Chapter5
Upper Arm Injuries
第五章
上臂损伤

Section1
Humeral Shaft Fractures
第一节
肱骨干骨折

Humerus fractures refer to fractures occurred below the surgical neck of the humerus and 2 cm above the medial and lateral epicondyle. As one of the most common clinical fractures, they normally happen to young adults. Guangzhou Orthopaedics Hospital has an average of more than 100 cases of humeral fracture every year with patients aged from 2 months to 96 years old (with an average age of 34.9 years old). Clinically, humerus fractures could be generally classified into three types of injuries based on the fracture site: proximal, mid-shaft and distal humerus fracture.

肱骨干骨折是指肱骨外科颈以下，肱骨内、外上髁2 cm以上的骨折，好发于青壮年，是临床上最常见的骨折之一，约占全身骨折的3%。广州市正骨医院平均一年有100余例的肱骨干骨折，患者最小2个月，最大96岁，平均年龄34.9岁。临床上根据其骨折部位，又可具体分为肱骨中上段骨折、中段骨折、中下段骨折。

1. Proximal Humerus Fracture
一、肱骨中上段骨折

【概述】
Introduction

Proximal humerus fracture occurs in the upper 1/3 of the humeral shaft with the fracture line above the insertion of deltoid. It is very rare due to the protection of deltoid muscles and other muscles（Figure5-1-1）.

发生于肱骨干上1/3处的骨折，骨折线在三角肌止点以上，因有三角肌等肌肉保护，骨折较为少见（图5-1-1）。

Etiology and pathogenesis
【病因病机】

Most proximal humerus fractures are the results of direct violence. Among them, comminuted and transverse fracture are the most common seen in clinical. The proximal fractured end is often displaced inward and forward while the distal end is outward and upward due to stretched muscles after a fracture.

多为直接暴力导致，骨折类型常为粉碎性、横形骨折。骨折后受肌肉牵引，近折端常向内、向前移位，远折端向外、上方移位。

Clinical presentations and diagnosis
【临床表现与诊断】

Patients normally had traumatic history, localized pain and swelling in the upper humerus after this injury, tenderness in the upper humerus; obvious bone crepitus and limited shoulder activities. Types and displacements of proximal humerus fractures could be identified by X-ray results. Thus, a clear diagnosis could be made by traumatic history, clinical presentations and X-ray results.

有明显的外伤史，伤后出现肱骨上段局部疼痛、肿胀，查体肱骨上段压痛明显，可触及明显骨摩擦音，肩关节活动受限明显。X线片检查可明确肱骨中上段骨折的类型及移位情况。根据受伤史、临床表现和X线检查可明确诊断。

Treatment based on syndrome diferentiation
【辨证论治】

Bone-setting manipulation

1．整复方法

The patient is in sitting position and one assistant uses triangular bandage to pull around through the patient’s armpit. Then the practitioner fixes the proximal of the patient’s upper arm with one hand to against the resistance, correcting the overlap and rotated deformity while pushing the proximal end of the fracture outward and backward with the other thumb and the distal end of fracture inward and forward with rest four fingers.

患者坐立位，助手用三角巾绕过患者腋窝向上牵引，术者一手固定患者上臂中下段与助手对抗牵引，纠正重叠及旋转畸形。术者用另一手拇指将患者骨折近端向外、后方推挤，其余四指将骨折远端向内、前方推挤，再采用推顶法检查骨折对位情况，同时使骨折端更加紧密对合。

Fixation

2．固定方法

Splints plus abduction splint shall be used for fixation (Figure5-1-2).

Requirements: An anterior splint starts from 2 cm over shoulder to 1.5 to 2 cm over the cubital crease; a posterior splint starts from 2 cm over shoulder to about 2 cm over olecranon; a lateral splint starts from 2 cm over shoulder to 2 cm over the lateral condyle of the humerus; a medial splint starts from 1.5 cm below the axillary to 1.5 cm above the medial condyle of the humerus.

