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Fractures of the Upper Limb - Comprehensive Notes

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1. CLAVICLE FRACTURES

Anatomy & Epidemiology

• Most common fracture in children; 90% of obstetric fractures
• Fractures typically occur at the junction of middle and distal thirds
• Proximity to subclavian vessels and brachial plexus makes neurovascular assessment essential

Mechanisms

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

Classification (by location)

Diagnosis

• AP radiograph is standard; cephalic tilt views (35-40°) for better visualisation
• CT for medial clavicle/physeal injuries
• Ultrasound for obstetric fractures

Clinical Features

• Pain at clavicle and shoulder with movement
• Crepitus, oedema, visible deformity (drooping shoulder)
• Assess for: brachial plexus injury, subclavian vessel injury, pneumothorax

Treatment

• Sling and swath for 4-6 weeks
• Figure-of-8 splinting NOT recommended (risk of brachial plexus palsy)
• Newborns: no treatment usually needed

• Absolute: open fractures, neurovascular compromise
• Relative: non-union, malunion, displacement >2 cm, floating shoulder (with scapular fracture), high-level athletes
• Options: plate fixation or intramedullary nailing

Complications

• Non-union (1-3%)
• Pneumothorax
• Neurovascular compromise
• Malunion

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2. PROXIMAL HUMERUS FRACTURES

Anatomy

• 80-90% of humeral growth occurs at proximal physis
• Fractures typically occur at the surgical neck (anatomical neck fractures are rare due to thick bone)
• Axillary nerve and posterior circumflex humeral artery are at risk - always test before relocation

Neer Classification (4-part system)

Treatment

• Minimally displaced (80%): Sling immobilisation + early pendulum exercises within 2 weeks
• Displaced fractures: ORIF with locking plate and screw fixation
• Elderly/osteoporotic/4-part/head-splitting: Hemiarthroplasty or reverse shoulder arthroplasty

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3. HUMERAL SHAFT FRACTURES

Key Points

• Most heal with non-operative management
• The radial nerve spirals in the spiral groove at the posterior humerus and is at high risk

Holstein-Lewis Fracture

• A spiral fracture of the distal one-third of the humeral shaft
• Classically associated with radial nerve neuropraxia causing wrist drop

Acceptable Alignment

• <20° anterior angulation
• <30° varus/valgus angulation
• <3 cm shortening

Treatment

• Conservative: Coaptation splint acutely → functional brace (plastic clamshell with Velcro)
• Operative: ORIF if open fracture, bilateral injuries, polytrauma, vascular injury, or failed closed reduction
• Radial nerve palsy: NOT a contraindication to conservative management; most neuropraxias recover within 3-4 months
  • Exception: open fracture with radial nerve palsy → explore at time of irrigation/debridement

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4. SUPRACONDYLAR FRACTURE OF THE HUMERUS

Epidemiology

• Most common elbow fracture in children
• Mechanism: fall on extended outstretched arm → distal fragment goes posterior/superior (extension type, ~97%)

Gartland Classification (Extension type)

Clinical Features

• Swelling, tenderness, reluctance to move
• CRITOE mnemonic for ossification centres (Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon, External epicondyle) - important to avoid mistaking for fracture lines on X-ray

Neurovascular Complications

• White pulseless hand: surgical emergency - urgent reduction required; if pulse does not return, vascular exploration needed
• Pink pulseless hand: more controversial; satisfactory perfusion - reduce and stabilise, take expectant approach; pulse often returns in 24-48 hours
• Nerve injury: most common is anterior interosseous nerve (AIN) - neuropraxia, typically resolves post-reduction
• Volkmann's ischaemic contracture: feared complication from excessive swelling and missed compartment syndrome; do NOT put elbow in deep flexion if very swollen

Treatment

• Type I: Collar and cuff or backslab, 3 weeks
• Type II: Closed reduction + above-elbow cast if periosteal hinge intact
• Type III: Closed reduction + percutaneous K-wires + above-elbow cast
• Malunion in cubitus varus (gunstock deformity) requires corrective osteotomy if symptomatic

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5. FOREARM FRACTURES (Radius & Ulna)

Monteggia Fracture-Dislocation

• Fracture of the proximal ulna + dislocation of the radial head
• Check the radiocapitellar line on lateral X-ray: a line drawn along the radial shaft should pass through the centre of the capitellum - disruption indicates radial head dislocation
• Treatment: Closed reduction and casting; reduction of ulna fracture usually reduces the radial head

Galeazzi Fracture-Dislocation

• Fracture of the distal radius + disruption of the distal radioulnar joint (DRUJ)
• Sometimes called a "fracture of necessity" in adults (ORIF required)
• Treatment: Orthopedic consultation; ORIF of radius usually required in adults; cast in children

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6. DISTAL RADIUS FRACTURES

Important Eponyms

Colles' Fracture - Classic Features

• Median nerve is most commonly injured (contusion, traction, or carpal tunnel syndrome)
• Indications for ED reduction: Neurovascular compromise, dorsal angulation >20°, significant deformity, skin tenting
• Reduction technique: Procedural sedation or hematoma block (5-10 mL 1% lidocaine into fracture haematoma via dorsal approach); finger traps useful
• Immobilisation: Double sugar-tong splint; avoid circumferential cast for 24 hours due to oedema

Scaphoid Fracture (special consideration at wrist)

• Blood supply enters distally and runs in retrograde fashion - waist fractures risk AVN of proximal pole
• May be radiographically occult initially
• Tender in anatomical snuffbox after FOOSH = treat as scaphoid fracture until excluded
• Investigate with: Repeat X-rays at 10-14 days, bone scan, MRI (most sensitive), or CT

• Undisplaced: Below-elbow cast (thumb immobilisation not routinely required)
• Displaced/unstable (>1 mm): ORIF with headless compression screw
• Complications: Non-union, AVN, malunion, carpal instability

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7. HAND FRACTURES

Bennett's Fracture

• Intra-articular fracture at the base of the 1st metacarpal (thumb CMC joint)
• A small volar fragment remains attached to the trapezium by the volar oblique ligament; the remainder of the metacarpal is pulled proximally and radially by abductor pollicis longus
• Treatment: Closed reduction (often unstable) → percutaneous K-wire fixation or ORIF

Rolando's Fracture

• Comminuted intra-articular fracture of the 1st metacarpal base (Y or T pattern)
• More complex and worse prognosis than Bennett's
• Treatment: ORIF if fragments large enough; spanning external fixation for highly comminuted

Boxer's Fracture (5th Metacarpal Neck)

• FOOSH or punch mechanism
• Typical finding: volar angulation of the metacarpal head
• Acceptable angulation: up to 40° for 5th metacarpal (10° for 2nd/3rd)
• Treatment: Buddy strapping ± ulnar gutter splint; ORIF if >40° or rotational deformity

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8. SALTER-HARRIS CLASSIFICATION (Physis Fractures in Children)

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9. NEUROLOGICAL ASSESSMENT OF THE UPPER LIMB AFTER FRACTURE

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10. QUICK SUMMARY TABLE

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