
tion of the radial head. Type III: Ulnar metaphyseal fracture with lateral
or anterolateral displacement of the radial head. Type IV: Fracture in the
proximal 1/3 of both the ulna and radius at the same level complicated
by forward dislocation of the radial head
extension of the fingers, strongly suggests the possibility
of forearm osteofascial compartment syndrome. The fore-
arm fascia compartment pressure can be measured for
early diagnosis. Once diagnosed, surgical decompression
should be performed as soon as possible.
8.1.5.2 Imaging Assessment
• X-ray in the anteroposterior, lateral, and oblique
positions.
–– Radiological examination must include the wrist and
elbow to determine whether the fracture is associated
with radioulnar joint dislocation (Fig. 8.13).
–– A line is drawn crossing the radial shaft and radial
head and should be through the humeral head regard-
less of the location of the elbow.
–– For a normal lateral radiograph, the rear edge of the
ulna should be a straight line. In Bado type I Monteggia
fracture, the ulnar arch sign can be observed with for-
ward arch protrusion of the ulnar margin.
–– In radius fracture, the following signs suggest injury in
the distal radioulnar joint:
Fracture at the base of the ulnar styloid process
Widened distal radioulnar joint at the anteroposte-
rior position
Ulnar subluxation at the lateral position
Radial shortening >5 mm
231
• CT scan can provide a detailed assessment of the ana-
tomical relationship between the proximal and distal
radioulnar joints, especially a 3-dimensional CT scan,
which can stereoscopically reveal the degree of commi-
nution of the fracture and the dislocation of the proximal
and distal radioulnar joints.
8.2 Surgical Treatment
8.2.1 Surgical Indications and Purpose
8.2.1.1 Surgical Indications
Forearm fractures in adults are considered intra-articular
fractures. Except for simple distal 2/3 ulnar close fractures
with no displacement (angle <10° and relative displacement
<50%), which can be treated with conservative treatment,
surgical treatment should be provided for all cases (Chow
and Leung 2010).
8.2.1.2 Purpose of Surgery
To restore the length and curvature of the ulna and radius; to
restore the normal anatomical relationship of the proximal
and distal radioulnar joints; to restore the rotation axis of the
radius; solid internal fixation; early functional exercise
(Jupiter 2008; Perez 2013).
8.2.2 Surgical Techniques
Selection of surgical procedure
• Simple radius fractures, including Galeazzi fractures:
–– Palmar Henry approach: This approach can expose the
entire length of the radius. This approach is especially
useful for fractures of the proximal and distal 1/3 of the
radius because the posterior interosseous nerve of the
proximal 1/3 of the radius is in the supinator, the ante-
rior approach can cut the supinator the starting point for
subperiosteal stripping, and the posterior interosseous
nerve can be protected with the supinator. The disadvan-
tage of Henry’s approach is that the position is deep and
the anatomy is complex, and thus, a certain level of
experience of the surgeon is required (Perez 2013).
–– Dorsal Thompson approach: This approach is suitable
for proximal and middle dorsal exposure of the radius.
For this approach, the supinator must be cut to reveal
the proximal 1/3 of the radius, and the posterior inter-
osseous nerve should be carefully protected at this
time to avoid injury. In addition, in the operation of the
middle of the radius, the extensor pollicis brevis mus-
cle and the abductor pollicis longus tunnel must be
crossed, and the exposure is not as good as in the
Henry approach (Thompson 1918).
232
a b
Fig. 8.13 Radiological examination of the forearm must include the
wrist and elbow joints to determine whether the fracture is complicated
by proximal or distal radioulnar joint dislocation. (a, b) X-ray images
showing a middle-to-distal radius fracture complicated by a widened
• Simple ulna fracture, including Monteggia fractures: The
ulna fracture approach is relatively simple because the
dorsal side is close to the subcutaneous layer, and the dor-
sal approach can be used.
• Double fracture of the ulna and radius:
–– Double incision is recommended, with the anterior
Henry approach for the radius and the conventional
dorsal approach for the ulna, to ensure the width of the
bridge and reduce incision complications.
Position and Preoperative Preparation
• Brachial plexus anesthesia or general anesthesia.
• The patient is lying on the operating table.
• The Thompson approach is applied for the treatment of
simple radius fractures, with the affected limb placed on
the holder on the chest.
• The Henry approach is applied for the treatment of simple
radius fractures or forearm double fracture, with the
affected limb outstretched flat on the holder next to the
operating table (Fig. 8.14).
• For simple ulna fracture, the affected limb of the forearm
is placed on the arm support holder on the chest, with the
forearm in the neutral position.
H. Chen et al.
c d
distal radioulnar joint. (c, d) X-ray images showing a proximal ulna
fracture complicated by dislocations of the proximal radioulnar and
humeroradial joints
Operative incision according to the projection on the
body surface (Fig. 8.15)
• Radial dorsal Thompson approach: A connecting line is
drawn from the lateral epicondyle of the humerus to
Lister’s tubercle of the dorsal distal radius, and the inci-
sion is extended toward both sides with the fracture site as
the center. The incision length is determined based on the
required exposure of the radius.
• Radial palmar Henry approach: A connecting line is drawn
from the level of the cubital crease from the lateral biceps
tendon to the radial styloid process, and the incision scope is
determined based on the required exposure of the radius.
• Ulnar approach: A connecting line is drawn along the
olecranon to the ulnar styloid process, with the fracture
site as the center, and the incision length is determined
based on the required exposure of the ulna.
Surgical approach
• Radial dorsal Thompson approach (Fig. 8.16):
–– The skin and subcutaneous tissue are cut, and the ana-
tomical space between the extensor communis digitorum
and the extensor carpi radialis brevis muscle is identified.
The 2 muscles are connected to the same aponeurosis at
the proximal end. At the distal end, the abductor pollicis
8 Fractures of the Ulnar and Radial Shaft 233

Fig. 8.14 (a) The affected a b

limb of the forearm is placed
on the holder in the pronation
position on the chest. (b) The
affected limb is abducted with
the forearm in the supination
position and placed on the
holder beside the operating
table

malleolus radialis

Lateral epicondyle of
a b humerus
Lister’s tubercle

Radial styloid process

Lateral epicondyle of humerus

Ulnar styloid process

Ulnar olecranon

Fig. 8.15 The preoperative incision marked by surface projection for approach: a connecting line is drawn from the lateral biceps tendon to
common surgical approaches. (a) Radial dorsal Thompson approach: a the radial styloid process. (c) Ulnar approach: a connecting line is
connecting line is drawn from the lateral epicondyle of the humerus to drawn between the ulnar olecranon and the ulnar styloid process
Lister’s tubercle of the dorsal distal radius. (b) Radial palmar Henry
234 H. Chen et al.

Fig. 8.16 (a) After the skin and subcutaneous a Extensor carpi radialis longus
tissue are cut, the anatomical space between the and brevis tendon
extensor communis digitorum and the extensor abductor pollicis longus
carpi radialis brevis muscle is identified. (b) A
separation is performed along the identified space Fascia over extensor carpi
between the extensor communis digitorum and radialis brevis
the extensor carpi radialis brevis muscle. (c) The
supinator muscle and musculi abductor pollicis
longus and the deep branch of the radial nerve are Fascia over extensor
extensor pollicis longus
exposed. (d) After the supinator muscle is cut at carpi radialis longus
its ending point in front of the radius, the deep
extensor pollicis brevis
branch of the radial nerve and musculi abductor
pollicis longus are pulled laterally to expose the
proximal end of the radius, paying special incision
attention to avoid damaging the radial nerve deep
branch and its sub-branches. The extensor carpi Extensor digitorum communis
radialis brevis and musculi abductor pollicis Extensor carpi radialis longus
longus are pulled toward the sides to expose the b and brevis tendon
distal end of the radius
extensor pollicis brevis
abductor pollicis longus

extensor carpi radialis brevis

extensor pollicis longus

Extensor digitorum communis

Extensor carpi radialis longus

c and brevis tendon

abductor pollicis longus

radius
pronator teres

extensor pollicis longus

extensor pollicis brevis

Extensor digitorum communis

posterior interosseous nerve

supinator

d extensor pollicis brevis

abductor pollicis longus
pronator teres
(stripped)

Distal radius
periosteum
radius
supinator
posterior interosseous nerve
8 Fractures of the Ulnar and Radial Shaft 235

longus muscle and the extensor pollicis brevis muscle
pierce from this space, and thus, this anatomical space
can be easily identified at the distal end.
–– The deep fascia between the 2 muscles is cut, followed
by retraction to both sides to expose the supinator and
the deep branch of the radial nerve through these parts,
which should be carefully protected. Care should be
taken to avoid damaging the muscle branch of the
supinator.
–– Exposure of the proximal 1/3 of the radius:
• With the forearm in the extreme supination position, the
supinator is longitudinally cut at the starting point of the
supinator (the radial nerve deep branch in the muscle
should be carefully protected when cutting the supinator),
followed by the subperiosteal stripping of the supinator to
expose the proximal 1/3 of the radius.
• Exposure of the middle 1/3 of the radius:
An incision is created along the upper and lower mar-
gins of the abductor pollicis longus muscle and the
extensor pollicis brevis muscle, which are separated
with the extensor carpi radialis longus and the extensor
carpi radialis brevis in the deep surface, and the radial
periosteum should be reached along the ulnar margin of
the extensor carpi radialis brevis to expose the radius.
At this time, the extensor carpi radialis longus and the
extensor carpi radialis brevis are operated as an entity,
with retraction to both ends to fully expose the radius.
–– Exposure of the distal 1/3 of the radius:
An incision is created between the extensor carpi
radialis brevis and extensor pollicis longus tendon
to reach the radial surface.
• Radial palmar Henry approach (Figs. 8.17 and 8.18):
–– The skin and subcutaneous tissue are cut and pulled to
both sides to expose the brachioradialis and the flexor
carpi radialis muscle.
–– The deep fascia between the brachioradialis and the
flexor carpi radialis muscle is cut to dissociate the
anterior margin of the brachioradialis.
–– The brachioradialis muscle is pulled to the rear to dis-
sect the superficial branch of the radial nerve (deep
surface of the brachioradialis muscle), which is
retracted using a rubber band for protection.
–– All branches originating from the lateral radial artery
of the flexor carpi radialis muscle (especially the radial

Fig. 8.17 (a) The space a

between the brachioradialis
and the flexor carpi radialis brachioradialis
muscle is cut to expose the
deep radial artery and its superficial branch of
branches. (b) All radial artery radial nerve
branches on the radial side
(especially the radial recurrent
artery) are ligated. Next, the
brachioradialis muscle and
the superficial branch of the
radial nerve are pulled toward radial artery
the lateral together, while the
radial artery and the flexor supinator
carpi radialis muscle are
pulled together toward the pronator teres
medial. As a result, the flexor carpi radialis
attachment points of the
pronator quadratus, musculi
flexor pollicis longus, brachioradialis
pronator teres, musculus
b
supinator incision
flexor digitorum superficialis,
superficial branch of radial nerve
and supinator muscle on the
radius are exposed pronator teres tendon
musculus flexor digitorum sublimis

extensor carpi radialis longus

pronator quadratus

biceps brachii tendon

recurrens radialis
(ligation)
radial artery
flexor carpi radialis
236 H. Chen et al.

Fig. 8.18 The entire radius is superficial branch

exposed by cutting the fascia in of radial nerve
the gap along the lateral margin biceps brachii tendon
brachioradialis
of the pronator quadratus, the a
lateral of the starting point of
supinator
the musculi flexor pollicis
longus, and the medial position radius
of the ending points of the pronator teres
pronator teres and supinator
muscle. (a) The anatomic musculus flexor
position of the deep branch of digitorum sublimis
radial nerve passing through the
supinator muscle. With the superficial branch of
forearm is in the supination radial nerve
position, the supinator is cut
arcade of Nervus radialis
along the medial margin at the
flexor carpi radialis Forhse
starting point of the supinator to
avoid damaging the radial supinator
radial artery
nerve, followed by subperiosteal
stripping of the supinator and
retraction of the supinator
muscle toward the lateral side to radius
expose the proximal 1/3 of the biceps brachii tendon
radius. (b) With the forearm in ulna biceps brachii bursa
the pronation position, the
ending point of the pronator
teres and the starting point of
the flexor digitorum superficialis radius
muscle are exposed, severed,
b supinator
and dissociated toward the
medial side to expose the superficial branch of radial nerve
middle 1/3 of the radius. (c)
With the forearm in the neutral
brachioradialis
position or slight supination, the
attachment point of the pronator
quadratus muscle is severed,
and the muscle is retracted biceps brachii tendon
toward the medial side to
expose the distal 1/3 of the
radius flexor carpi radialis

biceps brachii bursa

pronator teres
periosteum
incision
Radial styloid brachioradialis
process biceps brachii tendon
supinator
c
radius
superficial branch of
radial nerve

radial artery
flexor carpi radialis
8 Fractures of the Ulnar and Radial Shaft
returning artery) are identified to perform the ligation
and truncation; the radial artery is retracted to the ulnar
side for protection, and the radial superficial branch is
retracted to the outside with the brachioradialis
muscle.
–– Exposure of the proximal 1/3 of the radius:
With the forearm in the extreme supination posi-
tion, the supinator is longitudinally cut at the start-
ing point of the supinator (the radial nerve deep
branch in the muscle should be carefully protected
when cutting the supinator), followed by subperios-
teal stripping of the supinator.
–– Exposure of the middle 1/3 of the radius:
With the forearm in pronation position to expose
the ending point of the pronator teres, the pronator
teres is cut at the ending point for medial retraction;
the same method is used to treat the ending point of
the flexor digitorum superficialis muscle in the dis-
tal end.
Fig. 8.19 (a) After the skin a
and subcutaneous tissue are
cut to expose the extensor
carpi ulnaris and flexor carpi
ulnaris, the fascia is cut
between the two muscles. (b)
A separation is made toward
both sides to expose the ulnar
anterior fascia of anconeus
shaft
extensor carpi ulnaris
anconeus
237
–– Exposure of the distal 1/3 of the radius:
With the forearm in the neutral position or slight
supination, the flexor pollicis longus muscle and the
pronator quadratus muscle are cut at the starting
point of the attachment, followed by medial
retraction.
• Ulnar approach (Fig. 8.19):
–– The skin and subcutaneous tissue are cut to identify the
extensor carpi ulnaris and flexor carpi ulnaris.
–– The deep fascia between the 2 muscles is cut and
dissociated toward both sides to expose the ulnar
shaft.
Fracture Reduction and Internal Fixation
• Monteggia fracture (Perez 2013):
–– Reduction of ulna fracture should be performed first.
The shape of the ulna is relatively regular, with a
slight forward bend, and thus the selected DCP or
LCP steel plate can be slightly shaped to fit the ulnar
extensor carpi ulnaris
incision
flexor carpi ulnaris
ulna periosteum
flexor carpi ulnaris
ulna
238
• Galeazzi Fracture:
Fig. 8.20 For a Monteggia fracture, reduction of the ulna fracture
should first be performed, which is usually accompanied by natural
reduction of the radial head
shape. The steel plate and ulna can be temporarily
fixed with a reduction clamp, and the reduction of the
radial head should be checked.
–– Normally, after the ulna is reset, reduction of the radius
will be achieved. Failure to reset the radial head is
mostly due to poor reduction in the ulna, and thus the
reduction of the ulna should be checked (Fig. 8.20).
–– The position of the radial head should be examined
after the reduction. As mentioned earlier, the straight
line connecting the radial shaft and the radial head
should pass through the humeral capitellum, regard-
less of the location of the elbow. The reduction of the
radial head should be confirmed under fluoroscopy
from more than 2 angles of perspective (Mast et al.
1989) (Fig. 8.21).
–– For a small number of patients, the radial head cannot
be reset after reduction of the ulna. In this case, the
elbow muscle and ulnar flexor carpi fascia can be cut
following the Kocher approach in the previous section
to reset the radial head under direct vision. Failure to
reset can be caused by pressure of the annular ligament
after radial head dislocation. In this case, the annular
H. Chen et al.
ligament can be cut off and repaired after reduction of
the radial head.
–– After confirming the reduction of the radial head, the
ulna fracture should be finally fixed. The plate-screw
fixation technique is described in the section on
humeral shaft fracture.
–– The reduction of radius fracture should be performed
first. The shape of the radius is irregular, and anatomical
reduction is required to restore the normal arc of the radial
arch and the normal rotation function of the forearm.
–– In recent years, some scholars have designed an ana-
tomical locking plate for the fixation of middle and
proximal radius fractures with a preset arc correspond-
ing to the radial arch based on radial anatomical mor-
phology. The steel plates generally have 2 designs,
which can be placed on the lateral radius and the palm
side of the radius (Fig. 8.22). The anatomical shape of
the plate can be used as a template to assist reduction
of the fracture and to reduce surgical procedures such
as pre-shaping of the steel plate.
–– In general, after anatomical reduction of the radius, the
distal radioulnar joint should be automatically reset,
but the stability of the distal radioulnar joint should be
carefully examined (Fig. 8.23). The following signs
suggest that the distal radioulnar joint is unstable
(Bock et al. 1992; Bruckner et al. 1992):
Large resistance in resetting
Fracture in the ulnar styloid process base
Widened distal radioulnar joint at the anteroposte-
rior position
Ulnar subluxation at the lateral position
Radial shortening >5 mm
–– For a small number of patients, the distal radioulnar
joint cannot be reset after reduction of the radius,
which may be because the tendon of the flexor carpi
ulnaris, the tendon of the extensor digiti minimi, and
the tendon of extensor digitorum communis are stuck
in the distal radioulnar joint. In this case, a small inci-
sion is needed to remove the soft tissue under pressure
and reset the distal radioulnar joint (Bruckner et al.
1992; Cetti 1977; Itoh et al. 1987; Jenkins et al. 1987).
–– After the radius fracture and distal radioulnar joint are
reset, the forearm should be rotated to check the stabil-
ity of the distal radioulnar joint again. If the distal
radioulnar joint is unstable at any angle, the following
measures should be applied:
If the distal radioulnar joint is stable in the supina-
tion position, direct plaster fixation for 4–6 weeks
can be provided.
If the distal radioulnar joint is unstable in the supi-
nation position, one to two 2-mm Kirschner wires
can be used for cross-fixation. After 6 weeks, the
Kirschner wires are removed, and active rotation
8 Fractures of the Ulnar and Radial Shaft 239

