Upper limb fractures and dislocations

Overview

Upper limb injuries are very common, mostly from a fall on the outstretched hand (FOOSH). The bone that breaks depends largely on age: children break the supracondylar humerus and distal radius (greenstick or physeal), young adults the scaphoid and forearm, older women the distal radius (Colles) and proximal humerus.

MCQs focus on deformity, the nerve or vessel at risk, and the classic complications.

FOOSH: which bone at which age?

Clavicle fractures

• Fall on the shoulder or outstretched hand; very common (also in newborns after shoulder dystocia).
• Middle third is the commonest site.
• Deformity: the medial fragment is pulled up by sternocleidomastoid; the lateral fragment drops under the weight of the arm (and is pulled forwards and in by pectoralis major).
• Treatment: most heal well in a broad arm sling for a few weeks; a lump of callus is normal.
• Fixation for skin tenting or open fracture, neurovascular injury, floating shoulder, marked shortening or displacement in active adults, and displaced lateral-third fractures with torn coracoclavicular ligaments (high non-union rate).
• Complications: malunion (cosmetic), non-union (lateral third), rarely subclavian vessel or brachial plexus injury.

Acromioclavicular dislocation: fall on the point of the shoulder; the lateral clavicle rides up; complete displacement means the coracoclavicular ligaments are torn.

Posterior sternoclavicular dislocation: medial clavicle pushed behind the sternum; can compress the trachea, oesophagus or great vessels (stridor, dysphagia): urgent reduction.

Shoulder dislocation

Anterior dislocation (about 95%)

• Mechanism: fall on the hand or force with the arm abducted and externally rotated. The head escapes anteroinferiorly where the capsule is weakest.
• Clinical: severe pain, arm held by the other hand, loss of the round shoulder contour (flattened, prominent acromion), humeral head felt in front below the clavicle.
• X-ray: AP plus axillary or scapular-Y lateral; head lies below and medial to the glenoid.
• Lesions: Bankart lesion (anteroinferior labrum torn off the glenoid; cause of recurrence), Hill-Sachs lesion (dent in the posterolateral humeral head from the glenoid rim), greater tuberosity fracture, rotator cuff tear (older patients).
• Nerve: the axillary nerve is most often injured: loss of sensation over the lower deltoid (regimental badge area) and weak deltoid. Test before and after reduction. Usually neurapraxia that recovers.
• Reduction: sedation and analgesia; traction-countertraction (Hippocratic), Stimson (prone, arm hanging), external rotation methods; Kocher method is less favoured (risk of fracture and nerve injury).
• After: sling for a short time, then physiotherapy.
• Recurrence is very common in the young (under about 20-25 years), less in older patients (who more often tear the cuff instead). Recurrent instability: Bankart repair (open or arthroscopic) or bone block procedures.

Posterior dislocation (rare, under about 2-5%)

• Classic causes: epileptic seizure, electric shock, sometimes bilateral.
• Arm held adducted and internally rotated; cannot externally rotate.
• AP X-ray: humeral head looks round and symmetrical, the light-bulb sign; easily missed unless an axillary or Y view is taken.
• Reverse Hill-Sachs lesion on the anterior head.

Inferior dislocation (luxatio erecta)

Rare; arm stuck fully abducted above the head; high risk of nerve and axillary artery injury.

Proximal humerus fractures

• Elderly osteoporotic women; fall on the outstretched arm.
• Surgical neck fracture can injure the axillary nerve (deltoid and teres minor) and the posterior circumflex humeral artery.
• Neer classification by number of displaced parts (head, shaft, greater and lesser tuberosities).
• Most are minimally displaced: sling and early pendulum exercises.
• Complex displaced fractures in fit patients: fixation (locking plate) or replacement (hemiarthroplasty, reverse shoulder replacement).
• Complications: stiffness (most common), avascular necrosis of the head (four-part fractures), axillary nerve palsy.

Humeral shaft fractures

• Radial nerve runs in the spiral groove and is at risk, especially with distal third spiral fractures (Holstein-Lewis).
• Radial nerve palsy: wrist drop, loss of finger (MCP) extension, numbness of the first dorsal web space. Triceps is usually spared (its branches arise higher, in the axilla).
• Test radial function by active MCP joint extension before and after treatment.
• Most palsies are neurapraxias that recover: observe for about 3-4 months with a cock-up splint. Explore if the palsy is open, appears after manipulation, or does not recover.
• Treatment of the fracture: usually non-operative (hanging cast, U-slab, then functional brace). Fix (plate or nail) for open fractures, vascular injury, polytrauma, pathological fractures, floating elbow, failure of conservative care.
• Non-union is more common than in many other shafts, especially after distraction.

Elbow injuries

Supracondylar fracture of the humerus (children)

• The commonest elbow fracture in children (usually 5-10 years).
• Extension type (about 95%): FOOSH with the elbow hyperextended; distal fragment displaced posteriorly. Flexion type is rare (fall on the point of the elbow).

