Upper Limb Fractures
Bassem Haddad, MD
General Principles
• Upper limb fractures heal faster than lower limb fractures due to the
richer vascularity of the upper limb.
• In the mature skeleton the healing time is around 6 weeks, while in
the immature skeleton it is around 3 weeks.
• Extra-articular fractures require only functional reduction and
relatively stable fixation.
• Intra-articular fractures require anatomical reduction and an
absolutely stable fixation to prevent complications as secondary
ostroarthrosis and joint stiffness.
General Principles
• Most upper limb fractures result from falling down on an
outstretched hand (FOOSH).
• This will cause either a bending force resulting in an oblique fracture,
a twisting force resulting in a spiral fracture, or a direct force (hitting
an object) resulting in a transverse fracture.
• Transverse fractures result from the highest energy injuries causing
more soft tissue damage, thus requiring a longer time to heal
opposed to oblique or spiral fractures.
• When interpreting the displacement pattern of the fracture, think of
muscle pull, the direction of the causative injury, and gravity.
Clavicle Fractures
• Divided into 3 thirds.
• Most fractures occur in the middle third with the proximal piece
pointed cranially due to the pull of the sternocleidomastoid muscle
and the distal piece pulled caudally by the weight of the arm.
• Lateral third fractures are usually unstable as they involve
ligamentous injuries.
• Management:
ØConservative (sling or figure of eight brace) for middle third fractures.
ØOperative fixation for lateral third fractures.
Clavicle Fractures
• Middle third clavicle
fracture.
• Note the pattern
of displacement.
Proximal Humerus Fractures
1. Head of humerus.
2. Lesser tuberosity with subscapularis
tendon.
3. Greater tuberosity with supra- and
infraspinatus tendons.
4. Shaft of the humerus.
5. The line between piece 1 and the rest
is the anatomical neck.
6. The line between piece 4 and the rest
is the surgical neck.
Proximal Humerus Fractures
• Anatomical neck fractures have a high risk of avascular necrosis of the
head of humerus.
• Greater tuberosity fractures are avulsion fractures (by pull of the
supra- and infraspinatus) and can be associated with shoulder
dislocations.
• Surgical neck fractures are the most frequent and are considered
fragility fractures (along with hip fractures, vertebral compression
fractures, and distal radius fractures).
• The axillary nerve is in close proximity and should be assessed during
the physical examination.
Proximal Humerus Fractures
Treatment ranges from
conservative (arm sling) to
operative (fixation or
replacement) depending on
fracture comminution and
bone quality.
Humeral Shaft Fractures
• The patient presents with arm pain after trauma (either direct or
indirect).
• Physical exam shows one or more of swelling, bruising, deformity, or
wounds.
• The radial nerve should be assessed as it lies in close proximity to the
distal half of the humeral shaft.
• If injured the patient would have wrist drop and decreased sensation
in the dorsal aspect of the first web space.
Humeral Shaft Fractures
Humeral Shaft Fractures
• Notice in the previous slide the following:
• The first x-ray in the AP view there is medial translation of the distal
piece with varus angulation (due to deltoid pull of the proximal
piece). The lateral view shows posterior translation and posterior
angulation of the fracture.
• The second x-ray (after 6 weeks) shows callus formation.
• The last x-ray (after 3 months) shows consolidation of the callus.
• This is an example of secondary (indirect) bone healing.
Humeral Shaft Fractures
• This is a similar fracture,
it was treated by open
reduction and internal
fixation by a compression
plate.
• This x-ray was taken 3
months after surgery.
• Notice the absence of
callus, indicating that the
fracture healed by
primary (direct) healing.
Olecranon Fractures
• These are intra-articular fractures, so the treatment of choice is
anatomical reduction (to avoid osteoarthrosis) and absolutely stable
fixation (to allow early movement thus preventing stiffness).
• The mechanism is usually an avulsion injury due to forceful pull of the
triceps, that is why a fracture gap is usually seen.
• The next slide shows an olecranon fracture treated by tension band
wiring which is a method of absolute stability.
Olecranon Fractures
Forearm Fractures
• The radius and ulna act functionally as a joint as they pronate and
supinate (the radius rotates around the ulna).
• As these fractures form one functional unit, a fracture in one bone
usually is associated with an injury to the other bone (fracture or
dislocation). However, isolated single bone injuries can occur.
• Considering the pronation/supination movement along these bones,
they are treated by anatomical reduction and absolutely stable
fixation (like intra-articular fractures).
• This does not apply to children as they have a high remodeling
capacity.
Forearm Fractures
Monteggia Fracture Dislocation
1. Fracture of the proximal half of the ulna.
2. Dislocation of the proximal radius.
3. Possible injury to the radial nerve as is turns
around the radial neck.
If present this would result in finger drop at the MCP
joints but not wrist drop as the nerve supply to the
extensor carpi radialis longus already originated at a
point proximal to the injury site.
Galeazzi Fracture Dislocation
1. Fracture of the distal half of the
radius.
2. Dislocation of the distal ulna.
3. Possible injury to the ulnar nerve.
If present, this would result in
weakness of finger
abduction/adduction, and positive
Froment’s sign.
Isolated Ulna Fracture
• Also called nightstick injury.
• Results from a direct trauma to
the ulna (you can sea the
transverse fracture pattern).
• The radius is intact.
• Has a risk of non-union, so
surgical fixation is considered if
conservative management fails.
Colles’ Fracture
• A distal radius extra-articular
fracture.
• Occurs in the elderly after a
simple trauma (fragility
fracture).
• Dorsally displaced (see the
lateral view on the x-ray).
• Presents with wrist swelling
called dinner fork deformity.
• Treatment usually closed
reduction and casting for 6
weeks.
Smith’s Fracture
• Also called reverse Colles’
as it has the same
features but with volar
angulation.
• Caused by falling down
with the wrist in flexion
(in Colles’ the wrist is in
extension.
• Treatment is closed
reduction and casting for
6 weeks.
Barton’s Fracture
• Intra-articular fracture.
• Best seen on the lateral
view.
• Resembles a triangle
(articular surface, fracture,
cortex).
• Treatment is anatomical
reduction and fixation.
• Can be volar or dorsal.
Radial Styloid fracture
• Also called chauffeur fracture.
• Caused by sudden forceful
radial deviation of the wrist.
• Intra-articular fracture.
• Treatment is anatomical
reduction and fixation.
