Common fracture in upper limb

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Here is a structured overview of the common fractures of the upper limb, drawn from authoritative orthopaedic and surgical textbooks.

Common Fractures of the Upper Limb

1. Clavicle Fracture

Most common fracture in children; accounts for ~90% of obstetric fractures.

Mechanism:

Birth injury: direct pressure from the symphysis pubis
Older children/adults: fall on an outstretched hand (FOOSH), or direct trauma to the clavicle or acromion

Diagnosis:

Standard AP X-ray; cephalic tilt views (35-40 degrees) are helpful
CT for medial clavicle fractures or physeal separation evaluation

Classification: Middle-third fractures are most common (~80%)

Treatment:

Newborns and most children/adolescents: non-operative (figure-of-8 sling or arm sling)
Operative (plate fixation or IM nailing) for: open fractures, neurovascular compromise, displacement >2 cm, nonunion/malunion

Complications: Nonunion (1-3%), malunion, pneumothorax, neurovascular injury

Miller's Review of Orthopaedics, 9th ed.

2. Fracture Neck of Humerus (Surgical Neck)

Very common in older adults (osteoporosis-related) and children (physeal injuries).

Mechanism:

Fall on outstretched hand - upward thrust breaks the surgical neck and may shear off the greater tuberosity
Direct blow to the shoulder -> anatomical neck fracture (rarer)

Types:

Adduction type: inner halves of fractured ends are impacted
Abduction type: outer halves are impacted, shaft remains abducted; greater tuberosity may be avulsed

Anatomy note: The axillary nerve and posterior circumflex humeral artery may be at risk, but injury is uncommon.

Treatment: Varies from conservative (collar and cuff, sling) to ORIF or hemiarthroplasty depending on displacement and patient factors.

S Das Manual on Clinical Surgery, 13th ed.; Gray's Anatomy for Students

3. Colles' Fracture (Distal Radius)

The commonest wrist injury in adults.

$Colles' Fracture X-ray - AP and lateral views showing fracture within 2 cm of radiocarpal interface with dorsal tilt and ulnar styloid fracture$

Definition: Fracture of the radius within 2 cm of the distal radial articular surface, with dorsal angulation/displacement of the distal fragment, often with an associated ulnar styloid fracture. (First described by Colles in 1814.)

Mechanism: Fall on outstretched hand (FOOSH) with wrist in dorsiflexion

Classic deformity: "Dinner fork" deformity (dorsal displacement)

Treatment:

Undisplaced: below-elbow cast
Displaced: closed reduction + cast; unstable fractures may need K-wires, external fixation, or ORIF

Related distal radius fractures:

Fracture	Displacement	Mechanism
Colles'	Dorsal (most common)	Fall on dorsiflexed wrist
Smith's ("reversed Colles'")	Volar	Fall on volar-flexed wrist
Barton's	Rim fracture + radiocarpal subluxation	Shearing injury
Chauffeur's (Hutchinson)	Radial styloid, intra-articular	Axial load through scaphoid

Grainger & Allison's Diagnostic Radiology; Rockwood and Green's Fractures in Adults, 10th ed. 2025

4. Scaphoid Fracture

Accounts for ~60% of all carpal fractures. Most commonly missed fracture.

Mechanism: FOOSH in a young adult

Key anatomy: Blood supply enters distally and is retrograde - a displaced waist fracture interrupts supply to the proximal pole, risking avascular necrosis (AVN).

Diagnosis trap: May NOT be visible on initial X-rays. If the patient has anatomical snuff box tenderness after FOOSH, treat as scaphoid fracture until excluded.

Protocol for suspected scaphoid fracture (not visible on X-ray):

Immobilise the wrist
Re-examine at 10-14 days; repeat scaphoid views if tender
If resources allow: bone scan, MRI, or CT for earlier diagnosis

Treatment:

Undisplaced: below-elbow cast (thumb spica not mandatory)
Displaced (>1 mm) or unstable: ORIF with headless compression screw

Complications: Non-union, AVN (proximal pole), malunion, carpal instability

Bailey and Love's Short Practice of Surgery, 28th ed.; Tintinalli's Emergency Medicine

5. Supracondylar Fracture of the Humerus

The most common elbow fracture in children (typically age 5-10 years).

Mechanism: FOOSH with elbow in extension (extension type, >95%) - child presents holding swollen, flexed elbow with the opposite hand.

Treatment by displacement:

Undisplaced: collar and cuff / backslab for 3 weeks, then mobilisation
Displaced with intact periosteal hinge: closed reduction + above-elbow cast (3-4 weeks)
Displaced with broken periosteal hinge: closed reduction + percutaneous K-wires + above-elbow cast

Complications (critical to recognise):

Volkmann's ischaemic contracture - from missed compartment syndrome; avoid deep elbow flexion if swollen
Vascular injury: The "white pulseless hand" = surgical emergency; requires urgent reduction + vascular exploration if pulse doesn't return
"Pink pulseless hand": Controversial; requires senior decision-making; if adequate perfusion, stabilise fracture then reassess vascularity
Nerve injury: Anterior interosseous nerve (AIN) most commonly affected (weakness of thumb and index flexion)
Bailey and Love's Short Practice of Surgery, 28th ed.

Summary Table

Fracture	Typical Patient	Mechanism	Key Sign	Main Complication
Clavicle	Children, neonates	FOOSH / direct blow	Tenderness midclavicle	Pneumothorax, neurovascular injury
Surgical neck of humerus	Elderly (osteoporosis)	FOOSH / direct	Limited shoulder movement	Axillary nerve injury
Colles'	Middle-aged women	FOOSH (dorsiflexion)	Dinner fork deformity	Malunion, tendon rupture
Scaphoid	Young adults	FOOSH	Snuff box tenderness	AVN, non-union
Supracondylar	Children (5-10 yr)	FOOSH (elbow extension)	Swollen flexed elbow	Volkmann's contracture, vascular injury

Key mnemonic: Most upper limb fractures share a common mechanism - FOOSH (Fall On OutStretched Hand) - but produce different fractures depending on the patient's age, bone quality, and exact position of the limb at impact.

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