Fig. 8.21 A proximal ulnar

fracture complicated with a
a
dislocation of the radial head.
(a, b) Preoperative
anteroposterior and lateral
X-ray images demonstrating a
fracture in the proximal
segment of the ulna. (c, d)
The plate-screw fixation
technique is used to fix the
proximal ulnar fracture,
restoring the length of the
ulna and normal position of
the radial head, and plaster
fixation is applied for
postoperative protection

c d
240 H. Chen et al.

b c

Fig. 8.22 Pre-shaping of an anatomical locking plate for fixation of The plate on the palm side of the radius. (c) The plate on the lateral side
ulna and radius fractures based on morphologies of the ulnar and radial of the radial shaft
arches. (a) The re-shaped plate closely contacts the bone surface. (b)

a b

Fig. 8.23 Example of a Galeazzi fracture. (a) Preoperative anteropos- ture is anatomically reduced and fixed with an LCP plate; after reduc-
terior and lateral X-ray images of the forearm demonstrating the wid- tion of the distal ulnoradial joint is confirmed, a plaster brace is applied
ened distal radioulnar joint, suggesting that the distal radioulnar joint is at the supination position of the forearm for postoperative protection
unstable. (b) Open reduction and internal fixation: the radial shaft frac-

exercise of the forearm can be started (Rettig and r­eduction can be performed, with internal fixation
Raskin 2001; Macule Beneyto et al. 1994). using a wire tension band.
–– If the case is associated with ulnar styloid fracture and • Forearm ulnar and radial double fracture: Surgery is oper-
the fracture fragment is sufficiently large, open ated in accordance with the principle of reduction and
8 Fractures of the Ulnar and Radial Shaft
fixation for intra-articular fracture, that is, anatomical
reduction, strong fixation, and early functional exercise.
–– The order of fixation of ulnar and radius fractures
(Chow and Leung 2010):
The least severe fracture in the comminution should
be exposed and fixed first to correctly restore the
length of the forearm and to determine the length of
fracture fragments of more severe comminution
accordingly.
If the comminution levels of the fractures in the
ulna and radius are identical or are simple fractures,
the radius is usually first exposed and reset.
–– Temporary fixation of the first reset fracture:
Before revealing another bone, incomplete fixation
of the fracture is recommended. If the first bone is
completely fixed before anatomical reduction is
achieved, anatomical reduction for the second bone
will not be able to be achieved.
If the long bone is reset first, plate screws and bone
holding forceps can be used for temporary
fixation.
• For stable non-comminuted fractures, the temporary sta-
bilized steel plate-screw technique can be used for fixa-
tion with 1 screw (2 layers of cortex) on both sides of the
fracture.
• For comminuted fractures, 2 screws (4 layers of cortex)
are used for fixation.
• After reduction and fixation of the other bone, the final
fixation can be performed for the former bone.
–– Requirements for final fracture fixation.
The steel plate should cross the fracture ends for
stabilization and fixation, and 6-layer cortex screws
are required in the fixation of the distal and proxi-
mal ends.
For non-comminuted transverse fractures, a limited
contact DCP or locking plate with at least 6 holes is
needed for fixation.
For oblique fractures or comminuted fractures, a
longer plate is needed. The screw compression fixa-
tion technique is required to fix the fracture ends of
the oblique fracture (Fig. 8.24).
It can be difficult to provide 6 layers of cortical
screw for the fixation of distal ulna fractures. In
this case, a fixation system with two 2.7-mm steel
plates at 90° can be used for fixation. If stability is
still lacking after steel plate fixation, an auxiliary
brace should be provided for postoperative
protection.
–– For double fracture with strong plate fixation in a bone,
if the fractures of the other bone are segmental, elastic
intramedullary nail or intramedullary nail fixation can
be used to reduce iatrogenic injury caused by overex-
posure (Figs. 8.25 and 8.26).
241
Incision Closure
• Conventional closure of the incision can be performed,
and the deep fascia should be carefully sutured. The
implant should be covered with muscle to minimize stim-
ulation and wear on tendons and other soft tissue.
Drainage should be placed.
Postoperative Treatment
• According to the stability and fracture fixation of the
proximal and distal radioulnar joint, postoperative func-
tional exercise should be performed under guidance. If
the fracture fixation is strong with no joint damage, post-
operative functional exercise can be started as soon as
possible, and simple daily life can be restored in
2–3 weeks, while full recovery can be achieved in
12–16 weeks.
• Normally, removal of the forearm steel plate is not neces-
sary unless the internal fixation stimulates the soft tissue
and causes pain and other symptoms. The steel plate for
fixation can be removed after at least 12–18 months.
8.2.3 Prevention and Treatment of Surgical
Complications
• Postoperative instability of the proximal and distal radio-
ulnar joint (McDowell and Mullis 2012):
–– Missed diagnosis should be assessed first. The patient
should receive forearm X-ray examination including
the wrist and elbow joint, and the anatomical structure
of the proximal and distal radioulnar joint should be
observed carefully.
–– The medical history should be recorded in detail before
surgery, including whether pain and dysfunction of the
wrist and elbow are present. Deformity, tenderness,
and other clinical signs of the proximal and distal
radioulnar joint should be carefully checked.
–– In the operating room, the stability of the proximal and
distal radioulnar joint should be re-checked after frac-
ture reduction and fixation. If instability of the proxi-
mal and distal radioulnar joint is observed, appropriate
surgical repair or auxiliary fixation should be per-
formed to stabilize the distal radioulnar joint until the
soft tissue has healed (Fig. 8.27).
• Nonunion and malformations (McDowell and Mullis
2012):
–– The fractured forearm must bear not only the axial
load but also the rotation load, and thus the selected
internal fixation material should have sufficient
strength to fight against the axial and rotating double
load. Compared with intramedullary nails, external
fixation, and Kirschner wire tension band, the steel
plate shows stronger anti-rotation ability, and thus
242 H. Chen et al.

a b

c d

Fig. 8.24 Double fractures of the middle segments of the right ulnar internal fixation: both ulnar and radial shaft fractures are anatomically
shaft and radial shaft. (a) Preoperative anteroposterior and lateral X-ray reduced and fixed with compression. (c, d) The forearm shows good
images illustrating oblique double fractures of the middle segments of function during rotation at 2 years postoperative. (e, f) The plate is
the ulnar and radial shafts. (b) Double-incision open reduction and removed at 26 month postoperative
8 Fractures of the Ulnar and Radial Shaft 243

Fig. 8.24 (continued)

steel plate fixation is often used in forearm fracture. A

plate screw is preferred for fixation of Monteggia
­fracture very close to the proximal (Fig. 8.28) instead
of the Kirschner wire tension band.
–– In fixation, the principles of the use of a steel plate and
screws are as follows:
For transverse fracture and short oblique fracture,
compression fixation should be performed.
Fracture with butterfly-shaped fracture fragments
can be converted into a simple fracture using a lag
screw, followed by compression fixation.
For multi-segment and comminuted fractures,
bridge fixation can be applied, and the length of the
steel plate is very important in this case. A suffi-
cient working distance must be ensured.
At least 6 layers of cortex must be ensured in the
fixation of proximal distal fracture (Fig. 8.29).
–– For multi-segment fractures or comminuted frac-
Fig. 8.25 Forearm ulnar and radial double fracture. The plate-screw tures involving a wide range, a longer steel plate can
internal fixation technique combined with intramedullary nail fixation
be used, and the steel should be pre-curved to avoid
is applied to reduce iatrogenic injury
deformed healing that changes the shape of the
radial arch, thus affecting forearm rotation
function.
–– Fluoroscopy at the anterior and posterior positions
should be performed during surgery, and the ana-
tomical reduction can be judged according to the
244
a b
Fig. 8.26 Multi-segment fractures of the ulna are fixed with a locking
plate; the fractured radius is fixed with an elastic Kirschner wire and a
blockage screw is used to prevent lateral dislocation of the radial head
caused by the broad intramedullary cavity. (a, b) Preoperative X-ray
image demonstrating double fractures of multi-segment fractures of the
measurement of the maximum radial arc and the
vertex of the maximum radial arc as described
above.
• Cross healing refers to healing between the ulna and the
radius, which affects the rotation of the forearm
(Fig. 8.30).
–– The risk factors for cross healing include:
Completion of double fracture fixation through a
single incision, which causes greater soft tissue
injury due to excessive exposure, especially inter-
osseous membrane injury
High energy causing severe soft tissue injury
involving the interosseous membrane (Ayllon-­
Garcia et al. 1993; Breit 1983; Maempel 1984;
Razeman et al. 1965)
Inadvertent positioning of the bone graft material
between the ulna and radius
Stimulation of bone hyperplasia at the site of the fixa-
tion screw piercing the interosseous membrane
H. Chen et al.
c d
ulnar shaft and radial shaft. (c, d) Multi-segment fractures of the ulna
are fixed with a locking plate; the fractured radius is fixed with an elas-
tic Kirschner wire and a blockage screw is used to prevent lateral dislo-
cation of the radial head caused by the broad intramedullary cavity
(Botting 1970; Crenshaw 1987; Knight and Purvis
1949)
Central nervous injury and excessive fracture heal-
ing (Garland and Dowling 1983; Vince and Miller
1987)
Combination of radial head injury or Monteggia
fracture injury with interosseous membrane injury
–– Prevention of cross healing (Vince and Miller 1987;
Bauer et al. 1991):
Forearm double fracture should be repaired with
the radial followed by the ulnar approach to avoid
interfering with the soft tissue in the forearm inter-
osseous membrane.
The length of the screw should be accurately mea-
sured during surgery to avoid entering the interos-
seous membrane area.
If the bone graft is performed in surgery, placement
of the bone graft material in the interosseous mem-
brane area should be avoided.
8 Fractures of the Ulnar and Radial Shaft 245

b c

Fig. 8.27 Example of a 26-year-old male patient who underwent open
reduction and plate-screw fixation of the proximal ulna for his trau-
matic Monteggia fracture of the left forearm. Because the surgeon
lacked experience and skill, reduction of the radial head was not con-
firmed during the operation, and the plate used for reconstruction did
not have sufficient strength for fixation. As a result, the radial head
remained dislocated after surgery, and the patient had to undergo a sec-
ond surgery. (a) Preoperative X-ray image demonstrating a Monteggia
fracture of the left forearm and radial head dislocation. (b, c)
Postoperative examination showed that the radial head remained dislo-
cated, and the second surgical exploration confirmed that the annular
ligament was intact, but the radial head was outside the annular
ligament
246
c d
Fig. 8.28 Example of a patient with Monteggia fracture whose preop-
erative X-ray image data were missing; the X-ray images taken after
surgical treatment failure emphasize the possibility of elbow lateral
instability after radial head removal and the importance of the rotation-­
stress-­
resistance provided by fracture fixation of the forearm. The
patient self-described her experience of receiving radial head removal
and proximal ulnar plate fixation for comminuted fractures of the radial
head complicated by a proximal ulnar fracture caused by car accident.
(a) X-ray image at 3 months postoperative demonstrating that the radial
head has been resected and the proximal ulna was bundled by wires and
fixed with a plate, but the proximal fracture was fixed with only two
H. Chen et al.
screws. (b) Removal of the radial head reduces the anti-valgus ability of
the elbow, causing lateral instability of the elbow. In addition, the plate
fixation has very low strength; in particular, with only two screws for
fixation, the proximal end cannot bear the valgus stress and strong rota-
tion stress. At 4 months postoperative, the fracture line was clearly vis-
ible after bone absorption at the fracture site. (c) X-ray image at
5 months postoperative illustrating the broken plate. (d) During revi-
sion surgery, an anatomical locking plate of the ulnar olecranon was
used in combination with an auxiliary mini plate placed at the medial
ulna for fixation to resist strong valgus and rotation stress
8 Fractures of the Ulnar and Radial Shaft 247

Fig. 8.29 Case example of a

24-year-old male professional
a b
driver with a Monteggia
fracture caused by car
accident. (a) Preoperative
lateral X-ray image indicating
a fracture of the proximal 1/3
ulna, forward dislocation of
the fracture end, and
dislocation of the
humeroradial joint. (b) After
open reduction and locking
plate internal fixation, the
fractured bone was roughly
reduced, but the plate slightly
tilted. As a result, the screws
at the distal fracture end were
not fixed on the bone shaft
axis, reducing the effective
working distance of the
screws and resulting in
insufficient fixation strength.
(c) The patient started to
move his arm too early due to
career considerations and
went back to his driving job at
3 weeks postoperative. At c
5 months postoperative, the
patient felt pain after arm
movements and experienced
movement abnormalities.
Follow-up X-ray image
revealed that the screws in the
distal fracture end had slipped
out and the internal fixation
had failed
248 H. Chen et al.

a b

c d e

Fig. 8.30 Case example of a 44-year-old male patient with fractures of
the middle segments of both the ulna and radius complicated by severe
soft tissue contusion. (a) Preoperative anteroposterior and lateral X-ray
images illustrating a Type B3.3 fracture based on the AO system. (b)
Because soft tissue contusion was very severe, surgery was performed
after the soft tissue status became stable at 10 days post-injury. (c) The
double-incision reduction and fixation technique is used to fix the ulna
and radius. X-ray image showing the presence of a small amount of
bone debris on the interosseous membrane. (d) Follow-up X-ray image
at 14 months postoperative demonstrating that the fractured bone had
healed, but cross healing between the ulna and the radius had occurred,
affecting the rotation of the forearm. (e) At 5 months postoperative, the
rotation function of the forearm was restored after removal of internal
fixators and the bone bridge
8 Fractures of the Ulnar and Radial Shaft 249