Gartland classification (extension type):

• X-ray: anterior humeral line should pass through the middle third of the capitulum; Baumann angle checks varus tilt; posterior fat pad = hidden fracture.
• Clinical: swollen elbow, S-shaped deformity; the three-point relationship of the epicondyles and olecranon is preserved (unlike elbow dislocation, where it is lost).

Complications:

• Pink pulseless hand: if the hand is warm and well perfused after reduction, observe closely; a white pulseless hand after reduction needs urgent exploration of the brachial artery.
• Never hold the elbow in acute flexion if it obliterates the pulse; fix with wires instead.

Other elbow injuries in children

Elbow dislocation (adults and children)

• Commonest direction: posterior / posterolateral (about 90%); FOOSH with elbow extended.
• Three-point bony relationship lost.
• Check ulnar and median nerves and brachial artery.
• Closed reduction under sedation; short immobilisation, early movement (stiffness is common).
• "Terrible triad": dislocation + radial head fracture + coronoid fracture: unstable, needs surgery.

Radial head fracture (adults)

• FOOSH; tenderness over the radial head, painful pronation and supination.
• X-ray may show only a fat pad sign.
• Mason types: I undisplaced (sling, early movement), II displaced single fragment (fix if blocking movement), III comminuted (fix or replace).
• In children the radial neck fractures instead.

Olecranon fracture

• Fall on the point of the elbow; triceps pulls the proximal fragment apart, so the patient cannot extend actively against gravity.
• Displaced fractures: tension band wiring or plate.

Forearm fractures

Both-bone shaft fractures

• Adults: need open reduction and plate fixation (absolute stability) to restore rotation.
• Children: closed reduction and above-elbow cast usually suffice (greenstick).
• Watch for forearm compartment syndrome.

Monteggia and Galeazzi

Distal radius fractures

Treatment of Colles fracture: closed reduction (traction, then flexion, ulnar deviation and pronation of the distal fragment) and a below-elbow backslab/cast for about 6 weeks. Unstable or intra-articular fractures: K-wires or volar locking plate.

Complications of Colles fracture:

• Malunion (commonest): dinner-fork deformity, radial shortening, prominent ulna.
• Median nerve compression (acute carpal tunnel syndrome).
• Delayed rupture of extensor pollicis longus (weeks later, even after undisplaced fractures; cannot lift the thumb off the table).
• Complex regional pain syndrome (Sudeck atrophy).
• Stiffness of wrist, fingers and shoulder ("frozen shoulder" from disuse).

Scaphoid fracture

• Young adult, FOOSH; the commonest carpal fracture (about three-quarters).
• Signs: tenderness in the anatomical snuffbox, over the scaphoid tubercle, and pain on axial compression of the thumb.
• X-ray: scaphoid views (AP, lateral and obliques); the fracture may be invisible at first.
• Site: waist (most common), proximal pole, tubercle.
• Blood supply enters distally (dorsal ridge branches of the radial artery) and runs backwards, so the proximal pole is at risk of avascular necrosis; the more proximal the fracture, the higher the risk.

Management:

• Clinically suspected but X-ray normal: immobilise in a cast or splint and repeat X-ray at about 10-14 days, or obtain an MRI (best early test) or CT.
• Undisplaced waist fracture: below-elbow cast (thumb included or not) for about 6-8 weeks.
• Displaced, proximal pole, or delayed presentation: internal fixation with a compression (Herbert-type) screw.

Complications: non-union (scaphoid non-union advanced collapse, wrist arthritis), avascular necrosis of the proximal pole (dense proximal fragment on X-ray), malunion.

Lunate and perilunate dislocation: lunate tips into the carpal tunnel ("spilled teacup" on lateral X-ray) and may compress the median nerve; needs urgent reduction.

Hand injuries

Nerve and vessel injuries at a glance

Quick revision

• Clavicle: middle third; medial fragment up (sternocleidomastoid); sling.
• Shoulder: anterior 95%, axillary nerve, Bankart, Hill-Sachs; posterior after fits, light-bulb sign.
• Surgical neck: axillary nerve; shaft: radial nerve (wrist drop), observe.
• Supracondylar: child, extension type, brachial artery, AIN, compartment syndrome, Volkmann, cubitus varus.
• Lateral condyle non-union: cubitus valgus, tardy ulnar palsy. Pulled elbow: supinate and flex.
• Monteggia: ulna + radial head; Galeazzi: radius + DRUJ.
• Colles: dorsal, dinner-fork, elderly; complications malunion, EPL rupture, CRPS, median nerve.
• Smith: volar, garden-spade. Barton: intra-articular rim.
• Scaphoid: snuffbox tenderness, waist commonest, proximal pole AVN; normal X-ray → immobilise and re-image or MRI.
• Bennett: base of first metacarpal, APL pull; boxer's: fifth metacarpal neck.

Written by The House Job from standard orthopaedic references (Apley; Bailey & Love).

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