Fractures in the Upper Limb

Dr QUEEN D
VIHAS
 Learning Objectives

• Describe the fractures of the clavicle, humerus, ulna,

radius and carpal bones
• Describe the clinical presentation of fractures of the
clavicle, humerus, ulna, radius and carpal bones
• Identify relevant investigations for fractures of clavicle,
humerus, ulna, radius and carpalbones
• Describe the basic principles of management of fractures
of the clavicle, humerus, ulna,radius and carpal bones
• Explain the complications of fractures of clavicle,
humerus, ulna, radius and carpal bones
 Fractures of the Clavicle
• The clavicle connects the upper limb to the trunk.
• Its sternal end articulates with the manubrium of the
sternum at the sternoclavicular joint.
• Its acromial end articulates with the acromion of the
scapula at the acromioclavicular joint.

Fractures of the clavicle are common, accounting for 5-

10% of all fractures.
• Males are more commonly affected than females.
• Mechanisms of Injury
1. Fall on an outstretched hand
2. Fall on the point of a shoulder
3. A direct blow on to the clavicle
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Displaced clavicle fractures can injure subclavian
vessels, nerves and lung appex due to their
proximity to the clavicle bone.

• Location of clavicle fractures: approximately

80% of clavicle fractures occur in the
middle third,
15% involve the distal or lateral third, and
5% involve the proximal or medial third
 Clinical Presentation

• hx of trauma
• Patient presents with pain and tenderness, especially
with upper extremity movement.
• Swelling/oedema can be present.
• Deformity
• Echymosis, especially when displacement is severe,
causes tenting of skin.
• Bleeding from open fracture is rare but possible.
• If there are decreased breath sounds on auscultation,
this indicates possible pneumothorax.
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• There can be decreased pulses or evidence of
decreased perfusion on vascular examination,
suggesting vascular compromise.
• There is possible diminished sensation or
weakness on distal neurovascular examination,
suggesting neurologic compromise.
• There can be non- or limited use of the arm on
the affected side.
 Investigations

• Routine clavicle radiography

A fracture is usually demonstrated on an
anteroposterior (AP) view.
• Chest radiography is recommended if
pneumothorax is suspected
 Management of a Fracture of Clavicle

• The vast majority of clavicle fractures are treated conservatively

with the limb rested in a broad arm sling
• Mobilisation can be commenced as comfort allows, with a
return to full activities within 3-6 weeks.
• Malunion is common but is not usually a functional problem.
• Non-union may occur in up to five percent of fractures and is
more common after high energy mechanisms such as road traffic
accidents.
• Refer the patient if there are open fractures associated,
neurovascular injuries, or fractures of the lateral end of the
clavicle with significant displacement of the fragments or
nonunion.
 COMPLICATIONS
• Brachial plexus compression can occur resulting from
hypertrophic callus formation (may cause peripheral
neuropathy).
• Delayed union or non-union can occur (especially with distal
third fractures).
• Poor cosmetic appearance can occur.
• Posttraumatic arthritis can occur.
• Intrathoracic injury:
it is important to exclude underlying injuries.
Pneumothorax,Subclavian artery and vein injury,Internal
jugular vein injury,Axillary artery injury ETC
 Fractures of the Humerus

Proximal Humerus Fractures

• Fractures of the proximal humerus result from
direct or indirect trauma and are classified by
the anatomical region injured, which are the
greater tuberosity, surgical neck and anatomic
neck
 Clinical presentation

• Suspect the diagnosis from the history of

trauma.
• Physical findings include pain, swelling and
loss of motion of the shoulder joint.
 Investigations

• X-rays (AP and lateral views) to confirm the

type of fracture
 Management

• Immobilize non-displaced fractures in a sling and swath.

• Begin mobilization of the shoulder joint within a few days.
• Treat displaced fractures and fracture dislocations by closed
manipulation under anaesthesia.
• If the reduction is not acceptable, refer for surgical
treatment.
• Begin motion as soon as the patient can tolerate hanging
arm exercises.
• Begin active motion against gravity or with weights when
the fracture has healed.
• Note: This is usually at 6–8 weeks
 Humeral Shaft Fractures
• Fractures of the shaft of the humerus are the
result of direct trauma or rotational injuries.
• The radial nerve wraps around the posterior
midshaft of the bone and is injured in about 15
percent of humeral shaft fractures
 Clinical presentation

• Suspect the diagnosis from the history of trauma.

