1) The document provides an overview of common upper extremity injuries, including fractures of the clavicle, scapula, humerus, elbow, forearm, and wrist. 2) It describes the anatomy, mechanisms of injury, clinical features, diagnosis, and treatment approaches for each type of fracture. Conservative treatment involves splinting or casting while surgical treatment uses plates, screws, or other internal fixation devices. 3) Complications of these injuries include nonunion, malunion, stiffness, nerve damage, and in some cases may require further surgery if not properly treated.

1. Upper Extremity
Fractures
Nathnael Cherinet
Selamawit Mariye
Moderator Dr. Hibist Tefera (MD,ECCS)

2. Outline
Clavicular Fractures
Scapula
Humerus
Elbow
Forearm
01
02
04
05
06
08 Wrist
03 07
Shoulder Distal radius

3. INTRODUCTION
• Upper extremity injuries are routinely encountered in the ED
• Adequate assessment and proper handling significantly
reduces morbidity
• Approach to patients should be designed based on their
specific injury

4. “A broken bone can heal, but
the wound a word opens can
fester forever.”
—Jessamyn West

5. Clavicular fractures
01

6. • An s shaped bone
• Mid portion is the thinnest having no accompanying ligamentous or
muscular attachment
• Injury can occur following
• Fall on an outstretched hand
• Blow to the clavicle
• Birth trauma
• Common in young individuals who participate in sports like bicycling
and frequent violent collisions.
Clavicle

7. Types of clavicular fractures
12-28%
Lateral
69-85%
Mid Shaft
3-6%
Medial

8. Clinical features
Fracture and crepitus might be palpated
Arm is slumped inward and
downward
Limited range of motion
Swelling, deformity and tenderness
Sagging, shortening, tenting

9. Diagnosis
Physical exam
• Examination for signs of fracture and
concomitant injuries
• Assessment of neurovascular
compromise

10. Imaging
• Best initial test: X- ray in two projections (AP
and 45 degree cephalic tilt view)
• CT/MRI when associated injuries are
suspected or inconclusive x- rays.
• Arteriography in suspected vascular injury
• U/S in suspected fracture in children

11. Treatment
Mostly conservative Tx (shoulder sling) for 4-6 weeks
Exception : excessive shortening requires surgery
Mid shaft (group 1) fractures
Stable : conservative (simple shoulder sling)
Unstable : Surgical fixation
- Tension banding
- Clavicular plate
: Ligament repair
Lateral (group 2) fractures

12. Treatment contd….
• Conservative treatment similar to group 1
fractures
• Severe cases might need surgical
correction
• It is vital to assess for the presence
of intrathoracic trauma
• If present emergency intervention is
required
Medial (Group 3 fractures)

13. female Elderly
Significant trauma
Indications for
open reduction
Initial shortening
>2cm
Comminuted
fracture
Totally Displaced
fracture

14. Scapular fractures
02

15. • A flat bone triangularly shaped
• Can be injured due to
• High energy trauma to the
shoulder, esp polytrauma
• Fall from outstretched hand
• Fractures occur relatively infrequently
• Account only 0.4-0.9% of all fractures
Scapula

16. Types of scapular fractures

17. Clinical features
Arm is held in adduction
Assosciated injury of ipsilateral
lung & thoracic cage
Localized tenderness over the scapula
Fracture of the ribs

18. Imaging
• Chest x-ray
- Overlying structures obscure the scapula
• Scapular series
- AP, lateral and axillary view
• CT scan
- For associated injuries

20. Treatment
Conservative for most
Assosciated glenoid neck fracture,
acromial fracture and coracoid fractures
Surgical
Sling, ice, analgesics

21. Shoulder dislocation
03

22. • The head of the humerus is larger than the shallow glenoid fossa,
• Trauma (e.g., falling on an outstretched arm)
• Predisposing factors for recurrent shoulder dislocation
a. Loose joint capsule
b. Damage to the glenohumeral ligament
c. Rotator cuff tear
d. Bankart lesion and Hill-Sachs lesion
• For posterior dislocation: uncoordinated muscle contraction
(e.g., seizure, electrical shock)
Glenohumeral joint