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 Fracture of the Distal Radius
Hua Chen, Zhe Zhao, and Jiaqi Li
9.1 Basic Theory and Concepts
9.1.1 Overview
• Distal radius fracture refers to fracture within approxi-
mately 2.5 cm from the articular surface of the radial
wrist joint.
• Distal radius fracture is the most common orthopedic
injury, accounting for 17% of patients in orthopedic emer-
gency (Golden 1963; Hollingsworth and Morris 1976).
• Distal radius fracture is common in young male and
elderly female patients, with the age distribution peaking
at 5–14 years and 60–69 years of age (Owen et al. 1982;
Kreder et al. 2005, 2006; McClain and Wissinger 1976;
McQueen 1998a; Alffram and G’doran 1962; Cohen and
Jupiter 2009a).
• For elderly patients, it is mostly low-energy damage due
to osteoporosis. For young patients with good bone condi-
tion, it is mostly high-energy damage (Kreder et al. 2006;
McClain and Wissinger 1976).
• For simple fractures, conservative treatment has a high
success rate. For complex fractures, conservative treat-
ment has a poor result and is often complicated by pain,
deformity, and decreased grip strength after treatment.
• Because the blood supply of the distal radius is rich, the
fracture healing rate is very high.
9.1.2 Applied Anatomy
• Anatomical morphology and characteristics of the ulna
and distal radius (Fig. 9.1):
H. Chen (*) · J. Li
Chinese PLA General Hospital, Beijing, China
e-mail: chenhua0270@134.com
Z. Zhao
Beijing Tsinghua Changgung Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_9
9
–– Ulnar inclination: The ulnar inclination is the angle
between the line connecting the midpoint of the radial
sigmoid notch on the ulna side with the highest point
of the radial styloid process and the perpendicular line
of the radial long axis. The mean value is 24°, and a
value <15° is a surgical indication (Zhang 2009; Szabo
and Weber 1988; Medoff 2009; Dowling and Sawyer
Jr. 1952; Friberg and Lindstrom 1976).
–– Radial styloid height: The radial styloid height is the
distance between a perpendicular line through the mid-
point of the radial sigmoid notch on the ulna side to the
radial long axis and the highest point of the radial sty-
loid process. The mean value is 11.6 mm. The mea-
surement value is used to determine the degree of
shortening of the radius (Scheck 1962; Gartland and
Werley 1951; Older et al. 1965).
–– Ulnar difference: The ulnar difference is the distance
between 2 parallel lines running perpendicular through
the ulnar plane and the midpoint of the radial sigmoid
notch on the ulna side to the radial long axis. The ulnar
difference is usually negative, i.e., the length of the
radius exceeds the ulna, with an average value of
−0.6 mm. After fracture, the measurement of this value
can help determine the extent of radial shortening. An
ulnar difference of greater than 5 mm is a surgical indi-
cation (Szabo and Weber 1988; Rubinovich and Rennie
1983; Edwards et al. 2001; Flinkkila et al. 1998).
–– Palmar tilt: In the lateral image, the angle between the per-
pendicular line of the radial long axis and the connecting
line of the upper and lower lip of the radius is the palmar
tilt, which has a mean value of 10°. In the case of distal
radius fracture, according to the different mechanisms of
injury, the fracture fragments may have angular displace-
ment, and the palmar tilt will also become larger or smaller.
Fracture reduction requires the restoration of the palmar
tilt, and the palmar tilt can be used as a reference for intra-
operative reduction (Dowling and Sawyer Jr. 1952).
–– AP distance: In the lateral image, the measurement of
the distance between the palmar lip and the dorsal lip
251
252
a b
radial length
radial inclination
ulnar difference
Fig. 9.1 (a) Ulnar inclination: The ulnar inclination angle is the angle
between the line connecting the midpoint of the radial sigmoid notch on
the ulna side to the highest point of the radial styloid process and the
perpendicular line of the radial long axis. Ulnar difference: The ulnar
difference is the distance between two parallel lines running perpendicu-
lar through the ulnar plane and the midpoint of the radial sigmoid notch
on the ulna side to the radial long axis. Radial styloid height: The radial
of the distal radius is the AP distance. The mean value
is 20 mm for males and 18 mm for females. An
increased AP distance indicates separation of the pal-
mar bone and the dorsal bone, suggesting fractures of
the articular surface in the radiolunate fossa. In addi-
tion, an increase in the AP distance is the only sign of
some sigmoid notch fractures (McAuliffe et al. 1987).
–– Lister’s tubercle: The dorsal side of distal radius has a
small bone convex known as Lister’s tubercle. This
nodule has a stabilizing effect on the extensor hallucis
longus. The palmar side of the distal radius is rela-
tively flat for the placement of the steel plate, while the
dorsal side is not easy to match with the steel plate
because of the presence of this nodule. The plate on the
dorsal side of distal radius is usually designed in 2
pieces to avoid Lister’s tubercle in fixation (Rozental
et al. 2001).
• Stable structure of the distal radioulnar joint (Fig. 9.2):
–– The stability of the TFCC and the distal radioulnar
joint:
The external stability structure of the distal radioul-
nar joint includes the extensor carpi ulnaris muscle
tendon and its tendon sheath, the pronator quadra-
tus, and the interosseous membrane (Hanker 1991;
H. Chen et al.
volar tilt
AP distance
styloid height is the distance between a perpendicular line through the
midpoint of the radial sigmoid notch on the ulna side to the radial long
axis and the highest point of the radial styloid process. (b) Volar tilt: In
the lateral image, the angle between the perpendicular line of the radial
long axis and the connecting line of the upper and lower lip of the radius
is the volar tilt. (c) AP distance: In the lateral image, the distance between
the volar lip and the dorsal lip of the distal radius is the AP distance
Goldner and Hayes 1979; Spinner and Kaplan
1970; Ruby et al. 1996).
The internal stability structure of the distal radioul-
nar joint mainly refers to the TFCC, including the
cartilage disc, which is responsible for transmitting
20% of the compressive stress on the wrist; the
superficial fibers, divided into the palmar part and
the dorsal part, from the palmar and dorsal margins
of the sigmoid notch to the bottom of the radial sty-
loid process; the deep fibers, divided into the palmar
part and the dorsal part, from the palmar and dorsal
margins of the sigmoid notch to the ulnar fossa; and
2 cartilage disc-carpal bone ligaments (the ulnolu-
nate ligament and ulnotriquetral ligament)
(Hotchkiss et al. 1989; af Ekenstam and Hagert1985;
Bednar et al. 1991; Thiru-Pathi et al. 1986).
–– Fracture of the ulnar styloid process and stability of the
distal radioulnar joint: more than 50% of distal radius
fractures are associated with ulnar styloid fractures, of
which 39% of the fractures in the ulnar styloid process
involve the ulnar styloid process base. In particular,
oblique fracture in the ulnar styloid process base can
easily involve the attachment of the TFCC deep liga-
ment at the ulnar head fossa (Fig. 9.3c). When fracture
9 Fracture of the Distal Radius 253

a b radio-scaphoidlunate disc-carpal ligaments

ligament (D-L) (D-T)
ulnar collateral
ligament
1 radio-scapho-capitate long radio-lunate
ligament ligament
ECU

2 articular disc
radial collateral ligament (fibrocartilage)

deep and superficial

radio-uina ligaments

dorsal radio-ulna
capsule

4
dorsal branch
anterior interosseous artery

Fig. 9.2 (a) The external stabilization structure of the distal radioulnar joint includes the TFCC, which consists of the cartilage disc (white),
joint includes the extensor carpi ulnaris muscle tendon (1) and its ten- the superficial fibers (green), the deep fibers (blue), and two cartilage
don sheath (2), the pronator quadratus (3), and the interosseous mem- disc- carpal bone ligaments (cartilage disc—lunate bone and cartilage
brane (4). (b) The internal stabilization structure of the distal radioulnar disc—triquetral bone)

a TFCC superficial portion b

(styloid insertion)
TFCC deep portion or ligamentum
subcruentum (foveal insertion)
pronation supination

radius radius

TFCC superficial portion

(styloid insertion)
TFCC deep portion or ligamentum
subcruentum (foveal insertion)

c tip fracture

middle fracture

horizontal fracture in
the ulnar styloid
process base
oblique fracture in
the ulnar styloid
process base

Fig. 9.3 (a) In the pronation position, the tension of the volar ligament of ligament of the deep ligament of the TFCC plays the main role in stabiliza-
the deep ligament and the dorsal ligament of the superficial ligament of the tion. (c) Fractures of the ulnar styloid process are divided into four types,
TFCC play the main role in stabilization. (b) In the supination position, the tip fracture, middle fracture, and horizontal fracture, and oblique fracture
tension of the volar ligament of the superficial ligament and the dorsal in the ulnar styloid process base, based on the location of the fracture line
254 H. Chen et al.

mately 40% of the axial load. Due to the ulnar incli-

nation, the impact of navicular collision is likely to
cause lateral shear fracture, and the best position of
the supporting plate at this time should be on the
radial side.
The middle column is composed of the lunate fossa
and the semilunar notch of the radius and bears
radial

middle column
column ulnar
approximately 40% of the axial load. It is the most
column important part of the distal radius. Direct impact of
the lunate can also cause dorsal and palmar shear
fracture or isolated bone in the articular surface,
that is, die punch damage.
The ulnar column is composed of the ulnar styloid
process, TFCC, and carpal ulnar ligament and bears
approximately 20% of the axial load.
–– Melone classification and 3-column theory: Melone
described distal radius fractures in 4 parts: the radial
shaft, radial styloid process, dorsal medial bone, and
palmar medial bone. The latter 2 together constitute
the medial complex. Distal radius fractures are divided
into 5 types (Jakob et al. 2000) (Fig. 9.5).
–– Melone classification and reduction procedure:
According to the procedure described by Agee, the
4 parts described by Melone are reset manually:
Fig. 9.4 The distal radioulnar structure can be divided into three col-
umns. The radial column is composed of the navicular fossa and radial Vertical traction is applied to restore the length
semilunar notch (radial styloid process). The middle column is com- of the radius.
posed of the lunate fossa and the semilunar notch of the radius. The When the wrist is in flexion, the palmar tilt can
ulnar column is composed of the ulnar styloid process, TFCC, and car- be restored, and the surgeon can press the dorsal
pal ulnar ligament
bone down with the thumb if necessary.
When the hand of the affected limb is in slight
in the ulnar styloid process leads to instability of the pronation position, the supination displacement
distal radioulnar joint (the diagnosis is described of most distal radius fractures can be corrected,
below), surgical repair is required. with an appropriate bias on the ulnar side. If nec-
–– Intraoperative judgment of the stability of the distal essary, the surgeon can slightly press the radial
radioulnar joint: After fixation of the distal radius frac- styloid process inward.
ture, the stability of the distal radioulnar joint must be Limitations of ligament consolidation:
checked. In the extreme pronation position, the palmar The wrist palmar ligament is relatively strong,
ligament of the deep ligament of the TFCC is in ten- and the dorsal ligament is relatively weak
sion, playing the main role of stabilization. The ulnar (Fig. 9.6). In traction for reduction, it is very
bone is pushed to the dorsal side at this time, and the ease to tense the palmar ligament to retract the
distal radius is pulled to the palm side to check the reduction of the bone fragments on the palm
stability of the distal radioulnar joint. In the extreme side. The tension of the dorsal ligament is small,
supination position, the ulnar head is pushed toward and flexion of the wrist is generally needed to
the palmar side, and the distal radius is pushed toward increase the tension of the dorsal ligament for
the dorsal side (Fig. 9.3). reduction of the dorsal bone fragments.
• The column theory for distal radioulnar fractures: However, it is difficult to restore the 12° palmar
–– The 3-column theory for distal radioulnar fractures tilt angle.
(Fig. 9.4): Rikli et al. divided the wrist into 3 column The ligament of the wrist is attached to the mar-
structures based on the received force and other factors gin of the radial articular surface. In the presence
to help understand distal radius fractures (af Ekenstam of die punch damage (Melone 1993), that is, an
et al. 1984). intra-articular bone fragment, such as Melone
The radial column is composed of the navicular type IIB fracture, the reduction cannot be per-
fossa and radial styloid process and bears approxi- formed by hand.
9 Fracture of the Distal Radius
a b
2 3
2
4 3
4 4
4 4
1 1
Fig. 9.5 (a) Melone described and classified distal radius fractures
based on the following bone fragments: 1. radial shaft; 2. radial styloid
process; 3. dorsal medial bone; 4. volar medial bone. (b) Melone clas-
sification of distal radius fractures: Type I are stable, non-comminuted
fractures; Type II are unstable embedded fractures, including Type IIA,
Due to the characteristics of the ligament itself,
over time, the traction will weaken, leading to
secondary displacement of the fracture.
–– Three-column theory, Melone classification and inter-
nal fixation design (Scheck 1987; Melone 1984):
The design principle of the steel plate: According to
the Melone classification, the distal radius after
fracture regularly shows 4 bone fragments: radial
bone, radial styloid process, dorsal medial bone,
and palmar medial bone. Accordingly, fixation
designs with a radial styloid screw and middle bone
screws have been developed. In particular, the
screws are arranged along the anatomical shape of
the articular surface and locked with the steel plate
to achieve angular stability, conferring a “raft”
effect to support the articular surface and prevent
collapse.
The non-locking steel plate is generally placed on
the side of the unstable displacement of bone based
on the principle of the supporting steel plate. For
255
2
2 2
3 3 3
3
1 1 1
I IIA IIB
2 2
2 3
4 4
3
4 3 3
1 1 1
III IV V
which can be reduced by hand, and Type II B, which cannot be reduced
by hand due to the presence of die punch; Type III are osteophyte-like
fractures with an impaired volar structure; Type IV are fractures involv-
ing the middle complex with significant separation of the volar and dor-
sal bone fragments; Type V are burst fractures
the dorsal medial fragment, the dorsal approach can
be used to place the steel plate on the dorsal side;
for the palmar medial fragment, the palmar
approach can be used to place the steel plate on the
palmar side.
The locking steel plate can provide angular stabil-
ity, and thus the technique of fixing the dorsal bone
fragment through the palmar plate was developed.
There are 3 generations of palmar locking plate,
and currently generation II and III products are
mainly used.
The generation II palmer locking steel plate is
divided into 2 categories: distal locking screws
with the same angle and distal locking screws
with various angles. Some products have a spe-
cially designed radial styloid screw to provide
extra fixation for the lateral column (Fig. 9.7a).
The main feature of the generation III locking
plate is the distal locking screw to provide vari-
able direction (Fig. 9.7b).
256 H. Chen et al.

Fig. 9.6 (a) The volar a

radiocarpal ligamentous
ulna radius
structure. (b) The dorsal
radiocarpal ligamentous
structure. The volar ligaments distal radioulnar joint
are relatively stronger, and the radial styloid process
dorsal ligaments mostly run
ulnar styloid process lunate bone
obliquely and can be
passively stretched by palmar ulnocarpal ligament palmar radiocarpal ligament
retraction to reset the bone
fragments radiate carpal ligament
pisiform bone

pisohamate ligament carpometacarpal

pisometacarpal ligament joint of tumb
hook of hamate bone
palmar carpometacarpal
ligaments capitate bone

palmar metacarpal
ligaments

sesamoid bones
metacarpal ligaments
transverse metacarpal
ligaments

b
radius ulna

dorsal radiocarpal
ligament
styloid process of ulna
radial styloid process
dorsal intercarpal ligament
scaphoid bone
dorsal intercarpal triquetrum bone
ligament
hamate bone

trapezoid bone capitate bone

dorsal dorsal metacarpal

carpometacarpal ligaments
ligaments

collateral ligaments

metacarpophalangeal joint
9 Fracture of the Distal Radius
Fig. 9.7 (a) The generation a b
II volar locking stainless-steel
plate of the distal radius has a
specially designed radial
styloid screw. (b) The
generation III locking plate
has a distal locking screw to
provide a variable direction.
(c, d) The dorsal plate is
designed based on the
3-column theory
The design of the dorsal plate is also based on the
3-column theory. Because the radial dorsal shape is
irregular, the dorsal medial bone and the radial bone
can be fixed individually (Fig. 9.7c, d).
9.1.3 Mechanisms of Injury
According to the position of the wrist at injury and the char-
acteristics of the received force, the mechanism of bone
injury includes the following:
• Injury at dorsiflexion: extra-articular fractures, with dor-
sal displacement, metaphyseal defect or dorsal comminu-
tion, which all suggest dorsal instability.
• Injury at palmar flexion: extra-articular fractures, with
palmar displacement, which is often unstable and must be
reset and maintained until fracture healing.
• Dorsal shear fracture: fractures in the dorsal margin, with
severe instability of the wrist on the dorsal side.
• Palmar shear injury: fractures in the palmar margin, with
instability of the wrist on the palm side and severe com-
minution, often requiring surgical treatment.
257
• Simple 3-part fracture: low-energy damage resulting from
the joint effect of axial stress and dorsiflexion stress. The
metaphyseal fracture is combined with dorsal ulna frac-
ture through the ulnar notch of the distal radius.
• Comminuted intra-articular fracture: high-energy dam-
age, very unstable, showing a crushed articular surface
with collapse, which is combined with distal ulna insta-
bility and metaphyseal bone defects.
• Wrist avulsion: ligament injury of the wrist associated
with distal radial avulsion.
• High-energy damage: occurs in young people, with crush-
ing of the articular surface and extension of the fracture to
the ulnar and radial shaft.
9.1.4 Classification of Fractures
• Traditional eponymous fracture classification (Fig. 9.8):
The study of distal radius fractures has a long history, and
many names have been used for each type of fracture. With
the evolution of the new classification system, the role of the
eponymous classification has gradually weakened, but these
names are still frequently mentioned in clinical practice.
258
Fig. 9.8 (a) Colles fracture
a b
of the distal radius. (b) Smith
fracture of the distal radius.
(c) Barton fracture of the
distal radius. (d) Chauffeur
fracture of the distal radius
c d
–– Colles fracture is the most common fracture of the dis-
tal radius and is characterized by distal radius fracture
with dorsal displacement and angulation, accompanied
by radial tilt and radial shortening. The typical mani-
festation is the “dinner-fork” deformity (From Rikli
et al. 2005).
–– Smith fracture is also known as “reverse Colles frac-
ture” and is characterized by distal radius fracture with
palmar displacement and shortening. The typical man-
ifestation is “garden spade” deformity (Colles 1814).
–– Barton fracture is distal radius fracture on the palmar
or dorsal side through the articular surface and may be
associated with dislocation or subluxation of the radial
wrist (Ellis 1965; De Oliveira 1973).
–– Chauffeur fracture is shear fracture of the radial styloid
process caused by direct collision of the scaphoid or
the avulsion fractures of the radial styloid process
caused by the extreme ulnar bias of the wrist
(Thompson and Grant 1977).
• Fernandez classification (Fig. 9.9): This classification is
based on the mechanism of injury and has great guiding
significance for clinical treatment decision-making. There
H. Chen et al.
are 5 types in this classification (Cohen and Jupiter 2009b;
Fernandez 1987; Jupiter et al. 1996):
–– Type I: Metaphyseal fractures, with 2 major fracture
fragments in most cases, including bone fragments
with dorsal displacement (Colles fracture) and bone
fragments with palmar displacement (Smith fracture).
–– Type II: Shear fractures of the articular surface, with
large articular fractures caused by shear, including pal-
mar and dorsal shear fractures (Barton fracture), shear
fracture of the radial styloid process (Chauffeur frac-
ture), and 3-part fracture or comminuted fracture.
–– Type III: Embedded fractures of the articular surface,
with subchondral and metaphyseal die punch fracture
caused by axial stress, including 2-part, 3-part, 4-part,
and comminuted fractures.
–– Type IV: Avulsion fractures associated with radial
wrist fracture and dislocation and avulsion fractures of
the radial styloid process and ulnar styloid process
ligament attachment, which can be combined with the
palmar and dorsal fracture displacement.
–– Type V: Joint fracture for the above mechanism, usu-
ally due to high-energy damage.
9 Fracture of the Distal Radius
Fig. 9.9 Fernandez
a b
classification of distal radius
fractures (a) Type I:
Metaphyseal fractures. (b)
Type II: Shear fractures of the
articular surface. (c) Type III:
Embedded fractures of the
articular surface. (d) Type IV:
Avulsion fractures associated
with radial radiocarpal
dislocation. (e) Type V: Joint
c d
fractures of the above types
• AO classification (Fig. 9.10): The AO classification of the
distal ulna and radius is relatively complex, with 3 main
types, 9 groups, and 27 subgroups (Thompson and Grant
1977; Fernandez 1993; Muller et al. 1987).
–– Type A: extra-articular fractures:
Type A1 is ulna fracture with an intact radius. Type
A1.1 is ulna styloid fracture; type A1.2 is simple
fracture of the ulnar shaft; type A1.3 is ulna metaph-
yseal comminuted fracture.
Type A2 is radius metaphyseal simple fracture,
accompanied by insertion. Type A.2.1 is fracture
without displacement; type A2.2 includes angula-
tion of the radius on the dorsal side (Colles frac-
ture); type A2.3 includes angulation of the radius on
the palmar side (Smith fracture).
Type A3 is radius metaphyseal comminuted frac-
ture. Type A3.1 is radius compression; type A3.2 is
cases with a wedge-shaped radius bone fragment;
type A3.3 is radius metaphyseal comminuted
fracture.
–– Type B: Partial intra-articular fractures:
Type B1 is fracture on the sagittal plane of the
radius. Type B1.1 is simple fracture of the lateral
radius; type B1.2 is comminuted fracture of the lat-
eral radius; type B1.3 is medial radius fracture.
259
Type B2 is fracture at the dorsal margin of the radius
(dorsal Barton fracture). Type B2.1 is simple fracture;
type B2.2 is associated with lateral sagittal fracture;
type B2.3 is associated with dorsal wrist dislocation.
Type B3 is fracture at the palmar margin of the
radius (palmar Barton fracture).
Type B3.1 is simple fractures with small fracture
fragments; type B3.2 is simple fractures with large
fracture fragments; type B3.3 is comminuted
fracture.
–– Type C: Complete intra-articular fracture:
Type C1 is simple fracture in the articular surface
and metaphysis. Type C1.1 is posterior medial bone
fragment fracture; type C1.2 is articular surface
sagittal fracture; type C1.3 is articular surface coro-
nal fracture.
Type C2 is articular surface simple fracture and
metaphyseal comminuted fracture. Type C2.1 is
articular surface sagittal fracture; type C2.2 is artic-
ular surface coronal fracture; type C2.3 is joint frac-
ture extended to the radial shaft.
Type C3 is articular surface comminuted fracture.
Type C3.1 is metaphyseal simple fracture; type
C3.2 is metaphyseal comminuted fracture; type
C3.3 is joint fracture extended to the radial shaft.
260 H. Chen et al.

