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Thread: Managing Common Upper Extremity Fractures

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    Arrow Managing Common Upper Extremity Fractures

    Managing Common Upper Extremity Fractures

    Proceeding systematically from the proximal humerus to the distal radius, the authors discuss emergent treatment, referral considerations, and potential complications of fracture injury at the sites where it most often occurs.
    Upper extremity fractures not only are painful and traumatic but also threaten the patient's quality of life with the risk of significant loss of function. As clinicians, we have the opportunity to provide these patients with effective pain relief and start them on the road to recovery. With these injuries, a clear understanding of the structures involved in the upper extremities is imperative. Appropriate evaluation and initial management are key to minimizing complications. It is also important to know the indications for orthopedic consultation. This article will focus on common fractures of the arm and forearm, taking a systematic, proximal-to-distal approach.


    Ice, elevation, analgesia, and immobilization are the mainstay of treatment for all fractures. With upper extremity fractures, because of the close proximity of the neurovascular structures, it is extremely important to document normal distal function. Usually, this can be done by checking the brachial and radial pulses, and the ulnar, median, and radial nerve functions (motor and sensory) of the hand. In general, immobilization is accomplished with a sling and swathe for proximal humerus fractures, a coaptation (sugar-tong) splint for humeral shaft fractures, a posterior splint for the elbow, and a double sugar-tong or long-arm anterior-posterior splint for forearm fractures.

    Reduction of the fracture is imperative to align the bony fragments for optimal healing and to reduce soft tissue and neurovascular injury. Factors to consider in fracture reduction include: the physician's comfort level with the procedure; the acuity of the injury; the presence of neurovascular deficits; the degree of fracture displacement or angulation, or both; and the availability of an orthopedic surgeon.
    For open fractures, intravenous (IV) antibiotics, such as 2 gm of cefazolin, should be administered. Also, the patient's tetanus status should be updated, if necessary, and an orthopedist consulted.


    The proximal humerus includes the humeral head and extends to the surgical neck. Just above the greater and lesser tubercles of the head is the anatomic neck. The humeral shaft begins at the insertion of the pectoralis major just below the surgical neck; it ends at the beginning of the supracondylar ridges.

    The distal humerus consists of two columns of bone called condyles. The supracondylar ridges mark the beginning of these bones. They are held together by a thin piece of bone that expands distally and forms the coronoid fossa. The condyles form the two articular surfaces of the humerus in the elbow. The trochlea, which is the articular surface of the medial condyle, articulates with the olecranon of the ulna. The capitellum, the articular surface of the lateral condyle, articulates with the head of the radius. The nonarticular segments are the epicondyles.

    The radius and ulna are held together by proximal and distal joint capsules and radioulnar ligaments. Down their shafts they are held together by a fibrous interosseous membrane. The proximal ligaments allow the radial head to rotate over the ulna, enabling supination and pronation.

    The major neurovascular structures in the arm begin with the brachial plexus and axillary artery in the axilla. The axillary artery becomes the brachial artery in the arm and bifurcates into the radial and ulnar arteries in the elbow, which continue on their respective sides in the forearm. The median, ulnar, and radial nerves branch out of the brachial plexus. The median nerve runs anteriorly in the elbow with the brachial artery, then runs down the middle of the forearm and into the carpal tunnel to reach the hand. The ulnar nerve runs in the medial epicondylar fossa of the elbow (the so-called funny bone), then courses down the ulnar side of the forearm to the hand. The radial nerve wraps around the distal third of the humeral shaft, then around the lateral epicondyle to extend deep into the structures of the forearm.


    Proximal humerus fractures are more common in the elderly and are most often the result of a fall on an outstretched arm. Less commonly, they can occur from a direct blow to the lateral arm. When they occur in the younger population, it is usually the result of trauma.

    On examination, the patient will usually be holding the arm in an adducted position. There will be tenderness and swelling over the proximal humerus. Any deformity should be noted. The brachial plexus, axillary nerve, and vascular structures are in close proximity and are therefore easily injured. They are much more likely to be injured if the patient is holding the arm in an abducted position, since this suggests that a distal fragment is located in the axilla. Anteroposterior and lateral radiographic views will usually demonstrate these fractures, but an axillary view can be utilized if not all fragments are fully visualized.

    The most common classification system used for proximal humerus fractures is Neer's, which divides the humeral head into four parts: the anatomic neck, the lesser and greater tuberosities, and the surgical neck. If the fragments are more than one centimeter displaced or have more than 45 degrees of angulation, they are considered separate. A one-part fracture has no fragments that are considered separate. A two-, three-, or four-part fracture will have the corresponding number of separate fragments. There are also two-, three-, and four-part fracture-dislocations, where the articular portion of the humeral head is displaced either anteriorly or posteriorly.

    About 80% to 85% of all proximal humerus fractures are one-part fractures. Successful treatment for all proximal humerus fractures depends on early mobility, because the major complication encountered is joint stiffness.
    Surgical neck fractures. The normal angle between the humeral head and the shaft is 135 degrees. It is important to measure this angle in all proximal humerus x-rays. Using Neer's classification, this would mean that an angulation of less than 90 or more than 180 degrees would make the fracture a two-part fracture, which may mean that reduction is necessary (see image, below). Any displacement greater than one centimeter requires reduction. Similarly, any neurovascular compromise requires reduction, along with emergent orthopedic referral.


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