Upper Limb

FRACTURE MANAGEMENT GUIDELINES

(adapted from Practical Fracture Treatment by Ronald McRae, 4th edition)

Contents

UPPER LIMB FRACTURES

Scapular Fractures (including blade, neck, spine and coracoid)

Mechanism

  • Usually direct violence

Management

  • Even if comminuted or angled, healing is rapid and outcome excellent
  • Broad arm sling and mobilisation once acute symptoms settled (usually 2 weeks)

Fractures of the Clavicle

Mechanism

  • Usually fall / direct blow onto point of shoulder or FOOSH

Management

  • Middle and medial third
    • broad arm sling supporting elbow to hold fractured ends together.
    • clavicle straps sometimes used in conjunction with sling if there is displacement (often poorly tolerated)
    • support for 2-3 weeks or until tenderness at fracture site has disappeared, then PROM, AROM as tolerated
    • if widely displaced and patient athletic and privately insured refer to upper limb Orthopaedic Surgeon for ORIF
  • Outer third
    • broad arm sling (clavicle straps not necessary)
    • begin AROM once acute pain has settled

Fractured Greater Tuberosity of the Humerus

Mechanism

  • With shoulder dislocation
  • FOOSH

Management

  • If undisplaced – Collar and Cuff or Broad Arm Sling for 1-2 weeks until acute symptoms have resolved, then AROM as tolerated
  • If displaced, may need internal fixation

Fractures of the Surgical Neck of Humerus

Mechanism

  • FOOSH

Management

  • Undisplaced or minimally displaced with mild angulation – Collar and Cuff (or Broad Arm Sling initially if pain significant or if disimpaction is not desirable) until acute symptoms have settled (approx 1-3/52).
  • Especially in elderly, commence pendular exercises early (1-2 weeks)
  • Severely displaced or angulated – manipulation and as above; may need internal fixation

Fractures of the Anatomical Neck of the Humerus

Mechanism

  • FOOSH

Management

  • Undisplaced or minimally displaced – as per SNOH above
  • Severely displaced or angulated – may need internal fixation

Potential Complications

  • Avascular necrosis of the humeral head

Fractured Shaft of Humerus

Mechanism

  • FOOSH
  • Direct violence (eg blow or fall to arm)

Management

  • If undisplaced or only slight angulation – U slab and collar and cuff for 6-9 weeks
  • If displaced, may need manipulation and above management
  • If athletic patient, refer to orthopaedic surgeon for potential ORIF

Potential Complications

  • Radial nerve palsy – wrist, thumb and finger extension absent or compromised; sensory impairment on dorsum of hand

Supracondylar Fractures of the Humerus

Mechanism

  • FOOSH

Management

  • Undisplaced – long arm plaster slab
  • Displaced
    • Children – Manipulation into long arm plaster slab with generous layer of wool, secured with bandages and a sling for at least 3-4 weeks
    • Adults – Manipulation or internal fixation

Potential Complications

  • Brachial artery damage

Medial and Lateral Epicondylar Fractures of the Humerus

Mechanism

  • Fall onto elbow
  • Avulsion by muscles or collateral ligament

Management

  • Children
    • undisplaced – long arm, padded plaster for 2-4 weeks
    • displaced – reduction or internal fixation
  • Adults
    • undisplaced – symptomatic treatment – compression bandage and sling for 3-4 weeks; if pain severe, short period in long arm padded plaster
    • displaced – may need internal fixation

Potential Complications

  • Medial epicondyle trapped in elbow joint
  • Ulnar nerve palsy

Unicondylar Fractures of the Humerus

Mechanism

  • FOOSH

Management

  • Children – undisplaced, long arm padded back shell and sling for 3-4 weeks
  • Adults – undisplaced – long arm plaster and sling for 4-5 weeks
  • Children and Adults – displaced = needs reduction +/- internal fixation and above management

Intercondylar Fractures of the Humerus

Mechanism

  • FOOSH

Management

  • If undisplaced, long arm plaster and sling for 4-5 weeks
  • Otherwise, needs reduction +/- internal fixation and above management

Fracture of the Coronoid Process of the Ulna

Mechanism

  • Avulsion (brachialis)
  • Dislocation of elbow

Management

  • Involving less than half – conservatively – padded crepe bandage and collar & cuff or plaster back slab in 90 degrees of elbow flexion and collar & cuff for 2 weeks; mobilising at 2-3 weeks
  • Involving more than half – usually requires internal fixation

Fracture of the Olecranon of the Ulna

Mechanism

  • Fall on the point of elbow
  • Sudden triceps contraction

Management

  • If undisplaced – long arm plaster (3-4 weeks for a child, 6-8 weeks for an adult)
  • If displaced – may need internal fixation or surgical excision

Fracture of the Radial Head

Mechanism

  • FOOSH

Management

  • If undisplaced – light compression bandage and broad arm sling for 2-3 weeks, then mobilise and wean sling; use above elbow splint if more painful
  • If comminuted or displaced, need orthopaedic opinion

Potential Complications

  • Loss of elbow extension

Fracture of the Radial Neck

Mechanism

  • FOOSH

Management

  • If no or slight tilting (up to 20 degrees in adults, 30 degrees in children) – manage as per radial head
  • With marked tilting, manipulation is required.