Fixed position can be adjusted according to the fracture. Generally, it is fixed in the upper arm with abduction 60°to 80°and forearm in neutral position for 6 to 8 weeks (Figure5-1-3). The abducted splint shall be removed after regular review of X-ray as callus formed and other splints also can be removed gradually.

采用夹板（图5-1-2）配合外展架固定。夹板要求：前侧板上端超肩关节2 cm，下至肘横纹上1.5～2 cm；后侧板上端超肩关节2 cm，下至尺骨鹰嘴部上约2 cm；外侧板上端超肩关节2 cm，下至肱骨外髁处上约2 cm；内侧板上端始于腋下1.5 cm，下至肱骨内髁处上约1.5 cm。根据骨折情况调节固定体位，一般固定于上臂外展60°～80°，前臂中立位置（图5-1-3）。固定时间为6～8周，定期复查X线如骨痂生长稳定后可以拆除外展架，并逐步拆除夹板。

Functional exercises

3．康复治疗

In the early stage, rehabilitation exercises could be started at the day of bone-setting and fixation,including active flexion as well as extension of the elbow, wrist and metacarpophalangeal joints to eliminate swelling.

（1）骨折早期治疗在复位固定后当天，应该开始做肘、腕及掌指关节主动屈伸活动，以促进肿胀消除。

In the middle stage, shrugging shall be started after the external fixation being removed as well as shoulder flexion, extension, rotation and so on.

（2）骨折中期，骨痂生长后拆除外固定支架可做耸肩锻炼，并逐渐增加肩关节屈伸、旋转功能等各个方向功能锻炼。

In the later stage, splints shall be removed and functional trainings such as flexion and extension of the shoulder can performed gradually.

（3）骨折后期拆除夹板，逐渐做肩关节屈伸、旋转等大范围功能训练。

Clinical case
【病案分享】

A 71-year-old woman experienced an accidental fall while walking, resulting in localized left shoulder pain and came to Guangzhou Orthopaedics Hospital one day after the injury. Physical examination presented swelling and deformity in the proximal left upper arm, circulated tenderness,palpitation of bone friction, throbbing pain in the longitudinal axis of the upper arm and compromised left shoulder movements. X-ray shows a fracture of the proximal humerus（Figure5-1-4）. Therefore, the patients was managed with bone-setting manipulation and fixed with an abduction splint. Epiphysis was seen on the X-ray after 1 month（Figure5-1-5）and the abducted splint was removed. A large number of epiphyseal growths were found on the X-ray after 3 months (as shown in Figure5-1-6), and the splints were removed gradually. The appearance and functions of the injured shoulder recovered after 4 months（Figure5-1-7）.

肖某，女，71岁，步行时意外跌倒致左肩部疼痛活动受限，伤后1天来我院就诊。查体见：左上臂中上段肿胀、畸形，环形压痛，触及有骨摩擦感，上臂纵轴叩击痛，左肩关节活动受限。X线片提示：左肱骨中上段骨折（图5-1-4）。予手复位夹板配合外展架固定治疗。1个月后X线片可见骨痂生长（图5-1-5），予以拆除外固定架，继续维持夹板固定治疗。3个月后X线片可见大量骨痂生长（如图5-1-6），予逐步拆除夹板。4个月后，复查时患肢外观及功能恢复良好（图5-1-7）。

Experience sharing
【经验小结】

Patient’s requirements, age, type of fracture, concomitant injuries, comorbidities and patients’tolerance to surgery shall be all taken into consideration. Reduction for humeral shaft fractures expects less than that of other fractures-shortening within 2 cm, lateral displacement within 1/3, angular deformity within 30°, and rotational deformity within 15°without significant effect on function. So most humeral shaft fractures could be managed with conservative treatment. However, malunion of the fracture has always been a difficulty due to the special anatomy of the humeral shaft and the gravity of the upper arm. It may be effectively solved the above problems by using splints combined with the abducted splint. Reduction can be achieved gradually by using small external splints and cotton pads,owing to no shielding of the fracture end and fast growth of the epiphysis. Moreover, the angular displacement also can be corrected by 2 or 3 point pressured cotton pads. So does the residual displacement of the fracture end. The abducted splint prevents not only adduction of the fracture, but also rotation and the gravity of the upper limbs and bone separation. When the external fixation is firm, the joints can be moved as early as possible to prevent joint stiffness. Therefore, conservative treatment of humeral shaft fractures is recommend by using splints and abducted splint as long as the physical conditions allow.