Fig. 9.10 AO classification

of distal radius fractures. Type 23-A2 23-A3
A (extra-articular fractures): extra 23-A1
radius, simple and radius,
articular ulna, radisu intact
Type A1: ulna fractures with impacted multifragmentary
an intact radius, Type A2:
radius metaphyseal simple
fractures, accompanied by
bone fragment embedding,
and Type A3: radius
metaphyseal comminuted
fractures. Type B (partial
intra-articular fractures): Type
B1: fractures on the sagittal
plane of the radius, Type B2:
fractures at the dorsal margin
of the radius (dorsal Barton 23-B1 23-B2 23-B3
partial
fracture), and Type B3: radius, sagittal radius, frontal, radius, frontal,
articular
fractures at the volar margin dorsal rim volar rim
of the radius (volar Barton
fracture). Type C (complete
intra-articular fracture): Type
C1: simple fractures in the
joint surface and metaphysis,
Type C2: articular facet
simple and metaphyseal
comminuted fractures, and
Type C3: articular surface
comminuted fractures
23-C1 23-C2 23-C3
complete
simple, simple, metaphyseal multifragmentary
articular
metaphyseal simple multifragmentary

9.1.5 Assessment of Distal Radius Fractures
9.1.5.1 Clinical Assessment
• Typical manifestations: deformity, pain, swelling, and
dysfunction in the distal forearm of the affected limb.
• Blood vessels: assessment of radial artery pulsation.
• Nerves: assessment of the function of the radial nerve and
median nerve innervation areas.
9.1.5.2 Imaging Assessment
• Wrist X-ray examination (Fig. 9.11): standard anteropos-
terior and lateral position of the wrist with routine exami-
nation to characterize the following indicators (Szabo and
Weber 1988; Muller et al. 1990):
–– Carpal facet horizon: Imaging in the anteroposterior
position of a radiopaque horizon line that is used to
identify the palmar and dorsal margins of the joint. If
the articular surface is tilted to the palmar side, the
articular line represents the palmar margin. By con-
trast, if the articular surface is tilted to the dorsal side,
the articular line represents the dorsal margin. The
articular line is part of the articular surface shown on
the 10° lateral image.
–– Teardrop angle: Reflects the dorsal extension of the
articular surface on the palmar margin, with a normal
value of 70° ± 5°. If the teardrop angle drops below
45°, it suggests that the palmar margin of the lunate
articular surface rotates to the dorsal side with articular
9 Fracture of the Distal Radius
a b
Fig. 9.11 The lateral projection of the wrist at a 10° ulnar inclination
clearly shows the base and the entire half-moon-shaped articular sur-
face of the distal radial 3-column articular facet. (a) Standard lateral
surface collapse, which may be associated with axial
and dorsal subluxation of the wrist joint. It is important
to restore the teardrop angle and correct the dorsal
angle (Fig. 9.12).
–– Joint concentricity: The subchondral bone of the artic-
ular surface of distal radius and the lunate bone should
be concentric, with even spacing in the interval of the
radial and lunate joints (Medoff 2010).
–– AP distance: Distance between the dorsal and the pal-
mar angle of the lunate articular surface usually
assessed on the 10° lateral image (Van der Linden and
Ericson 1981).
–– Distal radial ulnar joint gap (DRUJ gap): The gap
between the ulna and the sigmoid notch widening sug-
261
10°
projection of the wrist. (b) The lateral projection of the wrist at a 10°
ulnar inclination
gests tear of the DRUJ articular capsule and triangular
ligament complex.
–– Lateral articular force line: With the wrist in neutral
position, the rotation center of the joint is located on
the extension line of the radial shaft on the palmar side,
and the rotation of the palmar margin to the dorsal side
can cause dorsal subluxation of the wrist (Fig. 9.13).
• CT examination can better reveal comminution of the
intra-articular fracture fragments, which is conducive to
the development of a treatment program for intra-articular
fracture (Rozental et al. 2001; Chan et al. 1999; Gausepohl
et al. 2001; Harness et al. 2006; Huch et al. 1996).
• MRI examination can reveal injury of the TFCC and other
soft tissues.
262 H. Chen et al.

a b

c d

Fig. 9.12 The carpal facet horizon and teardrop angle of the wrist facet parallel to the X-ray image beam, and the other part depends on
joint. (a) The carpal facet horizon represents the line distinguishing the whether the carpal facet is tilted to the volar or dorsal side. (c) Normal
volar and dorsal margins of the joint in the lateral image of the wrist. (b) teardrop angle. (d) The teardrop angle is compressed, indicating the
The normal carpal facet horizon consists of two parts: one is the carpal instability of the volar structure
9 Fracture of the Distal Radius
a b
d e
Fig. 9.13 Joint concentricity, AP distance, and the distal radioulnar
joint. (a) Normal joint concentricity. (b) Abnormal joint concentricity:
The fracture line passes through the volar and dorsal rims of the half-­
moon facet. (c) The AP distance is the distance between the apexes of
9.2 Surgical Treatment
9.2.1 Conservative Treatment
• Indications for conservative treatment: Conservative
treatment for distal radius fractures depends on whether
the fracture can be reset under closed conditions and
whether the reduction can be maintained through fixation
with plaster and a brace (Madhok and Green 1993;
Merrell and Truluck 2010).
–– Fernandez type I simple metaphyseal flexion fracture
and type III fracture with no articular surface die punch
injury can be reset manually.
–– Reduction standard: If reduction cannot meet the fol-
lowing requirements, surgical treatment is recom-
mended. Note: Due to the limitations of ligament
repair, a certain degree of reduction is usually lost, and
a dissatisfactory initial reduction result may lead to an
unacceptable outcome of deformed healing.
Ulnar inclination in the anteroposterior view ≥15°
Length of the radial styloid process in the antero-
posterior view exceeding the ulnar styloid process
by ≥7 mm
In the lateral view, a dorsal angle <15° or palmar
angle <20°
Articular step <2 mm (Dias 2010)
263
c
f
the dorsal and the volar angular articular borders of the radius on the
10° lateral image. (d) The distal ulnoradial articular interval. (e) Normal
structure of the wrist on the lateral image. (f) Dorsal subluxation of the
wrist joint
–– Judgment of stability after reduction: With the follow-
ing indications, it is difficult to maintain reduction by
plaster and brace fixation until healing.
Dorsal cortical comminution >50% of the width of
the radius
Palmer metaphyseal comminution
Dorsal angle of the fracture fragment before reduc-
tion >20°
Displacement of the fracture fragment before reduc-
tion >1 cm
Radial shortening of the radius before reduction
>5 mm (Knirk and Jupiter 1986; Trumble et al.
1994)
Fracture involving the articular surface
Combination with ulna fracture
Severe osteoporosis
• Plaster fixation: Short arm plaster fixation below the
elbow is usually applied.
• Follow-up and reduction loss after conservative
treatment:
–– After conservative treatment, X-ray examination
should be reviewed at weekly follow-up and should be
compared with the X-ray of the previous week and the
X-ray immediately after reduction.
–– Premature loss of reduction suggests fracture instabil-
ity: Collert et al. found that for the patients with redis-
placement of the fracture 1–6 days after the first
264
manual reduction, the failure rate of the secondary
manual reduction was 87%; for the patients with redis-
placement of the fracture at 7–15 days, the failure rate
was 50% (Aro and Koivunen 1991).
9.2.2 Surgical Indications and Purposes
9.2.2.1 Surgical Indications (Collert and Isacson
1978)
• For Fernandez type I metaphyseal flexion fracture, if sta-
bility is poor after manual reduction, fixation of percuta-
neous pinning with plaster, external fixation with a brace,
or open reduction with internal fixation can be applied.
• For Fernandez type II articular surface shear fractures,
radial styloid fracture (Chauffeur fracture) can be treated
with close reduction and percutaneous hollow screw fixa-
tion. All other palmar and dorsal shear fractures (Barton
fracture) are very unstable, and external fixation is not appli-
cable; thus open reduction and internal fixation are needed.
• For Fernandez type III fractures, most cases can be reset
through ligament reduction, and the stability can be main-
tained by a combination of percutaneous pinning and an
external fixator. Some fractures cannot be reset through
ligament reduction, especially cases with collision injury
on the articular surface, and thus, open reduction and
internal fixation are needed to ensure anatomical reduc-
tion of the articular surface.
• For Fernandez type IV fractures, due to avulsion fracture,
the wrist ligament and articular capsule are severely
injured, resulting in wrist instability. Thus, in addition to
the reduction and fixation of the radial styloid process, the
associated fracture in the ulnar styloid process (if any)
requires simultaneous fixation. The postoperative posi-
tion of the wrist can be maintained using the cross-­
articular external fixator.
• For Fernandez type V fractures, open reduction and inter-
nal fixation should be performed.
9.2.2.2 Purpose of Surgery
• To restore the articular surface and the anastomosis rela-
tionship of the adjacent articular surfaces
• To reconstruct the stability of the joint
• To restore a painless, well-functioning wrist
9.2.3 Surgical Techniques
9.2.3.1 Percutaneous Pinning Technology
(Jupiter 1997)
• Position and preoperative preparation:
–– Brachial plexus anesthesia
–– The patient is in the supine position, with the affected
limb placed flat on a radiolucent holder by the bedside
H. Chen et al.
–– C-arm and other image monitoring are set up
• Surgical techniques (Fig. 9.14):
–– Kirschner wire is used for manipulation from the back
side to restore the palmar tilt:
The wire enters from the back in a distal direction,
with an angle to the palm plane of approximately
45°, and a 1.5-mm Kirschner wire is placed into the
fracture line to pry and reset the palmar tilt.
The entry site of the wire can be determined by
observing the fracture line under fluoroscopy.
The entry direction of the Kirschner wire should
be parallel with the running direction of the ten-
don to limit tendon injury.
After contact with the bone surface, the Kirschner
wire should slide along the radial dorsal cortex
until the tip reaches the fracture line.
The fracture fragment is reset with combined pry
and traction.
The radial length is restored by ligament repair
with manual traction.
Simultaneously, the Kirschner wire is used to
pry and restore the anatomical position of the
fracture fragment in the distal radius and to
restore the palmar tilt to at least >0°.
While restoring the palmar tilt, the palmar and
dorsal cortex should be in contact as much as
possible, or redisplacement may occur after the
Kirschner wire is removed. Excessive recovery
of the palmar tilt should not be pursued and will
result in cortical bone separation or poor contact,
thus affecting the stability after fracture
reduction.
The Kirschner wire is used to maintain the reduc-
tion of the bone fragment through the proximal con-
tralateral cortex.
The same technique is applied to place another
Kirschner wire in the distal dorsal radius, so that the
2 Kirschner wires form a plane for joint reduction.
–– Entry of the lateral radius by Kirschner wire to restore
the ulnar inclination:
The Kirschner wire enters from the fracture line at
the radial styloid process to pry the side of the radial
styloid process and restore the ulnar inclination to
≥22°.
The Kirschner wire is used to maintain the reduc-
tion of the bone fragment through the proximal con-
tralateral cortex.
Another Kirschner wire can enter from the radial
styloid process to fix the bone.
–– If the distal radioulnar joint is unstable, the TFCC
should be repaired, or the ulnar styloid fracture should
be fixed.
–– The part of the Kirschner wire exposed to the skin is cut,
and the end is curved and covered with sterile dressing.
9 Fracture of the Distal Radius
a b
d e
Fig. 9.14 (a) A Kirschner wire is placed from the dorsal side passing
through the fracture line; the fracture fragment is reset, and the volar tilt
angle is restored with combined pry and traction. Both volar and dorsal
cortexes are in contact to provide a support, and the Kirschner wire is
used to maintain reduction of the bone fragment through the proximal
contralateral cortex. (b) A Kirschner wire enters from the fracture line
–– Postoperative treatment:
Plaster or splint auxiliary fixation is applied.
After the postoperative pain is reduced, flexion and
extension activities of the fingers can be started,
with the affected limb elevated to facilitate allevia-
tion of swelling.
265
c
f
at the radial styloid process to pry the side of the radial styloid process
and restore the ulnar inclination. The Kirschner wire is used to maintain
reduction of the bone fragment through the proximal contralateral cor-
tex. (c, d) Preoperative anteroposterior and lateral X-ray images of a
Colles fracture. (e, f) X-ray images after percutaneous pinning
(Kapandji) and plaster external fixation
X-ray examination is performed, and the Kirschner
wire is removed at approximately 6 weeks.
After removing the Kirschner wire, wrist activities
can be gradually started.
• Experience and techniques:
–– Option for patients under different conditions:
266
Percutaneous pinning technology is applicable for
patients without severe comminuted fracture and
without severe osteoporosis. Obvious dorsal com-
minution can easily lead to fracture collapse because
good support is not achievable. Fractures collapse is
also likely to occur in patients with severe osteopo-
rosis (McClain and Wissinger 1976; Ruch 2010;
Bednar and Al-Harran 2004; Fischer et al. 1999;
Hayes et al. 2008; McQueen et al. 1999).
A lag screw should be used to fix the fracture in the
radial styloid process because the stretch in the
Fig. 9.15 Case example of a distal radius fracture (female, 79 years
old). (a) Preoperative anteroposterior and lateral X-ray images demon-
strating a distal radial intra-articular fracture with a remarkably dislo-
cated dorsal bone fragment. (b) Prying reduction via a percutaneous
H. Chen et al.
b­rachioradialis may bend a Kirschner wire and
cause redisplacement of the fracture.
It is difficult to achieve reduction and fixation of an
intra-articular bone fragment through percutaneous
pinning.
–– The percutaneous pinning technique can be combined
with the external fixation technique to maintain the
position of the fracture fragments and prevent loss of
reduction (McQueen et al. 1996; Werber et al. 2003;
Braun and Gellman 1994; Dunning et al. 2001)
(Fig. 9.15).
pinning technique and fixation of an external fixator for the dorsal frag-
ment. (c) Follow-up X-ray image at postoperative month two demon-
strating an obscure fracture line
9 Fracture of the Distal Radius
9.2.3.2 External Fixation
• Fixation of distal radius fractures with a cross-articular
external fixator.
–– Position and preoperative preparation:
Brachial plexus anesthesia.
The patient is in the supine position, with the
affected limb placed flat on a radiolucent holder by
the bedside (Fig. 9.16).
A tourniquet is applied to the upper 1/3 of the arm.
Fluoroscopy monitoring is provided.
Fig. 9.16 The patient is in the supine position with the affected limb
placed flat on a radiolucent holder by the bedside
b c
Fig. 9.17 (a, b) Under sleeve protection, a Schanz screw is placed into
the radial side of the second metacarpal base, perpendicular to the sec-
ond metacarpal and parallel to the volar plane, which passes through
three layers of cortex (the ulnar and radial sides of the second metacar-
267
–– Surgical procedures:
Metacarpal screw placement (Fig. 9.17):
The first screw is placed in the base of the sec-
ond metacarpal. Between the tendon of the mus-
culus extensor indicis proprius and the first
interosseous dorsal muscle, an incision is cre-
ated on the skin, and the soft tissue is gently
separated with a surgical clamp, follow by sleeve
protection of the soft tissue. A 3-mm Schanz
screw is then inserted.
The direction of the screw is 45° to the plane of
the palm and can also be parallel to the palmar
plane.
The position of the second screw is determined
by the guiding device. The second 3-mm screw
is inserted in the second metacarpal.
The diameter of the metacarpal fixation wire should
not exceed 3 mm. The position of the fixation wire
should be at the proximal 1/3 end. For patients with
osteoporosis, the most distal proximal screw can
pass through 3 layers of cortex (the second metacar-
pal and the third metacarpal lateral cortex) so that
the fixation force arm of this screw is relatively long
with a large fixation torque, resulting in increased
stability of the fixation wire.
Radial screw placement (Fig. 9.18):
pal cortex and the radial side of the third metacarpal cortex). (c) Using
a guiding device, the second half-pin screw is placed parallel to the first
screw and passed through the cortex on the other side of the second
metacarpal
268
a b
Fig. 9.18 (a, b) Special attention should be paid to avoid damaging the
superficial radial nerve running between the brachioradialis and radial
wrist extensor. (b) Two Schanz screws are placed approximately 10 cm
On the lateral margin of the radius, between the
brachioradialis and radial wrist extensor, a skin
incision is created at more than 3 cm above the
proximal fracture line and approximately 10 cm
from the proximal wrist, followed by blunt sepa-
ration of the subcutaneous tissues using a hemo-
static forceps to reach bone surface. The
superficial radial nerve running in this area
should be carefully protected.
In the same plane of the metacarpal screw, with
sleeve protection of the soft tissue, 2 3-mm
Schanz screws are placed with the guidance by
the guiding device.
Fracture reduction and fixation:
Traction reduction is performed by hand, and the
reduction is checked with C-arm fluoroscopy.
It is difficult to fully restore the palmar tilt by
cross-wrist external fixation, and Kapandji wire
can be used for the auxiliary reduction and
fixation.
For patients with radial styloid process fracture,
Kirschner wire in the radial styloid process can
be used for fixation.
When the reduction is maintained, the external
fixing bracket is connected with the rotation cen-
ter of the external fixator placed on the same axis
as the rotation center of the wrist.
Whether the radial length, palmar tilt and ulnar
inclination are restored is checked with fluoros-
copy at the anteroposterior and lateral positions.
The fixation angle is adjusted until the fracture
reduction is satisfactory (Fig. 9.19).
Note that excessive traction of the external fixa-
tion can cause the iatrogenic fracture at the
metacarpal screw. (Fig. 9.20).
Distal radius fractures combined with distal radio-
ulnar joint (DRUJ) separation:
Most DRUJ can be reset after distal radius
reduction.
If the DRUJ is still separated after the distal
radius is reset, reduction can be performed by
H. Chen et al.
from the proximal wrist and in the same plane of two metacarpal screws
passing through two layers of cortex
hand, with fixation using the side bracket of the
external fixator (Fig. 9.21), or a through
Kirschner wire can be used to fix the DRUJ in
the neutral position or mild supination
position.
Distal radius fractures combined with ulnar styloid
fracture:
The stability of the distal radioulnar joint is
examined in the pronation, neutral, and supina-
tion positions of the forearm. If unstable, the
ulnar styloid process can be fixed by an auxiliary
Kirschner wire, repair of the TFCC ligament, or
the tension band principle.
Avoid excessive traction:
The fingers of the affected limb in the absence of
significant tension should exhibit complete
buckling and stretching.
The spaces of the radiolunate joint and the mid-
carpal joint are compared.
If the skin at the nail path is too tight, it can be prop-
erly cut to avoid infection.
The patient is encouraged to start early exercise of
the fingers, especially flexion and extension of the
metacarpophalangeal joint of the fingers and flex-
ion, extension, and abduction of the thumb.
• Fixation of distal radius fractures using an external fixator
not crossing the joint:
–– Position and preoperative preparation: same as above.
–– Surgical techniques (Fig. 9.22):
The safe zone for Kirschner wire placement in the
distal dorsal radius: both sides of Lister’s tubercle,
both sides of the extensor hallucis Achilles tendon,
and between the common digital extensor tendon
and extensor digiti minimi tendon.
Two Schanz screws are placed in the radial shaft
using the same method and connected with a con-
necting rod.
In the safe zone, 2 Schanz screws are placed in the
fracture fragment of the distal radius, 1 from the
radial side and the other from the dorsal side, with
an angle of 60°–90° between them.
9 Fracture of the Distal Radius
a b
Fig. 9.19 (a) After screw placement, the fracture is reduced by hand
and connected to an external fixator. (b) The external fixator is locked.
(c) Whether the radial length, volar tilt, and ulnar inclination are
The screw should be held on the contralateral cor-
tex. The tip of the screw placed to the radial side
must not enter the distal radioulnar joint through the
sigmoid notch.
The Schanz screw at the distal end of the radius is
connected with an arc connecting rod.
The 2 parts of the fracture are connected using the
middle connecting rod, but the chuck should not be
locked yet.
Using the middle connecting rod, the distal fracture
fragment is reset.
After reduction, the chuck on the connecting rod
can be locked to complete the final fixation.
–– Experience and lessons:
Differences between an external fixator that does
not cross the joint and a cross-articular external fix-
ator (Markiewitz and Gellman 2001; Kawaguchi
et al. 1998; Sommerkamp et al. 1994; McQueen
1998b):
Because multiple Schanz screws can be inserted
to complete the reduction and fixation of the
bone fragments, the surgical indications for an
269
restored is checked using fluoroscopy at the anteroposterior and lateral
positions. The fixation angle is adjusted until the fracture reduction is
satisfactory
external fixator that does not cross the joint are
broader than those for a cross-articular external
fixator. In addition to external fractures, an exter-
nal fixator that does not cross the joint can also
be used for 2-part and 3-part intra-articular
fractures.
A cross-articular external fixator will fix the
wrist and prevent early functional exercise,
while an external fixator that does not cross the
joint will allow early postoperative wrist func-
tional exercise.
9.2.3.3 Open Reduction and Internal Fixation
Determination of the Palmar or Dorsal Approach
(McQueen 1999)
• For most fractures, satisfactory efficacy can be achieved
by the modified Henry’s approach and palmar plate fixa-
tion. However, for the following circumstances, the dorsal
approach or palmar and dorsal joint approach for fixation
must be considered:
–– Shear fractures of the radial styloid process combined
with articular surface collapse, complex four-part
270 H. Chen et al.