23. Types of shoulder dislocation
95%
Anterior
4%
Posterior
1%
Inferior

24. Clinical features
A palpaple dent present at point where humerus lies
Inability to move the shoulder
Empty glenoid fossa
Severe shoulder pain

25. Clinical features
Humeral head palpated below coracoid process
Arm held in external rotation and slight abduction
Posterior
inferior
Antereor
Prominenence of posterior shoulder with ant flattening
Prominent coracoid process
Arm held above the head, pt unable to adduct arm
Neurologic dysfunction, especially in involvment of
axillay nerve

26. Diagnosis
Physical exam
• Examination for signs of fracture and
concomitant injuries
• Assessment of neurovascular
compromise

27. Shoulder X-ray
• AP and lateral view to confirm dislocation
and exclude fracture
• For posterior dislocation
- axillary + scapular lateral views
• Light bulb sign – diagnostic of posterior
dislocation

28. Hill Sachs lesion
• Seen in 35-40% of patients with
anterior dislocation
• Is an indentation of the posterolateral
surface of the humeral head
• Best detected by MRI
Bankart lesion
• Injury of the anterior inferior tip of the
glenoid labrum
• Occurs due to traumatic anterior
shoulder dislocation

29. Treatment
Immobilisation of joint with a splint/sling
Analgesia
Emergent management
Closed reduction indicated in
• Inferior dislocation and most anterior dislocation
• Uncomplicated posterior dislocation presenting
early
• Cases with no evidence of major arterial injury or
assosciated injury and fracture
Conservative management

30. Techniques of reduction
Gentle external rotation or outward pressure
on the proximal humerus may aid
reduction
Traction counter trachtion
method

31. Techniques of reduction
Kochers
Maneuver

32. Techniques of reduction
10-15 ib weight suspended
Stimsons Maneuver

33. Techniques of reduction
Pushing inferior tip of the scapula medially
and superior tip laterally
Scapular
manipulation

34. Treatment
indicated in
• Unsuccessful closed reduction
• Concomitant dislocated fracture of humerus,
clavicle or scapula
• Displaced bankart lestion
• Recurrent shoulder dislocations
• To prevent recurrent dislocation in the future
Surgical management
Continious neurovascular monitoring before and after reduction to detect axillary nerve
and artery damage

35. Joint stiffness
Osteoarthritis of
shoulder joint
Rotator cuff injury
complications
Axillary nerve
damage
Axillary artery
damage
Joint instability

36. Humeral fracture
04

37. • Can result from direct or indirect trauma
• Fall with axial loading on an outstretched hand
• Motor vehicle accidents
• Violent seizures
• Direct blow to the back of the humerus
• Pathologic fractures
• Pagets disease
• Metastatic bone disease
Humerus

38. Types of humeral fractures
Proximal Humeral shaft Distal

39. Proximal humerus fracture
• Common in the elderly
• Has four major segments
• Anatomical neck
• Humeral shaft
• The greater tuberosity
• Lesser tuberosity
• Neer classification : based on
displacement of these segments

40. Neer Classification
One part fracture : line involves 1-4 parts but no part displaced
Two part fracture : line involves 2-4 parts and 1 part is displaced
Three part fracture: line involve 3-4 parts and 2 part are displaced
Four part fracture: line involve 4 part 3 part are displaced

42. Humeral shaft fracture
• Classification according to location
- Proximal third
- Middle third
- Distal third
• Classification according to communition
- Type A (No communition)
- Type B (Butterfly fragment)
- Type C (communition present)

43. Distal humerus fracture
• According to anatomical site
- Lateral / medial fractures
- Supracondylar fractures
- transverse and above the epicondyles
- The most common pediatric elbow #
• AO classification
• Type A: extra-articular fracture
• Type B : Partial articular
• Type C: Complete articular

