Upper Limb Fractures

upper limb fractures
  • Fracture of clavicle
  • Fracture of scapula
  • Fracture of humerus
  • Fracture of radius and ulna
  • Fracture of carpal bone(s)
  • Fracture of metacarpal bone(s)

Fracture of clavicle

Clavicular fractures are common injuries that account for approximately 5% of all fractures seen in the Emergency Services. In neonates and children, these fractures are very common and generally heal well. In adults, the force required to fracture the clavicle is greater, healing occurs at a slower rate, and risk of potential complications is higher.

While the overwhelming majority of clavicle fractures are benign, associated life-threatening intrathoracic injuries are possible. Complications vary based on location of fracture.

Age

Clavicle fractures are the most common of all pediatric fractures. They can present in the newborn period, especially following a difficult delivery, and nearly half of all clavicle fractures occur in children younger than 7 years. In young children, the fracture is often incomplete (i.e. greenstick fracture) or a bowing deformity without definite fracture.

Mechanism of injury

  • The patient typically reports a fall onto an outstretched upper extremity, a fall onto a shoulder, or direct Clavicular trauma.
  • Pain, especially with upper extremity movement
  • Swelling

Physical

  • Tenderness
  • Crepitus
  • Edema
  • Deformity
  • Ecchymosis- especially when severe displacement causes tenting of skin
  • Bleeding from open fracture (rare)
  • Decreased breath sounds on auscultation, indicating possible pneumothorax
  • Decreased pulses or evidence of decreased perfusion on vascular examination, suggesting vascular compromise
  • Diminished sensation or weakness on distal neurovascular examination, suggesting neurologic compromise
  • Nonuse of the arm on the affected side in neonates

Causes

  • Fall onto a shoulder or an outstretched upper extremity
  • Direct blow to the clavicle

Imaging Studies

  • Routine clavicle radiography
    o Fracture is usually demonstrated on an anteroposterior (AP) view.
    o Apical lordotic views may be required to define the degree of displacement.

Other Tests

  • Other tests may be required when clinically indicated to assess the possibility of life-threatening associated injuries.
    o Chest radiography, if pneumothorax suspected
    o Angiography, if vascular injury suspected

Prehospital Care

  • Identify and treat associated life-threatening injuries.
    o Use the ABC approach to the evaluation, and stabilize the patient.
    o Perform a careful secondary survey.
    o Apply a cold pack to the injury.
    o Immobilize the upper extremity with a sling.

Scapula fracture

A scapula fracture is an uncommon injury. The scapula, or shoulder blade, is a wide, flat bone that sits behind the rib cage. The scapula connects to the clavicle (collar bone) in the front of the body, and to the humerus (arm bone) at the side. Part of the scapula is lined with cartilage (the glenoid) and forms the socket of the ball-and-socket shoulder joint.

Types of scapula fractures

  • Scapular Body Fractures : Scapular body fractures are the most common type of scapula fracture. These injuries seldom require any specific treatment more than a simple arm sling. The important fact is that scapular body fractures are commonly (80-90%) associated with other injuries such as lung and chest injuries.
  • Scapular Neck Fractures : Scapular neck fractures occur just adjacent to the glenoid–part of the shoulder joint. Again, most of these fractures can be treated without surgery unless there is significant angulation of the broken bones. In these cases, the shoulder joint can be affected if surgery is not done to realign the bones.
  • Glenoid Fractures : Glenoid fractures involve the cartilage surfaces of the shoulder joint. These fractures require surgery when the should joint becomes unstable or if the fragments are far out of alignment. Patients with glenoid fractures are at risk of developing shoulder arthritis

Symptoms

Symptoms include:

  • Extreme pain when you move the arm.
  • Swelling around the back of the shoulder.
  • Skin abrasions.

Without treatment, a fractured scapula can result in chronic shoulder pain and disability.

Diagnosis

To determine appropriate treatment, your doctor will probably need to take X-rays (radiographs) of your shoulder and chest to describe and classify the location(s) of fracture to the scapula. In some instances, your doctor may also need to use other diagnostic imaging tools such as computed tomography (CT).