Fig. 9.20 (a) Preoperative

a b
anteroposterior and lateral
X-ray images of a Colles
fracture of the distal radius.
(b) Anteroposterior and lateral
X-ray images after closed
reduction and fixation with an
external fixator demonstrating
a satisfactory reduction, but
the Schanz screws on the
second metacarpal bone were
too close to the distal end. (c)
At postoperative day 10, the
patient felt worsening wrist
pain but did not receive any
specific treatment; at
postoperative day 10, the
follow-up anteroposterior and
lateral X-ray images showed a
fracture of the second c d
metacarpal bone at the site of
the proximal Schanz screw. (d)
The external fixator was
removed, the second
metacarpal bone was fixed
with the plate-screw technique,
and the distal radius fracture
was fixed with an auxiliary
plaster brace

comminuted fractures, and lunate fossa articular sur-
face dorsal fractures cannot be reset through the pal-
mar approach.
–– Complex fractures combined with interphalangeal lig-
ament rupture.
–– Dorsal displacement fractures occurring 3 weeks or
more after injury.
Open Reduction and Internal Fixation with Palmar
Approach for Fracture of the Distal Radius (Hausman
and Matthew 2010; Badia and Khanchandani 2009)
• Position and preoperative preparation:
–– Brachial plexus anesthesia or general anesthesia.
–– The patient is in the supine position, with the
affected limb placed on a radiolucent holder by the
bedside.
–– A tourniquet is applied to the upper 1/3 of the arm.
–– C-arm fluoroscopy is applied during surgery.
• Operative incision according to the projection on the body
surface:
–– A longitudinal incision is created along the radial side
of the flexor carpi radialis muscle (Fig. 9.23).
• Surgical approach (Fig. 9.24):
–– The skin and the subcutaneous and deep fascia tissue
are cut with incision of approximately 5 cm.
–– Blunt separation is performed along the gap between
the flexor carpi radialis muscle and radial artery to
expose the pronator quadratus muscle.
–– The flexor carpi radialis muscle is pulled toward the
ulnar side, and an incision is created along the ending
point of the pronator quadratus muscle, followed by
subperiosteal stripping along the palmar side of the
radius. The pronator quadratus muscle is pulled toward
the ulnar side.
9 Fracture of the Distal Radius
a b
d e
Fig. 9.21 Use of an external fixator and a side bracket for fixation of
distal radius fractures. (a) Preoperative X-ray image illustrating remark-
able dislocation of the distal radius fracture toward the ulnar side. (b)
Intraoperative X-ray image of closed reduction and external fixation
demonstrating a separation of the distal ulnoradial joint. (c) The sur-
geon presses and pushes the distal ulna and radius to reduce the distal
271
c
f
ulnoradial joint. (d) The side bracket is used to assist in fixing the distal
end of the ulna and stabilize the anatomical position of the distal ulno-
radial joint. (e, f) Postoperative anteroposterior and lateral X-ray images
demonstrating satisfactory fracture reduction. (g) Postoperative photo-
graph demonstrating the trans-joint external fixator and the side bracket
of the distal radius
272 H. Chen et al.

c d

e f

Fig. 9.22 (a) The safe zone for Kirschner wire placement in the distal
dorsal radius. (b) Two Schanz screws are placed in the radial shaft and
connected with a connecting rod. (c) In the safe zone, two Schanz
screws are placed in the distal fracture fragment of the radius. (d) The
Schanz screws in the distal fracture fragment of the radius are bridged
with an arc connecting rod. (e) The two sides of the fracture are con-
nected with a connecting rod, but the chuck should not yet be locked;
the fracture fragments are reduced by hand. (f) After reduction, the
chuck on the connecting rod can be locked to complete the final
fixation
9 Fracture of the Distal Radius
Fig. 9.23 A longitudinal incision along the radial side of the flexor
carpi radialis muscle
• Fracture reduction and fixation:
–– Extra-articular fractures:
Dorsal angulation <15° and no compression on the
dorsal bone fragment (Fig. 9.25):
Manual resetting can be performed, with traction
and compression onto the dorsal side for fracture
reduction.
Alternatively, a fine periosteal stripper can be
inserted into the fracture line to pry and reset the
distal fracture fragment.
After temporary fixation by Kirschner wire,
ordinary steel plate screws should be used for
fixation.
The length of the screw should not be too long;
otherwise, there is risk of wear on the extensor
tendon.
Dorsal angulation <15° and compression on the
dorsal bone fragment (Fig. 9.26):
Because an ordinary steel plate cannot provide
angular stability, with increased loading on the
wrist, there is a risk of dorsal redisplacement.
After reduction using the above method, the
locking plate should be used for fixation.
The plate should be placed as close as possible
to the articular surface, so that the distal screw is
273
in the subchondral bone, to provide good
mechanical support, which is particularly impor-
tant for patients with osteoporosis.
In some anatomical locking plates, the radial
styloid screw is designed to fix the radial column
and the radial styloid process.
The third generation of distal radius anatomical
locking plates allows the placement of locking
screws at an angle within a certain range. In
addition, the bone fragment in the radial col-
umn and radial styloid process can be fixed by
placing screws toward the radial styloid
process.
Dorsal angulation >15° (Fig. 9.27):
A Kirschner wire is placed parallel to the articu-
lar surface of the distal radius through the nail
hole of the steel plate. The position of the wire
should be as close to the subchondral bone as
possible, with confirmation by fluoroscopy.
A lock screw is placed parallel to this Kirschner
wire. Note that the declination angle of the steel
plate from the radial shaft at this time is the
restored palmar tilt.
With ulnar declination of the wrist of 20°, the
screw position is checked under fluoroscopy to
prevent the screw from entering the joint.
At least 2 distal locking screws are inserted, and
then the Kirschner wire is removed.
The dorsal angulation deformity is corrected by
pressing the plate to attach to the radial shaft.
The remaining screws are placed to complete the
final fixation.
–– Intra-articular fractures:
According to the Melone classification, for intra-­
articular fractures, radial styloid process, dorsal lip,
palmar lip, die punch, and distal ulna fractures must
be treated.
Reduction and fixation of the radial styloid
process:
For radial styloid process fracture with displace-
ment, distraction of the brachioradialis muscle
may affect the result of the reduction, and thus
sharp separation can be performed for the attach-
ment point of the brachioradialis muscle at the
distal fracture. Alternatively, a Kirschner wire can
be placed in the radial styloid process as a rocker
to assist reduction and temporary fixation.
Second-generation and third-generation distal
steel plates for the distal radius can be used to
place the screws into the radial styloid process
for fixation.
For radial styloid process fracture that is difficult
to repair, the radial styloid plate can be inserted
274 H. Chen et al.

b
palmar branch of
motor nerve
Palmar branch of
sensory nerve
a flexor carpi radialis
Anterior capsule
median nerve
flexor pollicis longus
pronator
quadratus

radial artery Pronator quadratus

muscle

Median nerve

c
palmar branch of
motor nerve
Palmar branch of
sensory nerve

Anterior joint
capsule

pronator
quadratus muscle

Median nerve

Fig. 9.24 (a) Separation is performed along the gap between the flexor quadratus muscle. (c) After subperiosteal stripping along the volar side
carpi radialis muscle and radial artery to expose the pronator quadratus of the radius, the pronator quadratus muscle is pulled toward the ulnar
muscle. (b) An incision is created along the ending point of the pronator side to expose the fracture