44. Clinical features
Local swelling, deformity, crepitus
Events like radial nerve palsy
Severe local pain
Exacerbated during palpation or movement
Shortening of the arm
Especially in fractures of the middle third(mid shaft)
of humerus

45. Diagnosis
X-ray
• AP and lateral views of the humerus will
show radiographic features of fractures
CT
• if x-ray is not diagnostic
MRI
• If pathologic fracture is suspected
• To evaluate rotator cuff injury

46. Treatment
For non-displaced closed fractures
Hanging arm cast and sling for 1-2 weeks then follow up then brace
Early physical therapy to restore function
Conservative management
Indicated in
• Open fractures
• Displaced fractures that cant be reduced
• Assosciated injuries (nerve & vessles)
• Floating elbow (humerus + forearm)
Surgical management

47. Treatment
Procedures include
• Internal fixation – especially in supracondylar
fracture
• External fixation (Open fractures and polytrauma)
• Arthroplasty of humeral head or elbow (complex
fractures)
- Especially in elderly patients
Surgical management

48. Brachial artery
injury
Nerve injuries
Malunion
complications
Adhesive
capsulitis
Avascular
necrosis of
humeral head
Heterotopic bone
formation

49. Elbow Fracture and
Dislocation
05

50. Anatomy

51. • Elbow fractures include:
• Distal Humerus
• Proximal Ulna
• Proximal Radius

52. Distal Humeral Fractures
• Classified according to anatomical site
• Supracondylar – most common pediatric elbow fracture
• Transcondylar
• Intercondylar
• Condylar
• Epicondylar
• Capitellum
• Trochlear

53. Supracondylar fracture
• Occurs just above the two condyles of the lower humerus
• Commonly seen in Children between the age of 5-10years
• Two types
1. Posterior angulation or
displacement (extension) -
95%
2. Anterior angulation or
displacement (flexion)

54. Clinical features
• Pain and swollen elbow
• S – deformity of elbow
• Dimple sign
• Arm is short

56. Diagnosis
• AP and lateral X-ray of elbow
• Also important to check for adequacy of reduction
• AP view measurements – Baumann’s Angle
• Lateral view measurements and signs
– Fat pad sign (ant &post)
- Anterior humeral line (displaced)

57. • Baumann’s angle:
• Useful to assess the accuracy of distal
fragment reduction
• Line on the longitudinal axis of humeral
shaft and line through the coronal axis of
the capitellar physis
• Normally 90 degrees
• if < 90 – cubitus valgus -
• > 90 cubitus varus -

58. Management
1. Conservative therapy
• Indication: nondisplaced, closed fractures
• Procedures
• Hanging-arm cast or coaptation splint and sling for approx. one to
two weeks with subsequent follow-up x-ray and brace
• Early physical therapy to restore function

59. 2. Surgical treatment
• Indication: open fractures, displaced fractures that cannot be
reduced, associated injuries (nerves, blood vessels), floating
elbow (simultaneous humerus and forearm fracture),
• Procedures
• Internal fixation using plates and screws, or intramedullary
implants (especially supracondylar fractures)
• External fixation (e.g., open fracture, polytrauma)
• Arthroplasty of humeral head or elbow (e.g., in complex
fractures), especially in elderly patients

60. Complications
• Early= Compartment syndrome
Brachial Artery injury
Nerve Injury : Median, Ulnar or Radial
• Late= Stiffness
Volkmann's Ischemic contracture refusal to open hand, pain
with passive extension of fingers, and forearm pain out of
proportion
Mal-Union

62. Radial Head Fractures
• Most common fractures of the elbow
• Mechanism of Injury
• FOOSH with elbow extended and the forearm pronated ( causes impaction of
the radial head against the capitulum
• In children more likely to fracture neck of radius
Clinical Features
• Pain on supination and pronation
• Local tenderness posterolateral to the proximal end

63. Diagnosis
• AP and Lateral x-ray
Complications
• Joint stiffness
• Osteoarthritis
• Recurrent instability (if MCL is injured and radial head excised)

