Upper Limb

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

• Usually direct violence

• 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

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

• 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

• With shoulder dislocation
• FOOSH

• 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

• FOOSH

• 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

• FOOSH

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

• Avascular necrosis of the humeral head

Fractured Shaft of Humerus

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

• 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

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

Supracondylar Fractures of the Humerus

• FOOSH

• 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

• Brachial artery damage

Medial and Lateral Epicondylar Fractures of the Humerus

• Fall onto elbow
• Avulsion by muscles or collateral ligament

• 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

• Medial epicondyle trapped in elbow joint
• Ulnar nerve palsy

Unicondylar Fractures of the Humerus

• FOOSH

• 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

• FOOSH

• 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

• Avulsion (brachialis)
• Dislocation of elbow

• 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

• Fall on the point of elbow
• Sudden triceps contraction

• 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

• FOOSH

• 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

• Loss of elbow extension

Fracture of the Radial Neck

• FOOSH

• 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)

• FOOSH
• Direct blow on the arm

• 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)

• FOOSH
• Direct blow on the arm

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

Isolated Fractures of the Ulnar Shaft

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

• 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

• Direct violence

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

Fractures of the Distal Radius

• FOOSH

• 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

• FOOSH

• 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

• FOOSH
• Starting handle (crank) kickback

• 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 1^st 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

• Avascular necrosis

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

• FOOSH

• 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

• Hyperflexion
• Hyperextension
• Direct Violence

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

First Metacarpal Fractures

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

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

Second and Fifth Metacarpal Fractures

• Punching

• 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 3^rd and 4^th Metacarpals

• Punching

• 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

• FOOSH

• 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

• Crushing injury

• 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

• Punching

• 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

• Punching

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