• Physical findings include tenderness, deformity and
instability of the bone.

Investigations
• X-rays (AP and lateral views) to confirm diagnosis, but
are most useful in judging the position and healing of
the fracture during treatment.
• Always check the radial nerve function before and after
fracture reduction.
 Management

• Treat with closed reduction and apply a POP splint.

• It is not necessary for the alignment to be
anatomical; a few degrees of angulation or rotation
will not impair function.
• Radial nerve palsy (presents with a wrist drop) is
not associated with an open fracture.This will
resolve in most cases.
• Splint the wrist in extension, and begin passive
extension exercise until motor function returns
Supracondylar Fractures of the Humerus

Fracture patterns include:

 Supracondylar
 Intercondylar
 Fractures of the medial and lateral
epicondyles
 solated fractures of the capitulum and
trochlea
 Clinical presentation

• History of trauma
• Physical findings: swelling, tenderness about the elbow and pain
with attempted motion, deformity is often masked by swelling
• Evaluate the neurological and vascular status of the arm;
arterial injuries lead to compartment syndrome in the forearm
and are associated with:
􀂃 Extreme pain
􀂃 Decreased sensation
􀂃 Pain with passive extension of the digits
􀂃 Decreased pulse at the wrist
􀂃 Pallor of the hand
 Investigations

• X-rays (AP and lateral views) to confirm diagnosis.

Management
• Perform a closed reduction, using longitudinal traction on
the extended arm, followed by flexion at the elbow with
anterior pressure on the olecranon.
• Monitor the pulse during the reduction. If it decreases,
extend the elbow until it returns, and apply a posterior
splint in this position.
• Check the reduction by X-ray.
• If a satisfactory reduction cannot be obtained, refer the
patient for internal fixation
 Forearm Fractures

• Forearm fractures are caused by direct trauma or by a fall on the

outstretched arm with an accompanying rotatory or twisting force.
• One can have a fracture of the radius or ulna alone, or both.

• Fractures of both the ulna and the radius are the result of severe
injury.

• A direct injury usually produces transverse fractures at the same

level, often in the middle third of the bones. Because the shafts of
these bones are firmly bound together by the interosseous
membrane, a fracture of one bone is likely to be associated with
dislocation of the nearest joint.
 Olecranon Fractures

• Olecranon fractures result from a fall on the

tip of the elbow.
• The triceps muscle pulls the fracture
fragments apart
 Clinical Presentation

• Usually there is a history of trauma.

• Physical examination can show swelling about the olecranon
and a palpable gap at the fracture site.
• Examine the ulna nerve function.
• Investigation
o X-rays (AP and lateral views) to diagnose the fracture and
associated injuries.
• Management
• Treat non-displaced fractures in a splint with the elbow at 90
degrees.
• Refer displaced fractures for surgical management
 Fractures of the Radial Head and Neck

• The radial head is important for pronation and

supination of the forearm as well as for flexion
and extension motions at the elbow.
• Fractures are classified by the articular
involvement
 Clinical Presentation

• There is usually a history of trauma.

• Patients have pain and swelling over the
lateral aspect of the elbow. Some motion
remains in minimally displaced fractures.

Investigation
X-rays (AP and lateral views) to diagnose the
fracture and associated injuries.
 Management

• Treat fractures with minimal displacement in an arm sling and

begin motion when comfortable.
• To reduce displaced fractures of the radial neck:
 Place your thumb over the radial head and apply longitudinal
traction with a varus stress to the arm.
• Gently rotate the forearm while applying medial pressure with
your thumb to the radial head.
 Place the arm in a long arm splint.
 Begin motion out of the splint at 3 weeks.
 Treat comminuted or displaced intra-articular fractures with early
motion. If available, alternatives are surgical stabilization or radial
head excision
 Monteggia Fractures