One or more parts of the scapula may be fractured:

  • Scapular body (50% to 60% of patients)
  • Scapular neck (25% of patients)
  • Glenoid
  • Acromion
  • Coracoid

Treatment

Nonsurgical treatment with a simple sling works for most fractures of the scapula. The immobilization device holds your shoulder in place while the bone heals. Your doctor may want you to start early range-of-motion exercises within the first week after the injury. Other fractures may need 2 to 4 weeks of immobilization.

Your shoulder may feel stiff when the doctor removes the sling. Begin limited active use of your shoulder immediately. Passive stretching exercises should be continued until complete shoulder motion returns. This may take 6 months to 1 year.

If you have an isolated scapular body fracture, your doctor may want you to stay in the hospital. Certain types of scapular fractures may need further evaluation:

  • Fractures of the glenoid articular surface in which bone has moved out of place (displaced) significantly.
  • Fractures of the neck of the scapula with severe angular deformity.
  • Fractures of the acromion process with impingement syndrome.

In these instances, you may need surgery in which the doctor uses plates and screws to hold the bone together.

Humerus Fracture

A humerus fracture is an injury to the bone of the upper arm. The upper arm bone, the humerus, connects the shoulder to the elbow. Humerus fractures are generally divided into three types of injuries:

  • Proximal Humerus Fractures : Proximal humerus fractures occur near the shoulder joint. The shoulder joint is a ball-and-socket joint, with the ball being the top of the humerus bone. Fractures of this ball are considered proximal humerus fractures. These fractures may involve the insertion of the important rotator cuff tendons. Because these tendons are important to shoulder motion, treatment may depend on the position of these tendon insertions.
  • Mid-Shaft Humerus Fractures : Mid-shaft humerus fractures occur away from the shoulder and elbow joints. Most humeral shaft fractures will heal without surgery, but there are some situations that require surgical intervention. These injuries are commonly associated with injury to one of the large nerves in the arm, called the radial nerve. Injury to this nerve may cause symptoms in the wrist and hand.
  • Distal Humerus Fractures : Distal humerus fractures are uncommon injuries in adults. These fractures occur near the elbow joint. These fractures most often require surgical treatment unless the bones are held in proper position. This type of fracture is much more common in children, but the treatment is very different in this age group

Proximal humerus fractures

Epidemiology

  • 4-5% of all fractures

Mechanism of injury

  • Usually after fall onto an outstretched hand from standing height
  • Can also occur during seizures or electric shock when fracture may be associated with a posterior shoulder dislocation
  • Can also result from a direct blow

Age group affected

  • Middle age/elderly most commonly affected. Common in women. Many patients are osteoporotic.
  • n younger people, same injury mechanism can cause fracture with co-existing shoulder dislocation. In younger age groups, trauma is likely to be of higher energy and resulting injury more serious. Humeral epiphysis separation can occur in adolescents.

Presentation

  • History of trauma
  • Pain, loss of shoulder/arm function, swelling and bruising .

Investigations

  • Xrays – include AP, transscapular (or Y) and axillary views
  • CT scan may be needed in difficult cases

Classification

  • Neer classification: based on the 4 usual cleavage lines that occur due to the anatomy of the proximal head of the humerus (the articular segment or head, the lesser tuberosity, the greater tuberosity and the surgical neck/shaft). Two-part, three-part and four-part fractures can occur. The fractures are then classified by their degree of displacement and angulation.
  • Considered to be displaced if more than 10mm movement or angulation >45º.
  • Surgical neck fractures are the commonest type of proximal humeral fracture.

Management

  • General principles: the fracture should be immobilized as soon as possible and potent analgesia given. Keep patient comfortable and minimise any need for movement. Open fractures, those associated with a shoulder dislocation or combined with fracture in forearm are a surgical emergency and an immediate orthopaedic opinion is necessary.
  • Most fractures are extra-articular and minimally displaced.
  • Up to 85% of proximal humerus fractures can be treated non-operatively. This involves the use of a sling or shoulder immobiliser. A physiotherapy referral should be made.
  • If displaced, surgery may be needed but which surgical technique is used is controversial. Some advocate the use of conservative treatment for some displaced fractures.
  • Surgery involves either closed reduction with percutaneous fixation, open reduction and internal fixation, or proximal humeral head replacement.
  • Fracture dislocations and fractures of the anatomical neck should be referred for orthopaedic review.