肱骨干骨折治疗需考虑患者自身要求、年龄、骨折类型、伴发损伤和合并症及患者对手术的耐受程度等因素。肱骨干骨折复位要求较其他骨折低，2 cm以内的短缩、1/3以内的侧方移位、30°以内成角畸形及15°以内的旋转畸形对功能无明显影响，因此大多数肱骨干骨折可通过保守治疗获得良好效果。但由于肱骨干特殊解剖及上臂重力等原因，骨折不愈合一直是个治疗难点。夹板配合外展架固定可有效解决上述问题。小夹板外固定治疗，骨折端无应力遮挡，骨痂生长快，通过夹板、棉垫作用下骨折端慢慢自行复位，棉垫2点或3点加压下纠正成角移位，还可以纠正骨折端残余移位。外展架不仅能防止骨折内收，还能防止旋转及对抗上肢重力以防止骨分离。在外固定牢固情况下可早期活动关节，进行功能锻炼，防止关节僵硬。因此，肱骨干骨折保守治疗，只要身体条件允许，我们建议行夹板配合外展架固定治疗。

2. Mid-shaft Humerus Fracture
二、肱骨中段骨折

Introduction
【概述】

Mid-shaft humerus fracture occurs in 1/3 of the humeral shaft with fracture line below the insertion of deltoid. It is the most common fracture in humerus fractures which may be combined with radial nerve injury.

发生于肱骨干中1/3处的骨折，骨折线在三角肌止点以下，为最常见的肱骨干骨折类型，可合并桡神经损伤。

Etiology and pathogenesis
【病因病机】

Mid-shaft humerus fracture is usually caused by direct violence or indirect violence. Direct violence such as impaction could lead to transverse or comminuted fractures while indirect violence such as a fall on the hand or elbow to the ground could result in an oblique fracture or a spiral fracture by sprain. The fracture end is pulled by the muscles after a fracture with proximal end often displaced outward and forward and the distal end upward.

直接暴力如撞击可形成横形或粉碎性骨折。间接暴力如摔倒时手或肘着地，可形成斜形骨折；扭伤可形成螺旋形骨折。骨折后骨折端受肌肉牵引，近折端常向外、向前移位，远折端向上移位。

Clinical presentations and diagnosis
【临床表现与诊断】

Patients normally had traumatic history, localized pain and swelling in the middle humerus after an injury, tenderness in the middle humerus, obvious bone crepitus, limited shoulder and elbow movements with varied degrees and clinical symptoms associated with radial nerve injury. Types and displacements of the mid-shaft humerus fratures could be identified by X-ray. And a clear diagnosis could be made by traumatic history, clinical presentations and X-ray results.

有明显的外伤史，伤后出现肱骨中段局部疼痛、肿胀，查体肱骨中段压痛明显，触及有明显骨擦音，肩肘关节均有不同程度活动受限，合并桡神经损伤出现相应临床症状。X线片检查可明确肱骨中段的类型及移位情况。根据受伤史、临床表现和X线片检查可明确诊断。

Treatment based on syndrome diferentiation
【辨证论治】

Bone-setting manipulation: Similar to that of distal humerus fractures (see below).

（1）整复方法与肱骨下段骨折相似（见下文）。

Fixation: Similar to that of distal humerus fractures (Figure5-1-8).

（2）固定方法与肱骨下段骨折相似（图5-1-8）。

Functional exercises: Similar to that of distal humerus fractures.