• Involve the proximal ulna with dislocation of

the radial head, usually in the anterior direction
 Galeazzi Fractures

• A fracture of the distal radius and a dislocation

of the radial-ulnar joint at the wrist.
• The radius fracture is usually oblique, causing
the bone to shorten
 Clinical presentation

• There is often a history of direct trauma or a fall

on the outstretched arm.
• The forearm is swollen and tender, with limited
motion.
• Evaluate vascular function by checking pulse,
capillary refill and skin temperature of the
hand.
• Check sensory and motor function of the radial,
median and ulnar nerves.
 Investigations

X-rays (AP and lateral views) to diagnose the

fracture and associated injuries.
 Management

• oMidshaft fractures may involve one or both bones;

treat single bone fractures with
minimal displacement in a long arm cast, with the elbow
at 90 degrees and the forearm in neutral rotation.
• Treat displaced fractures by closed reduction and
application of a long arm splint;perform the reduction
by applying traction to the fingers and manipulating
theforearm with the elbow bent to 90 degrees. Apply
counter-traction above the bent elbow.
 CNT
• Reduce Monteggia fractures as described for displaced
fractures.
Apply a long arm cast in supination.
It is possible to obtain a satisfactory reduction in
children, but adults often require surgical management.

• Treat Galeazzi fractures as described for midshaft

fractures. They are unstable and often need surgical
stabilization.
Rehabilitation,Begin motion out of the cast at 6-8 weeks
 Distal Radius Fractures

• This includes Colle`s, Smith and Burton fractures.

• Fractures of the distal radius occur with a fall on
the outstretched hand.
• Colles fracture occurs at distal end of radius 2cm
from the wrist joint. There is a dorsal angulation of
the distal fragment, impaction, rotation, dislocation
of the radial- ulna joint and radial deviation.
• The direction of the deformity depends on the
position of the wrist at the time of impact
Colles Fracture (Dinner Fork Deformity)
 Clinical Presentation

• There is often a history of a fall on the

outstretched hand.
• Physical examination shows swelling and
tenderness about the wrist and the presence of
deformity.
• Evaluate tendon function, vascular supply and
sensation in the hand.
• This injury is commonly seen in elderly,
especially in women with osteoporosis
 Investigation

• X-rays (AP and lateral views) to diagnose the

fracture and associated injuries.
 Management:
• the goal of fracture treatment is to restore the
normal anatomy.
• Anaesthetize for closed reduction.
• Reduce the fracture by placing longitudinal
traction across the wrist and apply pressure to
the distal radial fragment to correct the
angular deformity
 CNT
• Apply Colle’s POP to maintain the fracture
position.
• Conduct a control X- ray to check the fracture
position after 1 week.
• Healing takes about 6 weeks.
• If a satisfactory position of the fracture
fragments cannot be obtained or maintained,
refer the patient for open reduction and
internal fixation.
Carpal Fractures and Fracture Dislocations

Injuries to the carpal bones fall into three major

categories:
 Scaphoid fractures
 Trans-scaphoid perilunate fracture/dislocations
 Perilunate dislocations
• The scaphoid bone bridges the proximal and distal
rows of carpal bones, making it especially vulnerable
to injury. Most commonly, fractures occur at the
waist but may also involve the proximal or distal
pole.
 Clinical presentation

There is often a history of trauma.

• Physical findings include that the wrist
appears swollen and painful to move.
• Scaphoid fractures are tender in the anatomic
snuff box and over the scaphoid tubercle on
the volar aspect of the wrist. (Pain occurs
primarily on the lateral side of the wrist,
especially during dorsiflexion and abduction of
the hand).
 Investigations

• X-rays are necessary to make a definitive

diagnosis.
• In perilunate dislocations, the lateral X-ray
shows an anteriorly displaced lunate bone,
with its concavity facing forward .The carpus is
shortened and the proximal margin of the
capitate does not articulate with the concavity
of the lunate.
 Management

• Treat scaphoid fractures with minimal

displacement in a thumb spica splint or cast.
• Healing time is between 6 and 20 weeks.
• Perilunate dislocations require reduction
followed by placement in a long arm thumb
spica splint. The reduction is usually unstable
over time and most patients will need surgical
stabilization