Complications

  • Neurovascular injury: 21-36% of proximal humerus fractures produce neurovascular injury. Axillary nerve damage is most common. Suprascapular, radial and musculocutaneous nerves can also be affected. Axillary artery injury may rarely occur (look for expanding mass over proximal shoulder girdle). Brachial artery is also rarely injured.
  • Avascular necrosis of the humeral head: more common in complex fractures with multiple fragments where interruption to the blood supply is more likely and in fractures of the surgical neck. Causes pain and stiffness in the shoulder. Shoulder arthroplasty may eventually be needed or may be the initial treatment of choice in the fracture management. However, the development of intramedullary nails and minimally invasive locking plates provides greater ability to fix more complex fractures with less risk to the blood supply.
  • Malunion
  • Associated glenohumeral dislocation
  • Associated rotator cuff injury

Prognosis

  • This depends on fracture type, mechanism of injury and patient’s age and underlying health. In general an elderly person with a proximal humerus fracture never regains full range of movement, whether treated conservatively or surgically. The aim is rehabilitation to a functional range of movement.
  • Generally recovery takes at least 1 year but union is expected at 6-8 weeks.

Prevention

  • Adequate treatment of those at risk of osteoporosis

Hill-Sachs lesion

This is a type of proximal humerus fracture. It is defined as a posterolateral humeral head compression fracture and can occur following anterior shoulder dislocation. It occurs in 35-40% of anterior dislocations and up to 80% of recurrent dislocations. Xray views should include an AP view of the shoulder in internal rotation and a special view known as the Stryker Notch view.The reverse Hill-Sachs lesion is a compression fracture of the anteromedial humeral head as a result of posterior shoulder dislocation.

Humeral shaft fractures

Epidemiology

  • 3% of all fractures
  • 3% of fractures in children <16

Mechanism of injury

  • A swedish study in 2006 found most are caused by a simple fall
  • May be linked to non-accidental injury in children <3 years
  • Usually direct trauma or torsion injury to upper limb. Occasionally fall onto outstretched abducted arm. Blunt injury/bending forces usually cause transverse fractures. Torsional force tends to result in spiral fracture.

Age group affected

  • The swedish study found that most fractures occurred in elderly patients.

Presentation

  • History of trauma
  • Arm pain, swelling and deformity

Investigations

  • AP and lateral Xrays of the humerus
  • Include views of the shoulder and the elbow

Classification

There is no recognised universally accepted classification. Can be described using:

  • Location – proximal, middle, distal. Distal third humeral fractures are also known as Holstein-Lewis fractures.
  • Type of fracture line – transverse, oblique, spiral, comminuted, segmental
  • Open or closed

Management

  • The same general principles as listed above should be applied.
  • Most can be treated non-operatively in a hanging arm cast or coaptation splint (a splint from the axilla to the nape of the neck with a stirrup around the elbow) followed by a functional arm brace (this has an anterior and posterior plastic shell held together by adjustable Velcro straps) after 1-3 weeks. A physiotherapy referral should be made.
  • Mildly displaced/overlapping humeral shaft fractures may be treated by closed reduction and long arm splint from shoulder to wrist. After any humeral closed reduction, neurovascular assessment and x-rays should be repeated.
  • Surgical fixation may be needed if the fracture is segmental or if there is vascular compromise. This involves open reduction and the use of plates and screws or intramedullary fixation/nailing. Radial nerve injury, which may only be temporary, is a risk in any operative procedure.