Fracture of the Ulna with Dislocation of the Radial Head (Monteggia fracture-dislocation)

Mechanism

  • FOOSH
  • Direct blow on the arm

Management

  • Adults and children with displaced fractures – usually needs ORIF
  • Children with undisplaced – manipulation to correct any angulation
    • Fractures with anterior angulation should be plastered into 90 degrees of flexion at the elbow and in supination
    • Fractures with posterior angulation should be plastered into full pronation for 3 weeks, then the plaster changed into more flexion

Fracture of the Radial Shaft with Dislocation of the Ulna (Galleazzi fracture-dislocation)

Mechanism

  • FOOSH
  • Direct blow on the arm

Management

  • Adults and children with displaced fractures – usually needs ORIF
  • Children with undisplaced – manipulation and plaster into supination

Isolated Fractures of the Ulnar Shaft

Mechanism

  • Direct violence
  • FOOSH (much more likely to fracture both forearm bones)

Management

  • If undisplaced  – long arm plaster with the forearm in mid pronation for 8 weeks
  • If displaced or angulated – may need reduction or internal fixation

Isolated Fractures of the Radial Shaft

Mechanism

  • Direct violence

Management

  • If undisplaced – Long arm plaster with forearm in supination
  • If displaced – need opinion

Fractures of the Distal Radius

Mechanism

  • FOOSH

Management

  • Undisplaced, minimally displaced and greenstick – below elbow plaster with forearm fully pronated, wrist in slight flexion and full  ulnar deviation (no manipulation necessary)
  • Colles Fracture (dorsally angulated and displaced) – manipulation and then below elbow plaster with forearm in full pronation, wrist in slight flexion and full ulnar deviation
  • Smith’s Fracture (palmar angulation and displacement; from fall onto dorsum of flexed wrist) – manipulation and then above elbow POP with wrist in full extension and forearm fully supinated

Fractures of the Radial Styloid

Mechanism

  • FOOSH

Management

  • Undisplaced or minimally displaced – below elbow plaster with wrist in slight flexion
  • If displacement is great, or alternatively may be need to be fixed

Scaphoid Fracture or Suspected Scaphoid Fracture

Mechanism

  • FOOSH
  • Starting handle (crank) kickback

Management

  • If undisplaced – below elbow POP, extending to cover MCP joint of thumb with the forearm fully pronated, wrist in moderate extension and radial deviation and the 1st MCP joint in mid abduction (OK position of thumb and second digit) usually for 6 weeks
  • If suspected but not confirmed – manage initially as above and repeat X-ray in 2 weeks or arrange early outpatient MRI
  • If displaced >1mm or angulated > 15 degrees – ORIF

Potential Complications

  • Avascular necrosis

Fractures of the Bodies of any of the Carpal Bones Other Than Scaphoid

Mechanism

  • FOOSH

Management

  • Below elbow plaster with wrist in slight flexion & ulnar deviation or scaphoid plaster for 6 weeks

Small Chip Fractures of the Carpal Bones Other Than Scaphoid

Mechanism

  • Hyperflexion
  • Hyperextension
  • Direct Violence

Management

  • Below elbow plaster with wrist in slight flexion and full ulnar deviation for 3 weeks

First Metacarpal Fractures

Mechanism

  • Fall or blow onto clenched fist
  • Forced abduction of the thumb

Management

  • Bennett’s Fracture (small medial fragment of base of the 1st metacarpal with proximal subluxation of the 1st CMC joint) – reduction, Below elbow POP with thumb in abduction, covering thumb up to IP joint; alternately ORIF
  • Fractures near the base of the 1st metacarpal – same as for Bennett’s; manipulation necessary for gross angulation then same as for Bennett’s

Second and Fifth Metacarpal Fractures

Mechanism

  • Punching

Management

  • Spiral and transverse fractures of the shaft
    • slight or moderate angulation or displacement and fractures of the base – below elbow plaster with forearm in full pronation, wrist in slight flexion and full ulnar deviation for 3-4 weeks
    • marked angulation – traction and local pressure and plaster as above
    • displaced fractures may be trialled as for angulated fractures, but may need open reduction secondary to soft tissue between the bone ends
  • Neck
    • if angulation is slight or moderate – below elbow dorsal slab, splint or plaster; can be reinforced with addition of a dorsal finger extension to the slab covering either just the fifth, or the fourth and the fifth digits, extending to the finger tip (buddy strapped distally); wrist should be in slight extension, CMC extension and MCP flexion
    • if angulation gross (>45 degrees) – reduction then ORIF or POP
  • Head
    • if small and/or minimally displaced – buddy strapping and early mobilisation; may use dorsal slab with CMC joints extended if pain substantial
    • if substantial and displaced, may need to be fixed

Fractures of the 3rd and 4th Metacarpals

Mechanism

  • Punching

Management

  • Undisplaced – Plaster slab, with wrist in slight flexion and full ulnar deviation
  • Displaced, angulated or with off-ending – manipulation or internal fixation

Fractures of the First Proximal Phalanx

Mechanism

  • FOOSH

Management

  • Undisplaced or minimally displaced or splintered – dorsal slab with wrist extended and thumb in OK abducted position (with extension girder supporting thumb) bandaged into position or splint for 6 weeks
  • Severely angulated – manipulation and above management

Fractures of the First Distal Phalanx

Mechanism

  • Crushing injury

Management

  • If undisplaced, minimally angled or splinter fracture – dorsal slab with thumb girder with wrist extended and thumb abducted or splint for 6 weeks
  • Displaced – reduction and above management

Fractures of the Second to Fifth Proximal and Middle Phalanges of the Hand

Mechanism

  • Punching

Management

  • If undisplaced – buddy strapping, or if pain severe, supplement with volar or dorsal slab with IP joints extended
  • If displaced or angulated > 10 degrees –  need manipulation and held in MCP flexion and IP extension with splinting, or splint-reinforced plaster, or ORIF

Fractures of the Second to Fifth Distal Phalanges of the Hand

Mechanism

  • Punching

Management

  • All fractures – strap the finger to a spatula or plastic finger splint as necessary