（3）康复治疗与肱骨下段骨折相似。

Clinical case
【病案分享】

A 23-year-old female experienced limited left upper arm pain due to a collision. She came to Guangzhou Orthopaedics Hospital half an hour after this injury. Physical examination presented obvious swelling in the left upper arm with adduction, tenderness in the middle part of the upper arm, obvious bone fremitus, percussion pain in the axis side, disappearing stick force in left upper arm and limited activities such as abduction and forward flexion. X-ray shows that the left mid-shaft humerus fracture with angled laterally and distal end displaced forward and inward（Figure5-1-9）. Reviewed X-ray shows good alignment after bone-setting manipulation（Figure5-1-10）. Therefore, splints plus abducted splint shall be used for fixation（Figure5-1-11）, continuing the standard treatment as usual. And reviewed X-ray shows that the fracture end is well-aligned with large number of grown epiphyses after 4 months（Figure5-1-12）. The function of left upper arm recovered well after external fixation being removed（Figure5-1-13）.

刘某，女，23岁，撞伤致左上臂疼痛活动受限，伤后半小时来广州市正骨医院就诊。查体见：左上臂肿胀明显，呈内收畸形，上臂中段压痛，触及有明显骨摩擦感，纵轴叩击痛，左上臂杆力消失，外展前屈等活动受限明显。予完善X线片检查提示左肱骨干中段骨折，骨折向外侧成角，远折端向前向内侧移位（图5-1-9），予手法复位后复查X线片检查提示对位对线良好（图5-1-10），予以夹板配合外展架固定治疗（图5-1-11），按骨折复位后常规处理，4个月后复查X线片提示骨折端对位对线良好，大量骨痂生长（图5-1-12），予拆除外固定后左上肢功能恢复良好（图5-1-13）。

3. Distal Humerus Fracture
三、肱骨中下段骨折

Introduction
【概述】

Distal humerus fracture refers to the fracture occurring at 1/3 of the humeral shaft whose incidence is only secondary to mid-shaft humerus fractures and often be accompanied by radial nerve injury.

发生于肱骨干下1/3骨折，其发生率次于中段骨折，常可合并桡神经损伤。

Etiology and pathogenesis
【病因病机】

Most of distal humerus fractures are caused by rotary violence, such as arm wrestling, or by strong contraction of internal muscles, for example, throwing javelins and softballs. Fractures are often helical or oblique and displacement of the stump depends on the position of the forearm and elbow joint, with angular or internal rotation normally.

多为旋转暴力致伤，如掰手腕致伤。因内在肌肉强力收缩，如投掷标枪、垒球等运动亦致伤。骨折常为螺旋形或者斜形，断端移位随前臂和肘关节位置而定，常呈成角、内旋等畸形。

Clinical presentations and diagnosis
【临床表现与诊断】

Patients had traumatic history, localized pain and swelling in the lower humerus after an injury,obvious tenderness in the lower humerus, and obvious bone fremitus. Internal rotation or angular deformity often occurs at the distal end, and elbow flexion as well as extension are restricted which often be combined with clinical symptoms associated with radial nerve injury. Types and displacements of the fracture could be identified by X-ray results. A clear diagnosis could be made based on the traumatic history, clinical presentations and X-ray results.

有明显的外伤史，伤后出现肱骨下段局部疼痛、肿胀，查体肱骨下段压痛明显，可触及明显骨摩擦音，远折端常出现内旋或成角畸形，肘关节屈伸活动受限明显，常可合并桡神经损伤出现相应临床症状。X线片检查可明确骨折的类型及移位情况。根据受伤史、临床表现和X线片检查可明确诊断。

Treatment based on syndrome diferentiation
【辨证论治】

Bone-setting manipulation

1．整复方法

The patient sits in an upright position. One assistant fixes the upper part of the patient’s upper arm with a triangle towel through the armpit while the practitioner holds the patient’s forearm and flexes his / her elbow by 90°with one hand, and the patient’s humerus epicondyle and medial epicondyle with a slight traction with the other hand to correct the angular displacement. The distal end then is rotated outward to correct the rotational displacement.

患者坐立位，一助手用三角巾经腋下向上牵引固定患者上臂上段，术者一手持患者前臂，使其肘关节屈曲90°，一手持患者肱骨外髁及内上髁，做轻度牵引纠正成角移位，再将远折端外旋以纠正旋转移位。

Fixation

2．固定方法

Splints plus abduction splint shall be used for fixation. Requirements for splints: The anterior,lateral, and posterior splints shall be parallelled to the shoulder. And the medial plate is 2 cm below the axillary striae; the medial and lateral plates exceed the elbow joint; the anterior plate is 2 cm above the elbow joint and the posterior plate exceeds the wrist joint（Figure5-1-14）.