Complications

  • Radial nerve injury: occurs in 11.8% of fractures. Most common in distal third fractures. More common in transverse or spiral fracture. Spontaneous recovery occurs in 70.7% treated conservatively. Initial expectant treatment may avoid unnecessary operations.
  • Brachial artery injury
  • Non-union

Prognosis

  • Usually heal within 4 months

Fractures of distal humerus

  • Supracondylar/transcondylar – most are extension-type injuries from fall on outstretched arm.
  • Transcondylar fractures are more common in elderly.
  • Supracondylar fractures are more common in children.
  • Patient usually presents with elbow swelling and pain.
  • Careful examination for neural or vascular involvement due to risk of damage to brachial artery and nerve.
  • Marked swelling of forearm or palpable induration of forearm flexors, with pain on passive extension of the fingers suggests acute volar compartment syndrome requiring emergency fasciotomy.
  • AP and lateral X-rays of elbow.
  • Images of transcondylar fracture and its repair.

Management

  • All but non-displaced or minimally displaced fractures without neural or vascular involvement should be referred for surgical repair.
  • Immobilize elbow in long arm posterior splint with elbow at 90° degrees forearm in neutral rotation.
  • Check distal pulses after splint applied and if absent, extend elbow to point where pulses return.
  • Frequent checking of neural and vascular function essential during first 7–10 days, ice and elevation are important in reducing swelling.
  • Re-examine within 24–48 hours.
  • After 2 weeks, patients should remove splint and perform gentle exercises and continue using splint for approx. 6 weeks, then start vigorous exercises.

Intercondylar fractures

  • T- or Y-shaped fractures with varying displacement between the condyles and the humerus.
  • Commonly caused by direct or indirect blow to elbow.
  • Patient usually presents with marked tissue swelling holding their forearm in pronation.
  • Injured forearm may appear shortened.
  • May feel crepitus of movement when condyles are pressed together.
  • AP and lateral views of intercondylar fracture.

Management

  • Most fractures require surgery because they are displaced.
  • Refer for orthopaedic opinion.
  • Rarely, non-displaced fractures can be treated similarly to non-displaced supracondylar fractures, as above.

Condylar fractures

  • Lateral condyle fractures are more common than medial.
  • Lateral fractures are usually due to direct impact on a flexed elbow.
  • Medial due to impact to olecranon with flexed elbow.
  • Sudden adduction or hyperextension may also cause these fractures.
  • Patients usually present with swelling, limited range of movement and tenderness over injured condyle.
  • Crepitus with motion is frequently present.
  • AP and lateral x-rays reveal a widened intercondylar distance and there may be displaced fracture fragments.

Management

  • Aspiration of joint haemarthrosis relieves discomfort.
  • Displaced fractures require surgical correction.
  • Undisplaced fractures can be treated with a long arm posterior splint with elbow at 90°.

Radial head and neck fractures

  • Radial head fracture is the commonest fracture around the elbow joint in adults, whereas radial neck fractures occur more commonly in children.
  • Most commonly due to fall on outstretched arm.
  • Patient presents with swelling over the lateral elbow with limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain increased with passive rotation.
  • Most reliable clinical sign is point tenderness over radial head.
  • Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
  • Important to detect a mechanical blockage of motion from displaced fracture fragments. Often needs aspiration of the haemarthrosis with instillation of local anaesthetic for pain relief.
  • Presence of severe crepitation or complete blockage of motion for full extension and flexion shows presence of displaced fragments.
  • If there is significant wrist pain and/or central forearm pain, may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.

Investigations

  • AP and lateral X-ray views of elbow are usually sufficient.
  • Findings may be quite subtle and only clue may be fat pad sign (triangular radiolucent shadows anterior and posterior to distal humerus on lateral x-ray, indicating haemarthrosis and displacement of intra-articular fat pad – often associated with intra-articular skeletal injury).
  • Image of elbow fat pad sign. Images of radial head fractures.

Management

  • Refer for urgent surgical treatment if elbow fracture-dislocation or evidence of nerve or vascular involvement.
  • Complex fractures require open reduction and internal fixation.
  • Otherwise give sufficient analgesia and consider joint aspiration and instillation of anesthetic as described above (usually in expert hands).
  • Immobilize elbow in long arm posterior splint with elbow at 90°.
  • In non-displaced fractures, remove posterior splint and replace with sling for comfort only, monitor for displacement and institute active range of movement exercises, including rotation, flexion and extension at least 3–4 times daily.

