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Upper limb fractures

Specialties > Musculoskeletal

Background knowledge 🧠

Definition

  • Upper limb fractures refer to breaks in the bones of the upper extremities: the humerus, radius, ulna, and bones of the hand and wrist.
  • Commonly caused by trauma, such as falls, direct blows, or accidents.
  • May involve single or multiple bones.

Epidemiology

  • Upper limb fractures are among the most common fractures encountered in clinical practice.
  • More frequent in males under 50 due to high-energy trauma and in females over 50 due to osteoporosis.
  • Distal radius fractures are the most common, followed by fractures of the humerus.

Aetiology and Pathophysiology

  • High-energy trauma: falls from height, sports injuries, road traffic accidents.
  • Low-energy trauma: falls in elderly patients with osteoporosis.
  • Pathological fractures: occur in weakened bones, often due to malignancy or metabolic bone disease.
  • Fractures disrupt normal bone architecture, potentially affecting surrounding soft tissues.

Types

  • Humerus fractures: proximal, midshaft, distal.
  • Forearm fractures: isolated ulna or radius fractures, both-bone fractures, Galeazzi and Monteggia fractures.
  • Wrist fractures: Colles’ fracture, Smith’s fracture, scaphoid fracture.
  • Hand fractures: metacarpal and phalangeal fractures.
  • Open vs. closed fractures: based on skin integrity.

Clinical Features 🌡️

Symptoms

  • Pain at the site of fracture, often severe and exacerbated by movement.
  • Swelling and bruising around the affected area.
  • Reduced range of motion and functional impairment.
  • Visible deformity in cases of displaced fractures.
  • Numbness or tingling if nerves are involved.

Signs

  • Tenderness on palpation at the fracture site.
  • Swelling, bruising, and sometimes an obvious deformity.
  • Crepitus or abnormal movement at the fracture site.
  • Neurovascular compromise: assess for pulse, capillary refill, and sensation.
  • Compartment syndrome signs: pain out of proportion, pallor, paresthesia, paralysis, pulselessness.

Investigations 🧪

Tests

  • Plain radiographs: the primary imaging modality, usually AP and lateral views.
  • CT scans: for complex fractures or pre-operative planning.
  • MRI: indicated if there is suspicion of associated soft tissue injury or occult fractures.
  • Bone scan: used occasionally for detecting stress fractures or in cases with malignancy.
  • Blood tests: may include FBC, CRP, and U&E to assess overall health and readiness for surgery.

Management 🥼

Management

  • Initial: analgesia, immobilisation with splints or slings.
  • Definitive: varies by fracture type – closed reduction and casting for simple fractures, ORIF (Open Reduction and Internal Fixation) for displaced or complex fractures.
  • Rehabilitation: physiotherapy to restore function and strength post-healing.
  • Monitoring: regular follow-up with X-rays to ensure proper healing.
  • Consideration of surgical options in cases of non-union or malunion.

Complications

  • Non-union or malunion, leading to functional impairment.
  • Neurovascular injury, including nerve damage or compromised blood supply.
  • Infection, particularly in open fractures or post-surgical cases.
  • Compartment syndrome, a surgical emergency.
  • Post-traumatic osteoarthritis, particularly in intra-articular fractures.

Prognosis

  • Varies with age, comorbidities, and fracture type.
  • Good in most cases with appropriate treatment.
  • Delayed union or non-union can lead to prolonged disability.
  • Risk of chronic pain and reduced function if complications arise.

Key Points

  • Upper limb fractures are common and can significantly impact function.
  • Prompt diagnosis and management are essential to prevent complications.
  • Management varies depending on the fracture type and patient factors.
  • Rehabilitation plays a critical role in recovery.
  • Complications can have long-term consequences, necessitating careful follow-up.

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Musculoskeletal