through the radial incision as a support (buttress)
(Fig. 9.28).
Treatment of intra-articular die punch fracture is
often difficult, especially in patients undergoing
delayed surgery. Using the navicular and lunate
articular surface as a template, reduction can be
achieved by pushing the isolated bone fragment
through the fracture line using special equipment.
Reduction and fixation of the bone fragment at the
dorsal lip:
A bone fragment at the dorsal lip, especially a
bone fragment close to the lower distal radioul-
nar joint, is difficult to fix with a palmar plate;
this site is the attachment of the distal radioulnar
ligament, and displacement can easily occur due
to rotation stress in the forearm rotation
movement.
Fixation should be performed using the screw
closest to the ulnar side of the distal steel plate.
If the fixation result is not satisfactory, a
Kirschner wire can be used to assist the fixation
of this bone fragment.
If the above methods cannot achieve a stable fixa-
tion, the dorsal plate can be used for the fixation.
Reduction and fixation of the bone fragment at the
palmar lip:
9 Fracture of the Distal Radius
c d
Fig. 9.25 (a) Under traction force at the volar flexion, the fracture is
reduced by hand to restore the ulnar inclination angle and volar tilt
angle of the distal radius, as well as the length of the radial styloid pro-
cess. (b) A Kirschner wire is used for temporary fixation of the distal
fracture fragment of the radius. (c) A screw is inserted in the sliding
Due to the presence of palmar tilt, the palmar lip
of the distal radius protrudes from the long axis
of the radial shaft. The forces on the navicular
and lunate bones are conducted toward the distal
radius and reach the palmar lip, showing a com-
ponent pointing to the palmar side, which can
easily cause the displacement of the bone
­fragment at the palmar lip, leading to sublux-
ation of the wrist (Fig. 9.29).
For most of the bone fragment, the plate should
be placed as close to the articular surface as pos-
sible, and screws through the palmar lip can be
used for fixation.
For a bone fragment at the palmar lip particu-
larly close to the articular surface, a Kirschner
wire can be used for auxiliary fixation.
Position of the screws for the radial distal plate:
McQueen et al. showed that the radial distal dor-
sal cortex is thin, whereas the subchondral bone
of the articular surface is denser; thus, the plate
275
hole and tied after placing and adjusting the stainless-steel plate to the
appropriate position for fixation. (d) A screw is placed on the distal
side; the length of the screw should be 2–4 mm shorter than the sound-
ing depth to avoid dorsal protrusion of the screws, which may lead to
wear-caused rupture of the extensor tendons
should be close to the distal radius with the
screws toward the dorsal distal, and the screw
can be fixed to the subchondral bone instead of
the dorsal cortex.
The reduction result of the articular surface is
observed under fluoroscopy. If the reduction is not
satisfactory, a small incision can be made in the
dorsal side to restore the articular surface under
direct vision.
Cutting the articular capsule on the palmar side
should be avoided to prevent a loss of stability of
the wrist.
• Indications for bone graft:
–– It is reported in the literature that bone graft should be
considered for patients with radial distal shortening
>10 mm, radial shortening on the ulnar side >5 mm, or
osteoporosis.
–– Commonly used bone graft materials include autolo-
gous bone, allogeneic bone, and artificial bone. In gen-
eral, autologous bone graft is recommended.
276
a b
c d
Fig. 9.26 (a) In the case of a bone defect or compression of the dorsal
bone fragment, there is a risk of re-dislocation with increased loading
on the wrist when using an ordinary stainless-steel plate for fracture
fixation. (b) The angular stability formed by the distal screw of the
locking plate and the plate itself contributes to reduced maintenance
• Treatment of distal radius fractures with fracture of the
ulnar styloid process:
–– After fixation of the radius fracture, a stress test should
be performed in the pronation position, the neutral
position, and the supination position to check the sta-
bility of the distal radioulnar joint.
–– When ulnar styloid fracture is present, especially frac-
ture at the base of the ulnar styloid process, an unstable
distal radioulnar joint after internal fixation of the dis-
tal radius fracture indicates ulnar instability caused by
the associated severe injury of the ulnar column.
Stability must be restored by internal fixation
(Fig. 9.30):
With the elbow in flexion and the forearm in
extreme supination, an incision is created along the
dorsal ulnar margin.
Damage to the dorsal sensory branch of the ulnar
nerve at this site, which is divided into 3 branches at
the level of ulnar styloid process, should be avoided.
The fracture fragments are identified, and exces-
sive stripping of soft tissue is avoided. Fixation
H. Chen et al.
e
even when the dorsal bone fragment is defective or compressed. (c, d)
In some anatomical locking plates, the radial styloid screw is designed
to fix the radial column and the radial styloid process. (e) The third
generation of distal radius locking plates allows the placement of distal
locking screws within a certain range
can be performed with the Kirschner wire tension
band, micro screw, or screw tension band
techniques.
• If the distal ulna fracture is not complicated, instability in
the distal radioulnar joint after fixation of distal radius
fracture indicates injury in the ligament for stability of the
distal radioulnar joint. Postoperative movement restric-
tion of the wrist and forearm by the elbow joint for
4 weeks, temporary fixation by ulnar and radial transverse
wire at the same time, or open repair of the TFCC should
be applied.
• Incision closure:
–– The steel plate covering the pronator quadratus muscle
is sutured; stimulation of the flexor digitorum profun-
dus tendon by the plate should be avoided.
–– The incision is sutured and closed layer by layer.
• Postoperative treatment:
–– According to the stability after fixation of the fracture
as well as the stability of the distal radioulnar joint and
the fracture of the ulnar styloid process, appropriate
movement restriction is selected.
9 Fracture of the Distal Radius 277

Fig. 9.27 The volar

a e
stainless-steel plate is used to
β1
reduce the fracture and
correct the dorsal angulation
β = β1
dislocation. (a) A Kirschner
wire is placed parallel to the
joint surface of the distal
radius through the nail hole of β
the stainless-steel plate. The
position of the wire should be
as close as possible to the
subchondral bone, with
confirmation by fluoroscopy.
f
(b) A locking screw is placed b
parallel to the Kirschner wire.
Note that the declination
angle of the stainless-steel
plate from the radial shaft is
the restored volar tilt angle.
(c) With ulnar declination of
the wrist of 20°, the screw
position is checked under
fluoroscopy to prevent the
screw from entering the joint.
(d) At least two distal locking c
screws are inserted, and then
the Kirschner wire is 20°
removed. (e) The dorsal
angulation deformity is
corrected by pressing the
g
plate for attachment to the
radial shaft. (f, g) Lateral
fluoroscopic images before
and after correction of dorsal
dislocation using a volar plate

–– Postoperative elevation of the affected limb is condu-
cive to subsidence of swelling. Patients are encouraged
to perform early finger exercise.
–– If the fracture fixation is strong and the distal radioulnar
joint is stable, with no ulnar styloid process fracture,
active wrist activities can start 1 week after surgery.
–– Muscle strength exercises can be gradually increased
6 weeks after surgery.
• Experience and lessons:
–– The distal screw placed in the subchondral bone can
enhance the stability of internal fixation, especially for
elderly patients with osteoporosis.
–– In situ suture is performed for the pronator quadratus
muscle, which can cover the internal fixation, thus pre-
venting stimulation of the flexor tendon and reducing
wrist pain and other surgical complications.
–– Barton fracture refers to radial wrist fracture and dislo-
cation caused by palmar shearing and often has more
than 2 bone fragments. The bone fragment on the pal-
mar and ulnar sides is often smaller. If full fixation is
not achieved, the loss of effective support between the
radius and wrist articular surface will result in sublux-
ation of the radial wrist joint with the bone fragment.
–– For elderly patients with osteoporosis, dorsal cortex
comminution should be considered in fractures of the
distal radius. The fixation implant in the palmar side
may push the distal palmar bone fragment with dis-
placement toward the distal end, which may cause dis-
placement of the dorsal bone fragment and loss of
normal palmar tilt.
–– When fixation on the palmar side cannot provide sta-
bility for the displaced radial styloid process, the end-
278
a b
radius
ulna
pronator
quadratus
muscle
unlar side
tendon
c
Fig. 9.28 (a) Anatomical drawing of the distal radius illustrating that
the brachioradialis muscle is attached to the lateral surface of the radial
styloid process and that its pulling effect might increase difficulty in
reducing the height of the lateral column of the distal radius. (b) The
joint surface is reduced by pushing and holding from the metaphyseal
ing point of the brachioradialis should be released and
fixed with a small radial plate.
–– If the bony support is lacking in the palmar bone frag-
ment of the lunate bone, a suture can be used for fixa-
tion to avoid bone flipping.
Open Reduction and Internal Fixation for Distal Radius
Fracture with the Dorsal Approach (Ross and Heiss-
Dunlop 2010):
• Position and preoperative preparation: same as the palmar
approach.
• Operative incision according to the projection on the body
surface:
–– The incision is on the radial side of Lister’s tubercle,
approximately 5 cm long and across the wrist
(Fig. 9.31).
• Surgical approach (Fig. 9.32):
–– The radial dorsal tendon is divided into 6 fascia
sheaths. The third fascia sheath can be cut, with the
approach between the first and second fascia sheath.
–– The skin and subcutaneous tissue are cut, and the flap
is separated to expose the extensor supporting band.
H. Chen et al.
side. (c) The volar lip of the distal radius protrudes from the long axis of
the radial shaft. The forces on the navicular and lunate bones that are
conducted toward the distal radius and reach the volar lip contain a com-
ponent pointing to the volar side, which can easily cause displacement of
the bone fragment at the volar lip, leading to subluxation of the wrist
–– The extensor supporting band is cut on the ulnar side
of Lister’s tubercle, and the third fascia sheath is
opened.
–– The extensor hallucis longus tendon is retracted and
protected with a rubber band.
–– The separation is performed along the dorsal perios-
teum of the radius. The fourth fascia sheath together
with the common digital extensor is pulled to the ulnar
side to expose the ulnar bone fragment and dorsal
articular capsule.
–– The separation is performed toward the ulnar side until
the fifth fascia sheath, and the soft tissue attached to
the ulnar angle bone should not be damaged.
–– A small transverse incision is made on the articular
capsule, and the ulnar angle bone fragment is reset
under direct vision, followed by temporary fixation
using Kirschner wire.
–– The extensor supporting band is cut between the first
and second fascia sheath, avoiding damage to the sec-
ond fascia sheath.
–– The first fascia sheath is dissected subperiosteally to
expose the radial column.
9 Fracture of the Distal Radius 279

a b

1
5 2

3
4

d e

Fig. 9.29 A distal radius comminuted fracture. (a) Preoperative
anteroposterior and lateral X-ray images demonstrating an intra-­
articular fracture at the distal radius with a distal dislocation of the
metaphysis. (b) Preoperative CT demonstrating a joint surface commi-
nuted fracture. (c) In the Fig., 1 denotes the radial styloid process frag-
ment, 2 denotes the volar fragment, 3 denotes the dorsal fragment, 4
denotes the distal end of the ulna, and 5 denotes the die punch fragment.
(d) Open reduction and internal fixation: A second-generation distal
radius volar stainless-steel plate was used, with the distal screws placed
asymmetrically in the radial styloid process fragment and dorsal frag-
ment; in addition, a buttress was placed at the side of the radial styloid
process using the same approach. (e) Postoperative CT scan-­
reconstructed images: Both anteroposterior and lateral observations
demonstrated that the distal radius E fracture was anatomically reduced
and the distal screw was in the subchondral bone without dorsal protru-
sion from the bone cortex
280 H. Chen et al.

Fig. 9.30 An intra-articular b

fracture at the distal radius
a
complicated with a fracture at
the base of the ulnar styloid
process. (a, b) Preoperative
anteroposterior and lateral
X-ray images. (c, d) Using
the volar approach, the distal
radius fracture was fixed, and
the base fragment of the ulnar
styloid process was fixed with
Kirschner wires

c d
9 Fracture of the Distal Radius
Fig. 9.31 A preoperative incision mark by surface projection: The
incision mark is on the dorsal wrist joint and on the radial side of
Lister’s tubercle (approximately 5 cm long)
• Fracture reduction and fixation:
–– First, the fracture fragments in the ulnar angle of the
distal radius and the radial styloid process are reset
under direct vision, followed by temporary fixation
using a Kirschner wire.
–– After shaping, the dorsal steel plate is placed on the
ulnar side of Lister’s tubercle, with temporary fixation
using a Kirschner wire, and a screw is placed in the
sliding hole for temporary fixation.
–– The radial styloid plate is placed on the radial side of
the radial styloid process, and a screw is placed in the
sliding hole for temporary fixation.
–– The locking screws are placed on the dorsal plate as
well as the metaphyseal end and the lateral side of the
shaft of the plate for the radial styloid process.
–– Note that the 2 steel plates are placed roughly verti-
cally so that the fixation is more secure (Figs. 9.33 and
9.34).
• Treatment for fracture of the ulnar styloid process and the
distal radioulnar joint: same as the palmar approach.
• Closure of the incision: The articular capsule is sutured,
and the steel plate is covered with the fascia sheath with
fascia suture under the tendon to protect the distal tendon
sheath, ensure the normal anatomical position of the ten-
don, and avoid contact between the tendon and steel plate,
thus preventing long-term wear and tear fracture of the
tendon.
• Postoperative treatment: same as the palmar approach.
281
• Experience and lessons:
–– For severe distal radius fractures, the palmar and dor-
sal combined approach can be applied.
9.2.4 Surgical Complications and their
Prevention and Treatment
• Malunion:
–– Nonunion of the distal radius is rare. However, either
conservative treatment or surgical treatment may result
in final malunion due to poor reduction or loss of
reduction.
–– For conservative treatment, to avoid loss of reduction,
the ability to achieve stability after reduction until
fracture healing can be achieved by external fixation
should be carefully assessed as described above. If
external fixation after reduction cannot adequately sta-
bilize the fracture, loss of reduction and deformity
healing are inevitable. In this case, surgical treatment
should be provided.
–– In the selection of an external fixator, if the metaphy-
seal bone fragment is sufficiently large, an external
fixator that does not cross the joint is recommended to
directly stabilize the fracture ends, which is conducive
to maintenance after fracture reduction (Carneiro et al.
2009).
–– For patients with severe comminuted fracture or severe
osteoporosis, locking plate fixation provides better sta-
bility than non-locking plate fixation (Ruch et al. 2005)
(Fig. 9.35).
–– When a palmar plate is used for fixation, the position
of the steel plate should be as close to the distal articu-
lar surface as possible to ensure that the screw is as
close to the subchondral bone as possible in fixation.
This position will not only effectively fix the articular
surface bone but also prevent the collapse of the articu-
lar surface when the raft-like screws are at a stable
angle (Liporace et al. 2009).
• Injury of the median nerve, tendon, and distal radioulnar
joint:
–– Conservative treatment and median nerve symptoms:
Wrist flexion greater than 20° at fixation using plaster
is likely to cause median nerve symptoms. This is also
the case for the application of an external fixator, and
wrist flexion greater than 20° should be avoided
(Harness et al. 2008; Turner et al. 2007).
–– Open reduction and internal fixation and median nerve
injury: In the fixation of distal radius fracture with a pal-
mar plate, the radial wrist flexor approach is often used.
In this case, misidentification of the palmaris longus
muscle as the radial wrist flexor should be avoided to
prevent incision too close to the ulnar side, which will
282 H. Chen et al.

a II III
IV b
4
3 5
6
2
I

radius ulna

c d e

extensor pollicis longus muscle

f g h
GAP 1
(abductor pollicis longus /
extensor pollicis brevis)

sensory branch
of radial nerve

Fig. 9.32 Dual plate fixation for complex three-column fractures via
the dorsal approach: Exposure and fixation of the radial column and the
dorsal angle bone fragment of the middle column. (a) The anatomical
relationship among the dorsal fascia sheaths of the radius: The distal
radius can be exposed by severing the third fascia sheath by the
approach between the first and second fascia sheath. (b) The skin and
subcutaneous tissue are cut to expose the extensor supporting band;
next, the extensor supporting band is cut on the ulnar side of Lister’s
tubercle, and the third fascia sheath is opened. (c) The extensor pollicis
longus tendon is retracted and protected with a rubber band. (d) The
separation is performed along the dorsal periosteum of the radius. The
fourth fascia sheath together with the common digital extensor is pulled
to the ulnar side to expose the ulnar angle bone fragment and dorsal
joint capsule. (e) A small transverse incision is made on the joint cap-
sule, and the ulnar angle bone fragment is reset under direct vision. (f,
g) The extensor supporting band is cut between the first and second
fascia sheath, avoiding damage to the second fascia sheath; then, the
first fascia sheath is dissected subperiosteally to expose the radial col-
umn. (h). The joint capsule is sutured, and the stainless-steel plate is
covered with the fascia sheath with the fascia suture under the tendon to
protect the distal tendon sheath, ensure the normal anatomical position
of the tendon, and avoid contact between the tendon and stainless-steel
plate, thus preventing long-term wear and tear fracture of the tendon
9 Fracture of the Distal Radius 283

a b c

d e

Fig. 9.33 Internal plate-screw fixation for a distal radius fracture via
the dorsal approach. (a, b) After fracture reduction, the re-shaped dorsal
stainless-steel plate is placed on the ulnar side of Lister’s tubercle and
temporarily fixed with a Kirschner wire and a screw placed in the slid-
ing hole. (c) The radial styloid process plate is placed on the lateral side
of the radial styloid process and temporarily fixed with a screw placed
in the sliding hole. A locking screw is placed in the locking hole on the
metaphyseal side of the dorsal plate. (d) The rest screws are inserted
and tightly locked. (e) The two stainless-steel plates are placed roughly
vertically (70–90°) so that the fixation is more secure