In children

  • Can be difficult to diagnose as radial head ossification does not occur until age 4.
  • May be associated ulna shaft fracture (equivalent to adult Monteggia fracture).
  • US or MRI may be needed to confirm the diagnosis.

 

Olecranon fractures

  • Low energy fractures occur most commonly in the elderly and result from indirect trauma due to sudden pull of triceps and brachioradialis muscles.
  • In younger patients usually follow direct blow to the point of the elbow and are often comminuted and may have associated ulna shaft fracture.
  • Patient presents with swelling and tenderness over the olecranon with haemarthrosis and limited range of motion.
  • An inability to extend the elbow against gravity indicates dysfunction of triceps lever.
  • Need to check for ulnar nerve damage and examine distal pulses.
  • True lateral X-ray of elbow should reveal the fracture.

Management

  • Immobilise elbow in long arm posterior splint with elbow in 60–90° flexion, well moulded posteriorly.
  • Support arm with collar and cuffs or standard arm sling.
  • Refer displaced fractures for surgery. In non-displaced fractures, splint for 5–7 days, remove and repeat x-ray to confirm non-displacement.
  • If still stable, gentle supination and pronation exercises using a sling or removable posterior splint for comfort.
  • Flexion and extension exercises after 2 weeks.

Fractures of the coronoid process

  • Associated with elbow dislocation in about 40%
  • Patients present with tenderness over antecubital fossa and swelling about the elbow.
  • Check strength of radial pulse with elbow at 90°.
  • Lateral X-ray of elbow.
  • Image of coronoid fracture.

Management

  • Non-displaced fractures should be immobilised in long arm posterior splint with elbow at 90° and forearm in full supination. After 3 weeks, start active range of movement exercises using sling for comfort.
  • Displaced fractures or those involving >50% of process need surgical repair.

Capitulum Fracture

  • Fracture involving the distal humeral articular surface.
  • Usually fall onto outstretched hand or direct trauma.
  • Present with anterior elbow pain and effusion.
  • Lateral and AP radiography usually reveals the fracture.
  • Images of capitulum fracture.
  • Management: undisplaced fractures may be splinted but more usually they are displaced and require surgical fixation.

Elbow dislocation

  • Very common especially in young people undertaking sport.
  • Often due to fall onto extended elbow.
  • Those without fracture are termed simple whereas dislocations with fracture are termed complex.
  • Classified according to position of ulna in relation to humerus after injury.
  • Often associated with injury to brachial artery and nerve so full examination of distal pulses, median and ulnar nerve function.
  • Patient usually presents with severe pain with elbow flexed and swelling and deformity apparent.
  • AP and lateral X-rays of elbow to confirm dislocation and exclude fractures.
  • Image of lateral view of posterior dislocation.

Management

  • Prompt reduction essential. This is usually performed under IV sedation and with adequate analgesia.
  • Posterior dislocation
    o First try countertraction on the humerus while applying longitudinal traction on the wrist and forearm.
    o Continue distal traction as elbow is flexed.
    o May need downward pressure on proximal forearm.
    o If this fails, place patient face down with elbow hanging off side of table and place small pillow under the humerus just proximal to the elbow joint and hang a 2½–10 kg weight from the wrist or apply gentle longitudinal traction.
    o Usually reduces within several minutes but may need forward pressure on the olecranon.
  • Anterior dislocation
    o Basically the reverse of above applying posterior and downward pressure to the forearm whilst applying anterior pressure from behind to the distal humerus.
    o After reduction, test joint mobility and stability and check neural and vascular function. Repeat x-ray and immobilize elbow in posterior splint with elbow at 90°.

Forearm fractures

Forearm fractures account for most limb fractures. Wrist fractures are the most common forearm fracture. Fracture risk factors include osteoporosis (more common in women than men) and malignancy (pathological fractures).

Classification

  • Forearm fractures can be classified as either proximal, middle or distal.
  • They can affect one or both forearm bones.
  • They are either open or closed.
  • Proximal forearm fractures may involve the elbow joint
  • Distal forearm fractures may involve the wrist

General assessment and initial management of forearm fractures

Some general principles should be followed for all forearm fractures. Specific points related to the different fracture types are discussed below. Forearm fractures in children can generally be treated differently from adult fractures because of continuing bone growth in the radius and the ulna after the fracture has healed.