65. • Management
• Adults
• Nondisplaced fractures – supporting the elbow in a collar and cuff
• Displaced – ORIF
• Comminuted – reconstruct the radial head
• Children
• Collar and cuff and exercises commenced after 1 week
• Displacement of >30 degrees – closed reduction
• If fails – open reduction

66. Elbow Dislocation
• Highest incidence in the young 10-20 years and usually sports injuries
• Posterior dislocations most common
• Mechanism of injury – fall on outstretched hand
• CP – Patients typically present guarding the injured extremity
- limited range of motion: inability to flex or extend the elbow
- Usually has gross deformity (Prominent olecranon posteriorly)
and swelling
- Limb length discrepency
- nerve injury (10%), rarely brachial artery

67. Diagnosis
• X-ray of the elbow joint
• AP view and lateral view to confirm dislocation and exclude fracture
• Posterior fat pad sign: seen in patients with
concomitant fractures (usually of the humerus/radial head)

68. Management
• Conservative – closed reduction
• can be done by single person or two people
• Operative – open reduction and stabilization
• Associated fractures

70. • After reduction
• Palpable “clunk” is heard
• Post reduction film
• Move elbow in all directions and assess stability
• Splint in long arm posterior splint

71. Associated Injuries
• Fracture of radial head (5-11%)
• Fracture of coronoid process (5-10%)
• Fracture of medial or lateral epicondyle (12-34%)
• Fracture of olecranon

72. Forearm fractures
06

73. Anatomy

74. Fracture of the Forearm bones
• The radius and ulna are commonly fractured together
• Highest ratio of open to closed
• More common in males than females
• Mechanisms of Injury
• MVA, falls from height, or direct blow
• Clinical features
• Typically present with gross deformity of the forearm with pain, swelling and
loss of function at the hand

75. • Diagnosis
• AP and Lateral view of the forearm with
the entire elbow and joints

76. • Management
• Conservative
• In children, closed treatment is usually succcessful because the
tough periosteum tends to guide and then control
• Full length cast – from axilla to metacarpal shaft
• Operative
• All adults unless the fragments are in close apposition
• Most fractures heal within 8-12 weeks

77. Monteggia’s Fracture-Dislocation
• Fracture of the proximal third of the ulna with dislocation of the
proximal head of radius
• Mechanism of Injury – FOOSH with forced pronaiton
• Clinical Features
• Pain and swelling at the elbow
• Angular deformity of the forearm
• Shortened arm
• Dislocated head of radius maybe masked by swelling

78. • Diagnosis
• AP and Lateral X-ray
• Ulnar fracture may be obvious and distract
from the radial dislocation
• Management
• ORIF with plate and screws
• Radial head usually reduced once the ulna
has been fixed

79. Galeazzi’s Fracture-Dislocation
• Fracture of the distal third of the radial shaft accompanied by a
dislocation of the distal radioulnar joint
• Mechanism of action- FOOSH with
hyperpronated forearm
• Clinical features
• Tenderness over the lower end of ulna
• Management
• ORIF

80. Wrist fractures
07

81. Anatomy

82. Colles’ Fracture
• Most common fracture in Osteoporotic bones (elderly/post-menopausal women)
• Distal radial metaphysis fracture that is dorsally angulated and displaced
proximally and dorsally
• Clinical features
• Dinner fork deformity

85. • Management
• Closed reduction and fixation with cast for 4-6 weeks + early ROM

86. Smith fracture/ Reverse Colles
• Fracture of the distal radius with ventral displacement
• Clinical features
• Garden spade deformity
• Diagnosis
• PA and lateral film of the wrist

89. Scaphoid Fracture
• Most common carpal bone fractured.
• Pain along the radial aspect of the wrist
• Pain with active movement of the thumb
• Snuffbox tenderness

90. Diagnosis
• X-ray: standard and scaphoid view

91. Management
• Analgesia
• Immobilize with long arm thumb spica splint
• Surgical

93. References
• Tintinalli’s emergency medicine: a comprehensive study guide, 9th
edition
• Amboss guide to clinical science and skills

94. ANY QUESTIONS?