Fig. 9.34 Case example of

a b
dual plate fixation of a distal
radius fracture via the dorsal
approach. (a) Postoperative
anteroposterior X-ray images.
(b) Postoperative lateral
X-ray images
284
a b
Fig. 9.35 Case example of an intra-articular comminuted fracture of the
distal radius (male, 55 years old). (a) Preoperative anteroposterior and
lateral X-ray images: The anteroposterior X-ray image shows that the
distal radius lost its ulnar inclination and instead inclined radially by
approximately 10°, accompanied by shortening of the radius by approxi-
mately 1 cm. The lateral X-ray image shows that the distal radius lost its
volar inclination and instead inclined dorsally by approximately 30°,
accompanied by a comminuted volar cortex. The X-ray images also show
a fracture of the radial styloid process. According to the assessment crite-
ria for post-reduction stability, various factors, which include a commi-
cause accidental median nerve injury. In the application
of the dorsal plate or percutaneous pinning technique,
internal fixation of a screw or Kirschner wire should be
carefully adjusted to avoid excessive protrusion to the
cortex on the palm side, which may cause accidental
injury in the median nerve (Gelberman et al. 1984).
H. Chen et al.
nuted volar metaphyseal fracture, pre-reduction dorsal angulation of the
fracture fragments greater than 20°, pre-reduction displacement of the
fracture fragments greater than 1 cm, and pre-reduction shortening of the
radius greater than 5 mm, indicate that stability is difficult to maintain
after reduction. (b) After closed reduction and fixation with an external
fixator, the length of the radius cannot be fully restored, and the volar
cortex cannot be satisfactorily aligned. (c) Follow-up X-ray image at
postoperative month one demonstrating that the radius continued to
shorten, the radial facet was remarkably lower than the distal ulna, and
the distal radius had a volar inclination angle of approximately 0°
–– Palmar plate and dorsal tendon injury (Crist and
Murtha 2012):
The anatomical morphology of the dorsal surface of
the distal radius is not regular. Lister’s tubercle nodule
is the highest point of the dorsal surface, with both
sides lower than Lister’s tubercle. Thus, although the
9 Fracture of the Distal Radius
a lister sigrnoid styloid process
tubercle notch of ulna
↑ dorsal
head of joint
styloid process
of radius
carpal articular distal radioulnar
surface joint
c d
Fig. 9.36 (a) Anatomical drawing of the distal radius illustrating an
irregular shape of the dorsal radius with Lister’s tubercle as the apex
higher than both the ulnar and radial sides. (b) Preoperative anteropos-
terior and lateral X-ray images of a distal radius fracture demonstrating
dorsal displacement of the distal fracture end. (c) Lateral X-ray image
lateral image shows that the tip of the screw is located
in the dorsal cortex, it may actually protrude the dor-
sal cortex, which will cause ­stimulation and even
wear and tear to the dorsal extensor tendon. In the
fixation of distal radius fractures using a palmar plate,
the depth should be carefully measured, and the
length is usually reduced by 2–4 mm to avoid pierc-
ing of the cortical bone and consequent tendon injury
and other complications (Fig. 9.36).
–– Placement of the screw in the distal ulnar and radial
joints:
To control the ulna fracture fragment of the distal
radius, the screws are usually fixed with the bias
285
b
illustrating three screws with their tips buried within the cortex after
volar plate fixation using the flexor carpi radialis approach. (d)
Postoperative CT demonstrating that the tip of the ulnar screw pro-
trudes from the dorsal bone cortex, potentially leading to wear of the
dorsal tendons
toward the ulnar side. If the screw is too biased
toward the ulnar side, its tip is likely to enter the
distal ulnar and radial joints, thus affecting the rota-
tion of the forearm.
An anatomical locking steel plate not only fixes the
bone fragment on the ulnar side of the middle col-
umn more effectively but also avoids straying of
screws into the distal ulnar and radial joints due to
their design with a specific orientation. In addition,
the omnidirectional anatomical locking plate
allows the screw to be fixed in a certain range of
direction, which can reduce the incidence of screws
entering the distal ulnar and radial joints. In fixa-
286 H. Chen et al.

a b

c d

Fig. 9.37 Example of an intra-articular fracture of the distal radius
complicated with a fracture of the ulnar styloid process (female,
49 years old). (a) Preoperative anteroposterior and lateral X-ray images
illustrating a comminuted intra-articular fracture and significant volar
displacement of the distal radius complicated by a fracture of the radial
styloid process. (b) During the open reduction and internal fixation
operation with a non-anatomical plate, to secure the ulnar fracture frag-
ment, the screws were too biased toward the ulnar side, leading to pro-
trusion of the screw tips into the distal ulnoradial joint. (c) X-ray image
at postoperative month 16 showing a healed fracture accompanied by a
small amount of damaged bone at the distal ulnoradial joint. (d)
Anteroposterior and lateral X-ray images after surgical removal of the
internal fixators

tion using an omnidirectional anatomical locking joints and re-fixed without changing the position of
plate, if the screw strays into the distal ulnar and the steel plate, thus facilitating the operation
radial joints, the orientation of the screw can be (Nelson 2009; (Ross and Heiss-Dunlop 2010)
adjusted away from the distal ulnar and radial (Fig. 9.37).
9 Fracture of the Distal Radius 287

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 Fractures of the Scaphoid
Yonghui Liang, Xuefeng Zhou, and Hao Guo
10.1 Basic Theory and Concepts
10.1.1 Overview (Sendher and Ladd 2013;
Wolf et al. 2009; Van Tassel et al. 2010)
• Fractures of the scaphoid account for 2% of all fractures
and 71.2% of wrist fractures, with an average annual inci-
dence of 23–43/100,000 and an average patient age of
25 years.
• In adults, 70–80% of scaphoid fractures occur at its waist,
10–20% occur at its proximal pole, and 20.4% are com-
plicated with scapholunate and lunotriquetral ligament
injuries.
• The scaphoid between the proximal and distal carpal rows
acts as a connecting lever between the two carpal rows.
When the scaphoid is fractured, the distal fracture frag-
ment moves along with the distal carpal row, and the
proximal fracture fragment moves along with the proxi-
mal carpal row. Therefore, the scaphoid fracture largely
affects the movement and stability of the wrist joint. A
nonunion of the scaphoid fracture can cause wrist insta-
bility, long-term chronic pain, traumatic arthritis, etc.
• Due to a poor blood supply, especially at the proximal
pole, the risk of osteonecrosis is high for the fractured
scaphoid. Regardless of the treatment method, the
reported osteonecrosis rate of scaphoid fractures reaches
13–50% and even higher for fractures at the proximal
pole of the scaphoid.
• Diagnosis of scaphoid fractures, especially those without
displacement, is challenging. Evaluations of fracture dis-
placement and fracture healing, as well as the selection of
Y. Liang (*)
Aerospace Center Hospital, Beijing, China
X. Zhou
Chinese PLA Strategic Support Force Characteristic Medical
Center, Beijing, China
H. Guo
Chinese PLA General Hospital, Beijing, China
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0208-5_10
10
treatment methods, are difficult. A missed diagnosis of an
occult fracture or a displaced fracture without proper cor-
rection will lead to kinematic changes in the wrist joint
and inevitably result in instability of the dorsal carpal
joint in the long term.
10.1.2 Applied Anatomy
• The scaphoid is the longest and largest bone in the proxi-
mal carpal row. It has a long-arc boat-like irregular shape,
with its distal end exceeding the proximal carpal row and
positioned at the same level of the waist of the capitate.
Therefore, the scaphoid waist forms a plane between the
articular facets of the two rows of carpal bones.
• The scaphoid is divided into three parts: tubercle, waist,
and body. It is mostly covered by articular cartilage and
forms 5 joints with the surrounding bones (Fig. 10.1):
–– The joint between the concave facet of the distal pole
of the scaphoid and the capitate
–– The joint between the convex facet of the proximal
pole of the scaphoid and the distal radius
–– The joint between the ulnar side of the scaphoid and
the lunate
–– The joints formed by the radial side of the scaphoid
with the trapezium and trapezoid
• The scaphoid is 23 ± 0.8 mm in length, with blood-­
supplying vessels entering from the dorsal ridge
(Fig. 10.2). Its waist dominantly receives both the distal
(79%) and proximal (14%) blood supply, and its tubercle
receives a volar blood supply (7%).
–– The artery branches are distributed in only the part of
the scaphoid covered by periosteum, and they are
divided into the dorsal and volar groups. The dorsal
group contains a large quantity of larger-diameter
artery branches that enter the scaphoid from the distal
2/3 dorsal ridge and supply the proximal 70–80% of
the scaphoid. The volar group includes a small number
of smaller-diameter vessels that enter the scaphoid
289
290 Y. Liang et al.

Fig. 10.1 Eighty percent of

the scaphoid surface is
covered by articular cartilage,
and only the dorsal lateral
surface of the tubercle and
waist parts has bare bone for
ligament attachment and entry
of blood-supplying vessels

volar radial dorsal ulnar

Fig. 10.2 The blood-supplying vessels enter the scaphoid from its dor-
sal ridge

volar scaphoid
scaphoid tubercle
branch

Fig. 10.4 Micro-structure of the trabecular bone

The volar vessels originate from the radial artery and

dorsal scaphoid branch
Fig. 10.3 Angiography of the scaphoid
from the volar tubercle and supply the distal 20–30%
of the scaphoid, mostly only the tubercle and the distal
pole (Fig. 10.3).
–– The dorsal vessels are mainly from the radial artery,
with a small number from the dorsal intercarpal arch.
its superficial palmar branch.
–– The distal end of the scaphoid (tubercle) receives an
abundant blood supply, which allows relatively more
satisfactory fracture healing. Conversely, there is no
vessels entering the proximal end, and as a result, a
proximal scaphoid fracture easily develops into osteo-
necrosis or nonunion of the proximal pole of the
scaphoid due to destruction of its retrograde blood
supply.
• The bone trabecula is dense at the two ends and sparse in
the waist of the scaphoid, making the scaphoid waist a
mechanically weaker area (Fig. 10.4).
10 Fractures of the Scaphoid
10.1.3 Mechanism of Injury
• Scaphoid fractures are more common in adult males. The
fractures occur at the posture where the patient lands on
the palm(s) in a fall, with the body inclining forward, the
forearm rotating inward, and the wrist in a radial devia-
tion and a dorsiflexion exceeding 90°.
• During a fall onto the outstretched hand at a posture of the
forearm extending forward and the wrist extending dor-
sally with a radial deviation, the thenar area touches the
ground first, causing an excessive dorsiflexion of the
scaphoid due to compressing and pushing forces from the
trapezium and trapezoid. Simultaneously, the dorsal side
of the scaphoid is against the radial styloid and the dorsal
edge of the joint, and the proximal volar radiocarpal liga-
ment is placed under tension, preventing the scaphoid
from dorsal displacement. At this moment, the body
weight and the ground counterforce act together and
directly strike the scaphoid waist, resulting in a scaphoid
fracture (Figs. 10.5 and 10.6).
• Scaphoid fractures caused by direct violence are rare.
10.1.4 Classification of Scaphoid Fractures
• There is not yet a unified classification system. Currently,
scaphoid fractures are classified mostly based on fracture
location and degree of fracture stability.
• Classification based on fracture location (Fig. 10.7):
–– Tuberous fractures: The scaphoid tubercle is the
attachment site of the joint capsule and ligaments, and
Fig. 10.6 Mechanism of scaphoid fracture injury
DIC STT
DIC
S
RS
RC
R R
Fig. 10.5 Changes in the tension of the ligaments surrounding the scaphoid during movement
291
its fractures are mostly avulsion fractures and can heal
relatively fast due to the abundant blood supply.
–– Distal 1/3 fractures: Benefiting from good blood circu-
lation in the distal scaphoid, this type of fracture has a
low nonunion rate, but it requires a relatively longer
time for healing.
–– Scaphoid waist fractures: It is the most common type
of scaphoid fracture. Because of large variations of
blood vessels in the scaphoid and poor blood circula-
tion in the scaphoid waist, this type of fracture requires
a longer time for healing and has a nonunion rate of
approximately 30%.
–– Proximal 1/3 fractures: Almost no blood vessels enter
the proximal scaphoid, which mostly receives the ret-
rograde blood supply from the scaphoid waist.
Therefore, the fracture is difficult to heal and often
leads to osteonecrosis.
fracture produced by bending force
at the distal pole of the scaphoid
external force
STT
S
RSC
292 Y. Liang et al.

a b c d

Fig. 10.7 Classification of scaphoid fractures based on fracture location. (a) Tuberous avulsion fractures. (b) Distal 1/3 fractures. (c) Scaphoid
waist fractures. (d) Proximal 1/3 fractures

A B1 B2 Table 10.1 Herbert classification of scaphoid fractures

Type A (fresh stable A1 Tuberous fracture
1 fracture) A2 Non-displaced waist fracture
A3 Non-displaced proximal fracture
2
Type B (fresh B1 Distal 1/3 oblique fracture
unstable fracture) B2 Waist fracture with a displacement or
movement range ≥1 mm
B3 Displaced proximal fracture
3 B4 Scaphoid fracture accompanied with
B3 B4 B5 other carpal fractures or dislocation
B5 Comminuted scaphoid fracture
Type C Delayed fracture healing
Type D (bone D1 Fibrous nonunion
nonunion) D2 Sclerotic nonunion

C D1
• Herbert classification:
–– This classification system was first proposed by
D2 Herbert et al. in 1984 (Fig. 10.8) and has been adopted
by orthopedic trauma centers in many renowned hospi-
tals worldwide. This system takes full account of mul-
tiple factors affecting treatment options, including
fracture location, the time of injury, fracture type, frac-
ture stability, and tendency toward nonunion
(Table 10.1).

Fig. 10.8 Herbert classification of scaphoid fractures

10.1.5 Assessment of Scaphoid Fractures

• Classification based on the degree of fracture stability: 10.1.5.1 Clinical Assessment

–– Stable fractures: There is no displacement or lateral
displacement <1 mm.
–– Unstable fractures: There is a lateral displacement
>1 mm and dorsal or radial angulation, accompanied
by a dorsal extension instability of the wrist or disloca-
tion of the carpal bones. This type of fracture mostly
requires surgical treatment.
• Local swelling of the wrist joint is present, with swelling
in the anatomical snuffbox being the most significant. The
anatomical snuffbox is normally presented as a soft tissue
depression, and the disappearance of this depression indi-
cates swelling.
• Patients suffer wrist joint pain (especially at the radial
side), and some patients may have limited wrist move-
10 Fractures of the Scaphoid
Fig. 10.9 Clinical examination of scaphoid fractures
ment. However, symptoms of swelling, pain, or limited
movement of the wrist joint may not be present in some
patients, for whom the tenderness at the anatomical snuff-
box is of great value in fracture diagnosis (Fig. 10.9).
–– Tenderness at the anatomical snuffbox (sensitivity
100%, specificity 9%), scaphoid tubercle tenderness
(sensitivity 100%, specificity 38%), and pain induced
by axially compressing the first metacarpal (sensitivity
100%, specificity 48%).
–– The three signs described above show a very high sen-
sitivity but low specificity when individually used for
the diagnosis of scaphoid fractures. However, com-
bined use of the three signs has significantly improved
specificity for diagnosis, reaching 70%. A previous
study found that the absence of tenderness in the ana-
tomic snuffbox significantly reduces the diagnosis
probability of scaphoid fractures.
10.1.5.2 Imaging Assessment
The commonly used imaging methods, X-ray, computed
tomography (CT), and magnetic resonance imaging (MRI),
show different advantages and disadvantages.
• X-ray is easy and convenient to operate and has a diag-
nostic accuracy of 70–90%. However, it has a high rate of
missed diagnosis, especially for non-displaced stable
scaphoid fractures, which are easily missed on X-ray
films at an early stage and often diagnosed in further
examinations for joint pain. It has been reported that the
combined use of the anteroposterior and lateral wrist
views and the axial and oblique scaphoid views of the
affected side in comparison with those of the unaffected
293
contralateral side can achieve a diagnostic rate of 95% or
higher for scaphoid fractures.
–– Routine X-rays include the standard wrist views
(anteroposterior, lateral, and oblique views) and a
scaphoid view (anteroposterior view). (Fig. 10.10).
–– Standard anteroposterior and lateral wrist views alone
are not suitable for diagnosing scaphoid fractures due
to significant overlapping of bone shadows. However,
these X-rays have a high reproducibility owing to a
stable body position and can clearly display the
changes in the articular spaces, angles between carpal
bones, and the structure and shape of most carpal
bones, and therefore, they can be used to rule out
scaphoid tubercle fractures, distal radius or ulna frac-
tures, and other accompanying damage, including
fractures and displacements of other carpal bones and
wrist instability.(Figs. 10.11, 10.12, and 10.13).
–– Oblique wrist views show more overlapping bone
shadows than those of the anteroposterior scaphoid
view but remarkably less than those of anteroposterior
and lateral wrist views. Its combined use with antero-
posterior scaphoid view can significantly improve the
diagnostic accuracy for fractures.
–– A comparison between the views of the ipsilateral side
and the unaffected contralateral side can contribute
greatly to the diagnosis of small non-displaced
fractures.
• CT is a more accurate diagnostic tool that can be used to
not only to evaluate the degree of fracture displacement
but also to detect occult fractures that cannot be observed
by X-ray. Although it can improve the diagnostic rate, CT
has some limitations, including a certain rate of missed
diagnosis and higher operation requirements that cannot
be met in some low-level local hospitals.(Fig. 10.14).
–– A scaphoid cross-section CT scan can identify a frac-
ture line or bone separation at least 1 mm in width, and
the scaphoid long axial scan can display the dorsal
convex deformity of fractures. However, the regular
axial CT scan is not a satisfactory tool for diagnosis.
–– Long-axis sagittal CT of the scaphoid, also known as
the “oblique sagittal projection,” is specifically
designed for the detection of scaphoid lesions. The
patient is positioned for a “sagittal” CT scan with the
wrist join in ulnar deviation of the wrist joint to
allow a CT projection plane parallel to the line con-
necting the base of the first metacarpal base to
Lister’s tubercle. Long-axis sagittal CT of the scaph-
oid can diagnose most scaphoid fractures. It can
clearly display the defective bone at the fracture site,
294 Y. Liang et al.

a b

PA View PA with
ulnar deviaton

c d

Lateral Semipronated oblique

Fig. 10.10 Wrist X-rays. (a) 45° supination. (b) 45° pronation. (c) Standard lateral view. (d) Standard anteroposterior view with the hand in ulnar
deviation

angulation deformities (the volar-flexed distal frac-
ture fragment or the dorsiflexed displacement or
deformity of the proximal fracture fragment), hard-
ened fracture ends, “humpback” deformity caused
by fracture malunion, and acute non-displaced
scaphoid fractures. In addition, it can be used to
diagnose other scaphoid lesions (e.g., intraosseous
cysts), collision between the radial styloid process
and scaphoid waist, and osteoarthritis of the scaph-
oid trapezium and trapezoid (STT) and to assess the
status of fracture reduction, location of bone graft
and internal fixators, and fracture healing.
• MRI is the most sensitive method for the diagnosis of
scaphoid fractures, with a sensitivity of close to 100%.
Moreover, it can be applied to discover soft tissue injuries
that are difficult to detect on CT. (Fig. 10.15).
–– MRI can be used to evaluate the structural integrity
and blood supply of the scaphoid, providing informa-
10 Fractures of the Scaphoid 295

Fig. 10.11 Standard anteroposterior scaphoid X-ray showing the

entire longitudinal axis of the scaphoid and a clear fracture line

Fig. 10.12 Standard anteroposterior X-ray: the fracture line is difficult

to see due to overlapping of the scaphoid contour

Fig. 10.13 Position for X-ray: approximately 30° dorsiflexion of the wrist with slight ulnar deviation by approximately 15° and a soft support
placed under the dorsal wrist
296 Y. Liang et al.

a b c d

Fig. 10.14 Radiographs of the same patient: (a) anteroposterior and (b) lateral views showing the absence of fracture displacement. CT images
of the same patient. (c) Axial and (d) coronal CT images showing the presence of fracture displacement of the scaphoid

Fig. 10.15 MRI showing

post-fracture osteonecrosis

tion for post-injury blood supply assessment and treat-
ment selection. In addition, it can identify delayed
union, nonunion, or ischemic osteonecrosis of frac-
tured bones, which represent critical information for
determining surgical indications and selecting appro-
priate surgical methods (Lutsky 2012).
–– If available, MRI examination is recommended to fur-
ther clarify or rule out the diagnosis of suspected
scaphoid fractures when the regular X-ray of a patient
is normal. Effective communication with the patient
and a 2-week plaster fixation are necessary prior to the
MRI examination.
• Other diagnostic methods include bone scintigraphy,
wrist fat pad sign, audio-frequency vibration, and
ultrasonography.
–– Bone scintigraphy, a nuclear medicine imaging
method, has been widely used in the diagnosis of
scaphoid fractures abroad in recent years.
10 Fractures of the Scaphoid 297

–– The greatest advantage of bone scintigraphy is that
scaphoid fractures can show a positive result within 24 h
post-fracture. It can be used to screen cases that are nega-
tive based on both X-ray and clinical evaluation.
–– Research has reported a sensitivity of 92–95% and a
specificity of 60–95% of bone scintigraphy for scaph-
oid fractures. The results obtained using this method
and MRI are mostly consistent.
–– The nutritive vessels of the distal scaphoid (20%)
derive from the volar branch of the superficial palmar
arch.
–– The blood supply of the scaphoid waist derives
from the dorsal radial artery, which passes through
the lateral surface of the scaphoid waist and dorsal
ridge (non-joint margin) and extends to the proxi-
mal end.