  • Assess Airway, Breathing and Circulation and manage as necessary.
  • Assess upper limb neurovascular function
    o Sensory function: the median nerve supplies the thumb, index, middle and radial half of the ring finger on the palmar side of the hand and the tip of the thumb, index, middle and ring finger on dorsum of the hand; the radial nerve supplies the dorsolateral aspect of the hand and the dorsal aspect of the thumb, index, middle and lateral half of the ring fingers; the ulnar nerve supplies the dorsal and palmar aspects of the medial half of the ring finger and the whole of the little finger.
    o Motor function: test anterior interosseous branch of the median nerve by asking patient to make the ‘OK’ sign; test radial nerve by asking patient to extend their fingers or wrist against resistance; test ulnar nerve by asking patient to separate their fingers against resistance.
    o Vascular function: examine radial (and ulnar) pulse. Assess capillary refill.
  • Examine the wrist, elbow and forearm for tenderness and range of motion.
  • Perform a complete examination for other injuries.
  • Immobilize the forearm and upper arm whilst waiting for Xray.
  • Provide analgesia.
  • Immediate fracture reduction is required if there is neurovascular compromise, severe displacement or skin tenting.

Adult both-bone forearm fractures

  • Mechanism of injury: usually significant force injury. Most commonly occur in motor vehicle accidents, also occur from direct blow, fall from a height or during sport.
  • Presentation: pain and swelling at site with obvious deformity.
  • Assessment: may be nerve involvement with paraesthesiae, paresis or loss of function. Do not elicit crepitus as may cause further soft tissue injury. Do not probe open fractures as may cause deeper contamination.
  • Investigation: X-ray entire length of forearm, wrist and elbow, with AP and lateral views.
  • Management: displaced fractures are the usual situation in adults. Operative treatment with internal fixation or intramedullary nailing will be needed in nearly all cases, so refer urgently. Closed reduction may be attempted (with sufficient sedation/analgesia ± muscle relaxants) if there is acute neurovascular compromise.

Paediatric both-bone forearm fractures

Fractures may be of greenstick type (incomplete) or complete. A greenstick fracture can occur in one bone with a complete fracture in the other. Complete fractures may be undisplaced, minimally displaced or overriding. Fractures of the proximal third are relatively rare. Middle third fractures account for about 18% of both-bones fractures and distal third about 75%.

  • Mechanism of injury: usually an indirect injury following fall on outstretched hand. Occasionally caused by direct trauma.
  • Presentation: pain, swelling and deformity at fracture site.
  • Investigation: X-rays of wrist, elbow and whole forearm should be taken.
  • Management: unlike adults, many both-bone fractures of the forearm can be treated by closed reduction. After reduction, forearm pronation and supination should be checked and arm placed in a long-arm cast or splint. Surgical treatment is by open reduction and plating/intramedullary nails depending on degree of overriding/angulation.

Radial shaft fractures (Gallezzi fractures)

  • Definition: solitary fractures of the distal one third of the radius with accompanying subluxation or dislocation of distal radioulnar joint (DRUJ). Synonym is reverse Monteggia fracture.
  • Mechanism of injury: commonly caused by fall on extended, pronated wrist.
  • Presentation: pain, swelling and deformity of the wrist and forearm. Tenderness and swelling at the distal radius and tenderness at DRUJ.
  • Investigation: X-ray the entire length of the forearm including wrist and elbow joints, AP and lateral views usually sufficient.
  • Management: in adults, requires surgical open reduction of the distal radius and DRUJ with internal fixation. In children the fracture can often be treated by closed reduction with longitudinal traction and correction of radial angulation. General anaesthesia may be required in difficult cases. If closed reduction under GA fails, K-wire insertion may be needed to lever the fracture into position. Open reduction may be needed in some cases.4