采用夹板配合外展架固定。夹板要求：前侧、外侧、后侧板均平肩关节，内侧板自腋横纹下2 cm，内外侧板超肘关节，前侧板至肘关节上2 cm，后侧板超腕关节（图5-1-14）。

Fixed position can be adjusted according to the fracture. Generally speaking, it shall be fixed in the upper arm with abduction 45°to 90°with forearm in neutral position. The abducted splint shall be removed after 6 to 8 weeks and regular review of X-rays are needed at the same time. Other splints also shall be removed gradually as callus formed.

根据骨折情况调节固定体位，一般固定于上臂外展45°，肘关节屈曲90°，前臂中立位置（图5-1-15）。固定时间6～8周，定期复查X线片，待骨痂生长稳定后可以拆除外展架并逐步拆除夹板。

Functional exercises

3．康复治疗

In the early stage, rehabilitation exercises could be started at the day of bone-setting and fixation,doing active flexion and extension of the wrist and fingers to eliminate swelling.

（1）骨折早期治疗在复位固定后当天进行，应该开始做腕、指关节主动屈伸活动，并逐渐增加运动幅度及用力程度，以促进肿胀消除。

In the middle stage, shrugging, flexion and extension of the shoulder and rotations movements shall be started after the external fixation splint being removed. And the posterior splint shall be used for forearm rotation.

（2）骨折中期，骨痂生长后拆除外固定支架可做耸肩及肩关节屈伸、旋转功能锻炼。后侧板平腕关节后可做前臂旋转活动。

In the later stage, the splint shall be removed and functional training such as flexion and extension of the shoulder shall be started gradually.

（3）骨折后期拆除夹板，逐渐做肘关节伸直或者屈曲活动。

Clinical case
【病案分享】

A 22-year-old woman fell down accidently when walking, resulting in localized right shoulder pain and came to Guangzhou Orthopaedics Hospital 1 hour after this injury. Physical examination presented swelling and adducted deformity in the distal right upper arm, circulated tenderness, obvious sense of bone rubbing, percussion pain in the axis side and compromised right shoulder movements. X-ray shows that comminuted fracture in the right distal humerus（Figure5-1-16）. Reviewed X-ray shows good alignment after bone-setting manipulation（Figure5-1-17）. Therefore, splints combined with abducted splint shall be used for fixation（Figure5-1-18）. The abducted splint was removed after one month as callus formed and accepted splints fixation as maintenance therapy（Figure5-1-19）. A large number of grown epiphyseal were seen on the X-ray and the fracture healed gradually after 3 months（Figure5-1-20）. And splints were removed and the patient was encouraged to do functional exercises. The appearance and functions of the injured shoulder recovered well after three and a half months（Figure5-1-21）. Reviewed X-ray shows well-aligned fractured end（Figure5-1-22）.

钟某，女，22岁，运动时意外跌倒致右上臂疼痛活动受限，伤后1小时来院就诊。检查见：右上臂中下段肿胀，内旋畸形，环形压痛，触及有明显骨擦感，上臂纵轴叩击痛，右肘关节屈伸活动受限。予完善X线片检查提示右肱骨干中下段粉碎性骨折（图5-1-16）；手法复位后提示骨折对位对线良好（图5-1-17），予夹板配合外展架固定治疗（图5-1-18）；1个月后复查X线片提示骨痂开始生长，骨折端开始稳定，予拆除外展架，继续维持夹板固定治疗（图5-1-19）；3个月后X线片提示骨折端大量骨痂生长，骨折基本愈合（图5-1-20），予拆除夹板，指导功能锻炼；3个半月后，复查时患肢外形及功能恢复良好（图5-1-21）；随访1年后X线片提示骨折端对位对线良好，骨性愈合（图5-1-22）。