10.2 Surgical Treatment 10.2.2 Minimally Invasive Percutaneous

Cannulated Screw Fixation Technique
10.2.1 Surgical Indications (Bond et al. 2001)

Although the majority of scaphoid fractures can be cured by 10.2.2.1 Technical Features
non-surgical treatment, immobilization caused by plaster • Minimally invasive percutaneous cannulated screw fixa-
fixation for a long time may result in joint stiffness, gypsum-­ tion is suitable for the non-displaced fracture of the scaph-
associated complications, and a decrease in the patient’s oid waist. Research has confirmed that this fixation
physical ability. Therefore, surgical treatment gradually technique leads to a faster fracture healing and healing
becomes common for acute scaphoid fractures (MCQueen rate.
et al. 2008). • Percutaneous fixation can reduce soft tissue damage and
accelerate the healing of fractures. However, this tech-
• Conservative treatment: Non-displaced fractures of the nique cannot achieve accurate fracture reduction, and it is
distal pole and a portion of waist fractures of the scaphoid difficult to precisely estimate the proper length of the
can be fixed by short-arm plaster. screws, which often increases the incidence of internal-­
• Surgical treatment: This method is suitable for all dis- fixator-­associated irritability symptoms.
placed scaphoid fractures, a portion of non-displaced • Percutaneous fixation under fluoroscopy using either
waist fractures, and non-united scaphoid fractures. Herbert screws or headless screws is mostly recom-
• The volar approach is often used for scaphoid waist frac- mended in clinical practice.
tures, and the dorsal approach is generally recommended –– The advantages of percutaneous fixation include a low
for the proximal scaphoid fracture to avoid damaging the risk of vascular damage and no need to sever the volar
blood-supplying system. carpal ligaments, which offers stable fixation of the
–– The blood supply of the scaphoid mainly derives from proximal fracture fragment and allows early functional
the radial artery and its branches (Fig. 10.16). exercise.

Fig. 10.16 Blood supply volar dorsal

schematics of the volar and
dorsal approaches

superficial palmar dorsal carpal branch

branch radial artery radial artery

radial artery
298 Y. Liang et al.

10.2.2.2 Surgical Techniques

• Patient preparation and position: The affected hand is
placed on a small table beside the operation bed with the
palm side facing upright. Assisted with the C-arm, a guide
wire is inserted in the sagittal direction from the anterior
scaphoid (Figs. 10.17, 10.18, and 10.19).
• When the wrist joint remains in a dorsiflexion position, a
guide wire is placed along the central axis of the scaph-

Fig. 10.17 In the volar and dorsal approach, the needle entry point is Fig. 10.19 The guide wires are inserted along the front and sagittal
radially deviated at the distal scaphoid planes of the scaphoid

Fig. 10.18 The guide wires

are inserted along the front
and sagittal planes of the
scaphoid

true
axis
10 Fractures of the Scaphoid
oid, with the entry point slightly radially deviated on the
distal scaphoid.
• Prior to screw placement, the second guide wire is inserted
parallel to and at the radial side of the first guide wire to
avoid rotation of the fracture fragment. The desired screw
length is determined, and then a cannulated screw with a
proper length is countersunk and screwed in (Figs. 10.20
and 10.21).
–– To avoid complications caused by improper length of
the screw, the guide wires and screw should not pene-
Fig. 10.20 The desired screw length is determined, and then a screw
with a proper length is countersunk and screwed in
Fig. 10.21 X-rays after
a b
percutaneous placement of a
3.0 mm-long headless screw
from distal to proximal. (a)
Wrist AP position. (b)
Scaphoid AP position
299
trate the opposite side of the bone cortex. It is recom-
mended that the screw be 4 mm shorter than the length
measured with the guide wire; this slight difference
can avoid the joint irritation caused by the protrusion
of the screw from the opposite side of the bone
cortex.
Essentials of Surgical Treatment
• The most common mistakes are the improper length and
wrong placement location of screws. The ideal location
for screw placement remains controversial; some experts
have recommended that the screws be placed in the center
of the scaphoid, and some have suggested that the direc-
tion of screw placement should be perpendicular to the
fracture line. The placement of screws at the central
scaphoid may reduce the fixation strength of the fracture,
but it can reduce the chance of the screw penetrating into
the scaphoid-capitate joint space.
• Technically, the placement of guide wires and screws via
the volar approach is less difficult. The guide wire is
placed from the opposite direction; if the guide wire itself
or the final inserted screw protrudes into the radius-­
scaphoid joint, then the patient would suffer pain and
early joint injury. Percutaneous fixation of the scaphoid
can be safely achieved under the premise of precise fluo-
roscopy and protection of the radial artery.
• For a fracture with significant displacement before sur-
gery, open reduction is recommended to reduce the risk of
300 Y. Liang et al.

damaging the radial artery, superficial radial nerve branch, along the radiolunate and radioscaphocapitate ligaments,
and median nerve recurrent branch. In addition, this oper- and the soft tissue around the scaphoid is carefully disso-
ation allows direct assessments of the fracture displace- ciated to further expose the scaphoid (Fig. 10.22).
ment, joint surface injury, and fracture reduction, among
other parameters.
10.2.4 Non-Healing of Scaphoid Fractures

10.2.3 Open Reduction and Internal Fixation
• Incision: The incision of the Russe approach is prolonged,
which starts from the proximal 8 cm of the transverse
crease of the wrist (rasceta), extends along the radial
­margin of the flexor carpi radialis tendon toward the distal
end, turns to the base of the thumb at the transverse crease
of the wrist, and ends at the level of the trapezium bone.
• After the sheath of the extensor carpi radialis longus ten-
don is cut open, the tendon is pulled toward the ulnar side;
then, the scaphoid is exposed with a sharp separation
• The incidence of scaphoid nonunion accounts for approx-
imately 5–15% of all acute scaphoid fractures and has an
osteonecrosis rate of 3%.
• To determine whether a scaphoid nonunion should be
treated non-surgically or surgically, various factors, includ-
ing the patient’s age, health status, and expectation of wrist
function, nonunion duration, preserved motor function of
the wrist, blood supply, fracture displacement, and degen-
erative changes in the joint, should be considered.
• For young and healthy patients, if the position of the frac-
ture fragments and the local joint condition allow a surgi-

Fig. 10.22 The surgical

a b
approach for open reduction
of scaphoid fractures. (a) The
extended Russe approach. (b)
The tendon sheath of the
extensor carpi radialis longus
tendon is cut open, and the
tendon is pulled toward the
ulnar side. (c) The scaphoid
fracture site is exposed by a
sharp separation along the
radiolunate and
radioscaphocapitate ligaments

c
10 Fractures of the Scaphoid
cal method that promotes fracture healing should be
considered, e.g., autologous bone marrow
transplantation.
• For fracture non-healing, a combined treatment of autolo-
gous bone marrow transplantation, open reduction and
internal fixation plus bone grafting can be considered.
Bone grafts include allogeneic bone, autogenous bone,
and autogenous bone with a vascular pedicle.
–– Indications for transplanting autogenous bone with a
vascular pedicle include proximal scaphoid ischemic
necrosis, symptomatic proximal pole scaphoid fracture
nonunion, proximal pole scaphoid fracture displace-
ment, and scaphoid fracture after an open reduction
and internal fixation failure.
• For elderly patients with a relatively well functioning
wrist joint, non-surgical treatments can be considered,
and symptoms can be relieved by reduced use of the wrist
and its strength. Arthroplasty or arthrodesis is considered
when the pain of the wrist is aggravating with a limited
range of motion and significantly degenerative joints are
present around the fracture.
Surgical Techniques
• Bone grafting is suitable for fracture nonunions without
ischemic necrosis and osteoarthritis. Currently, Russe
bone grafting is commonly used and achieves a cure rate
ranging from 92% to 97%.
–– Surgical incision: An approximately 4-cm-long longi-
tudinal incision at the radial side of the flexor carpi
radialis tendon is generated toward the proximal side
from the volar carpal scaphoid tubercle.
–– The skin, subcutaneous tissue, and deep fascia are cut,
with careful protection of the radial artery and its
branches; especially, the blood supply on the dorsal
scaphoid must not be damaged. After the flexor carpi
radialis is pulled to the ulnar side, the joint capsule is
longitudinally cut at the distal end of the radiocarpal
joint to expose the scaphoid and its fracture. If the
exposure is insufficient, the wrist joint can be placed in
extreme dorsiflexion.
–– Abnormal activity of pseudarthrosis of the scaphoid
can be observed to identify the location of the fracture
nonunion by moving the wrist joint.
–– Bone groove preparation: Under extreme dorsiflexion
of the wrist joint, the sclerotic bones at both ends of the
fracture line are removed. A rectangular bone groove
with even surfaces is generated at the center of the
fracture line using a micro electrodrill or air drill. The
volume of the bone groove is measured.
–– Bone graft trimming: The size of the harvested ilium is
determined according to the volume of the bone
grooves and is slightly larger than the actual size to
ease trimming. The bone graft is then trimmed into the
shape of the bone groove.
301
–– Bone grafting: The trimmed bone graft is wedged into
the scaphoid bone groove with proper force and filling.
If the scaphoid fracture end or the bone graft is unsta-
ble, a 0.8-mm-diameter Kirschner’s wire can be used
for internal fixation from the scaphoid tubercle toward
the proximal end. The tail of Kirschner’s wire can be
left out of the skin or fixed with a cannulated screw.
–– The size of the bone graft should match the volume of
the scaphoid bone groove as much as possible. If the
bone graft is too small, the probability of bone nonunion
will increase; if it is too large, the forced intercalation
will push the two fracture ends away from each other.
–– To prevent the effect of forearm rotation on the scaph-
oid, a long-arm plaster support can be used for fixation
with the wrist in the neutral position. At postoperative
days 10–12, the suture is removed, and the original
support is replaced with a forearm tubular plaster with
its distal end reaching the level of the interphalangeal
joint of the thumb. The fixation duration is 12–16 weeks,
during which time the plaster is replaced in a timely
manner when it becomes loose.
10.2.5 Other Options
• Internal fixation of fracture mainly refers to fixation with
Herbert double-threaded compression screws, which is
suitable for unstable fresh fractures or fractures with
delayed healing or nonunion. Herbert screws can avoid
the bone fragment separation caused by ordinary screws
in fixation. The Herbert screw fixation operation has
higher technical requirements, requiring full exposure
and both ends of the screws not protruding from the carti-
lage. This technique must not be used for fractures with
complete ischemic necrosis in the proximal fragment.
Various types of screws have been developed based on the
principle of Herbert double-threaded compression screws.
• Resection of the radial styloid process: The radial styloid
process is subperiosteally resected through the anatomi-
cal snuffbox, and the removed bone block can be used for
bone grafting. Simple radial styloid process resection
cannot achieve satisfactory outcomes, and therefore, it is
usually combined with bone grafting. This method was
first used by Bentzon in 1939, and its main purpose is to
convert a painful bone nonunion into a painless bone non-
union by filling soft tissue flaps into the gap between the
two fracture ends to establish a pseudarthrosis. However,
it is worth noting that an excessive resection of the radial
styloid process should be avoided because it may cause
instability of the wrist joint.
• Proximal row carpectomy: This method can be used to
treat scaphoid bone nonunion with significant symptoms
such as wrist pain and weakness. During proximal row
carpectomy, if necessary, Kirschner’s wires can be used to
302
temporarily fix the instable wrist for 3 weeks, followed by
4–6 weeks of plaster fixation and gradually intensified
functional exercise of the wrist joint.
• Limited arthrodesis or silicone prosthesis placement: In
patients with bone nonunion, confirmed non-connected
proximal bone fragment, or ischemic necrosis in proximal
fracture fragment, partial replacement with silicone or
metal prosthesis can be applied because total prosthetic
replacement of the scaphoid usually has poor outcomes.
10.2.6 Surgical Complications and their
Prevention and Treatment Measures
(Buijze et al. 2010)
• Scaphoid necrosis and fracture nonunion:
–– The causes for scaphoid necrosis and fracture non-
union mostly include 1) old fracture scars without
thorough removal, or post-grafting osteonecrosis; 2)
poor fracture reduction, and internal fixation loosening
or falling off; 3) loss of blood supply due to excessive
dissection of the joint capsule; and 4) infections.
–– Prevention and treatment: After external fixation and
immobilization for a period of time, physical therapy
and other treatments can be used; if no improvement is
achieved, a second surgery is considered, including
internal fixation with bone flap and bone graft or wrist
arthrodesis. During the second surgery, special atten-
tion should be paid to thoroughly remove the scar tis-
sue, properly fix the fractured bone, appropriately
reduce and fix fractures, reduce the dissection of the
joint capsule, etc. In addition, external immobilization
should be applied conventionally for a period of time
after surgery.
• Injury of the superficial branch of the radial nerve:
–– An incision too close to the radial side would easily
cause accidental severing or traction injury of the
superficial branch of the radial nerve when the surgical
view is unclear due to bleeding or unclear anatomical
layers.
–– Prevention and treatment: The incision should not be
made too close to the radial side.
• Thumb extension dysfunction:
–– Causes: Severing or damage of the extensor pollicis
longus tendon would result in postoperative tendon
adhesion and scar formation, affecting the function of
thumb extension.
–– Prevention and treatment: During the operation, spe-
cial attention should be paid to protect tendons and
avoid injuring tendons and aponeuroses as much as
possible; bleeding, hematoma formation, and infection
Y. Liang et al.
should also be avoided. For patients with significantly
strained tendons, local postoperative injection of
sodium hyaluronate or chitosan may be helpful.
Patients with postoperative adhesions should receive
physical therapy and perform early joint functional
exercise; if necessary, tenolysis can be conducted.
• Traumatic carpal arthritis and wrist pain:
–– The main causes include scar adhesion of the scaphoid-­
radial joint and other joints or fracture- or operation-­
associated damage of the scaphoid articular facet
cartilage that results in scar adhesion or even a bony
fusion.
–– Prevention and treatment: Traumatic carpal arthritis
and wrist pain can be treated mostly by symptomatic
treatments and physical therapy. Wrist arthrodesis or
arthroplasty is applied in patients with severe symp-
toms. The articular cartilage facet injury should be
avoided as much as possible, and the fracture should
be accurately reduced in surgery.
• Instability of the wrist joint:
–– Causes: The scaphoid fracture is not well reduced, or
its reduction cannot be well maintained because the
ligaments surrounding the scaphoid or the dorsal
­transverse carpal ligament are severed and not repaired
during surgery.
–– Prevention and treatment: The damaged ligaments and
joint capsule should be repaired as much as possible
during surgery, and patients should receive physical
therapy and do functional exercise after surgery. Wrist
arthrodesis can be considered in serious cases.
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