Ulna shaft fractures

  • Definition: isolated mid-shaft ulna fractures have the synonym ‘nightstick fracture’.
  • Mechanism of injury: usually caused by a direct blow to the ulnar border, classically if someone receives a blow from an object whilst raising their arm in defence.5
  • Presentation: point tenderness over ulna shaft and forearm swelling.
  • Investigation: need to x-ray ulna from wrist to elbow.
  • Management: require orthopaedic referral. Non-displaced or minimally-displaced fractures can be treated with posterior splint from mid-upper arm to dorsum of the metacarpal joints with wrist in slight extension, forearm in neutral position and elbow at 90°. After 7-10 days, when swelling has subsided, use plaster sleeve or functional brace for next 4-6 weeks. Monitor weekly for first 3 weeks for any displacement. Fractures with marked displacement or angulation should be treated with open reduction and internal fixation.

Monteggia fractures

  • Definition: these are fractures of the proximal third (usually) of the ulna with associated dislocation of the radial head. Classified as:
    o Type I – Fracture with anterior radial head dislocation. Commonest (60%).
    o Type II – Fracture of the proximal ulna with posterior or posterolateral dislocation of the radial head (15%).
    o Type III – Fracture of the ulna metaphysis with lateral or anterolateral dislocation of the radial head (20%).
    o Type IV – Fracture of both radius and ulna at their proximal third with anterior dislocation of radial head (5%).
  • Mechanism of injury: usually caused by a fall onto outstretched, extended and pronated elbow or direct blow.
  • Presentation: acute, severe pain and swelling in forearm and elbow. Damage may occur to the posterior interosseous nerve.
  • Investigation: X-ray the entire length of radius and ulna, including wrist and elbow, AP and lateral views usually sufficient but may need radiocapitellar views.
  • Management: in adults, immobilize joint in splint and refer for open reduction and internal fixation. Most paediatric monteggia fractures are treated closed.7

Complications of forearm fractures

  • Non-union and malunion (uncommon)
  • Compromise of brachial/radial artery blood supply
  • Median, ulnar or radial nerve injury
  • Infection (more likely if fracture secondary to crush injury)
  • Compartment syndrome (more common in both-bone forearm fractures)
  • Radioulnar fusion (synostosis)
  • Re-fracture

Prevention of forearm fractures

  • Prevention of osteoporosis.
  • Adequate treatment of existing osteoporosis.
  • The use of wrist and elbow guards whilst taking part in certain sports activities such as mountain biking and skating.

Fracture of carpal bone(s)

Scaphoid Fracture

The scaphoid is one of the small bones in the wrist. It is the wrist bone that is most likely to break.

Causes

A fracture of the scaphoid usually happens from a fall on an outstretched hand, with the weight landing on the palm. The end of one of the forearm bones (the radius) may also break in this type of fall, depending on the position of the hand on landing. Pain and swelling in the wrist will usually cause a person with a scaphoid fracture to see a doctor.

Fractures of the scaphoid occur in people of all ages, including children. The injury often happens during sports activities or a motor vehicle accident. Men aged 20 to 30 years are most likely to experience this injury.

There are no specific risks or diseases that increase the chance of having a scaphoid fracture. Some studies have shown that use of wrist guards during activities like inline skating and snowboarding can decrease the chance of breaking a bone around the wrist.

Symptoms

Unless the wrist is deformed, it might not be obvious that the scaphoid bone is broken. Sometimes, it might seem to be just a sprained wrist.

It is important to see a doctor if there is pain on the thumb side of the wrist that starts after a fall or accident and does not go away within a few days.

Scaphoid fractures usually cause pain in the base of the thumb, with swelling in the same area. The pain may be severe when the thumb or wrist is moved or the hand grips anything. In some cases, the pain is not severe, and may be mistaken for a sprain.

Diagnosis

This X-ray shows the location of the scaphoid and the surrounding bones of the hand and wrist.

X-rays will be used to assess the bone. Sometimes, a broken scaphoid does not show up on an X-ray right away. If this is the case, the wrist might be put in a splint for a week or two. A new X-ray will be taken to see if the fracture will become visible. The splint should be worn during this waiting period, and heavy lifting should be avoided.

An MRI (magnetic resonance image) may be taken to visualize the bones and soft tissues. This sometimes shows a fracture of the scaphoid before it can be seen on an X-ray.

TREATMENT

Nonsurgical Treatment:Treatment of scaphoid fractures depends on the location of the break in the bone.

Fractures of the scaphoid at the end near the thumb usually heal in a matter of weeks with proper protection. This part of the bone has a good supply of blood. Most fractures here heal well when they are placed in a cast. The cast will usually be below the elbow. It may or may not include the thumb. The time frame for healing is best determined by X-rays or other imaging studies such as a computed tomography (CT) scan. These imaging studies are used to confirm that the bone has healed.

If the scaphoid is broken in the middle (waist) or at the part closer to the forearm (proximal pole), healing is more difficult. These areas of the scaphoid do not have very good blood supply. This makes it more difficult to heal. If a fracture of the scaphoid in these locations is treated in a cast, it will probably include the thumb. The cast will extend above the elbow.

Surgical Treatment: When the scaphoid is broken at the waist or proximal pole, surgery may be recommended. A screw or wire may be used to stabilize the scaphoid while the bone heals.

Where the incision is placed and how large it is depends on what part of the scaphoid is broken. The incision will be on the front or the back of the wrist. Sometimes the screw or wire can be placed in bone fragments with a small incision. In other cases, a larger incision is needed to ensure that the fragments of the scaphoid are aligned properly

Nonunion, Avascular Necrosis, and Arthritis 

A bone that fails to heal is called a nonunion. Nonunions are more common after scaphoid fractures because blood supply to the scaphoid bone is poor. Blood supply to the bone is very important in its healing. Bones need blood to carry oxygen and nutrients to the site of the fracture.

When the scaphoid is broken, especially when the fragments have moved apart (displaced), the blood supply to those fragments may be disrupted. Sometimes, the blood supply to one of the fragments is so poor that the piece does not get enough nutrients and the cells in that fragment die. This is called avascular necrosis.

Over time, nonunion and avascular necrosis of the scaphoid can lead to arthritis of the wrist. Symptoms of arthritis in the wrist that results from scaphoid nonunion or avascular necrosis include:

  • Aching in the wrist
  • Decreased range of motion of the wrist
  • Pain with activities such as lifting or gripping

If X-rays show arthritis in the wrist as a result of an old break in the scaphoid, treatment focuses on improving the symptoms of arthritis. At first, this may include taking anti-inflammatory medicine and wearing a splint when the wrist is painful. Sometimes, the doctor may inject a steroid into the wrist to help to lessen wrist pain.

If this does not work, surgery may be recommended. Many types of operations can be performed for wrist arthritis.

Rehabilitation 

A cast or splint will need to be worn while the scaphoid fracture is healing. This may be for as long as six months. During this period of healing,

  •  Avoid heavy lifting, carrying, pushing, pulling or throwing with the injured arm
  • Do not participate in contact sports
  • Do not climb ladders or trees
  • Avoid activities with a risk of falling onto hand (for example, inline skating, jumping on a trampoline)

Some people have stiffness in the wrist after scaphoid fractures. This is more common when a cast was needed for a long time or when surgery was done through a long incision. Hand therapy may be recommended to help regain the motion and strength in the wrist. Even with therapy, some people do not recover the same motion and strength in their wrists that they had before the injury.

 

Boxer’s fracture

Boxer’s fracture is the common name for a break in the end of the small finger metacarpal bone

Causes

It is usually caused by punching something harder than the hand, such as a wall or another person’s head. The end of the metacarpal bone takes the brunt of the impact, which usually breaks through the narrowest area near the end (the “neck”), and bends down toward the palm.

Treatment

Ice, elevation, and hangover help if needed.

A therapist can make a splint to help protect the broken bone.

A doctor can set the bone, but many times the bone falls back after being set. If the break is bad enough, it may be best to have the fracture set and then held in place with pins or other hardware.

Casting or splinting the break is helpful to keep from injuring the area further, but without surgery, the break usually heals with a bend at the site of the break. The most reliable way to get the bones to heal straight is to use with pins or other orthopedic hardware. This works well in most people – but is not usually needed, as most people do just fine even if the bone heals with a bit of a bend.