Upper Limb Fractures

Elbow Fractures

Elbow Fracture occurs from a break in one or more of the bones of the elbow joint.Three bones—humerus, radius, and ulna—make up the elbow joint. The bones are held together by ligaments thus providing stability to the joint. Muscles and tendons around the bones coordinate the movements and help in performing various activities.

Causes

Elbow fractures may occur from trauma resulting from a variety of reasons, some of them being a fall on an outstretched arm, a direct blow to the elbow, or an abnormal twist to the joint beyond its functional limit.

Types

The types of elbow fractures include:

  • Radial head and neck fractures: Fractures in the head portion of the radius bone are referred to as radial head and neck fractures. In these fractures pain gets worsened with the movement of the forearm. Fractures that are not displaced do not require surgery and are treated by early motion. However, surgery is indicated if it is a displaced fracture to repair and align the fragments. In severe cases the radial head is either removed or replaced.
  • Olecranon fractures: These are fractures occurring at bony prominence of the ulna.  The fractures, if stable, are treated using an immobilizing splint followed by a regimen of motion exercises. However severe fractures require surgical repair.
  • Distal humerus fractures: These fractures are common in children and elderly people. Nerves and arteries in the joint may sometimes be injured in these fractures. Surgery is usually required for displaced fractures and fractures compounded by nerve and/or artery injuries.

Symptoms

Symptoms of an elbow fracture include pain, swelling, bruising, stiffness in and around the elbow, a popping or cracking sound, and deformity of the elbow bones.

Diagnosis

To diagnose elbow fractures X-rays of the joint are taken. In some cases, a CT scan may be needed to get to know the details of the joint surface.

Conservative Treatment Options

The aim of the treatment is to maximize early motion to reduce the risk of stiffness. Nonsurgical treatment options include use of a splint or a sling to immobilize the elbow during the healing process.

Surgery

Surgery is indicated in displaced and open fractures to realign the bones and stabilize the joint as well as to avoid deep infections. Strengthening exercises, scar massage, therapy with ultrasound, heat, and ice are recommended to improve the range of motion. Splints are also used to facilitate stretching of the joint.

 

Shoulder Fracture

A fracture is a break in the bone that commonly occurs as a result of injury, such as a fall or a direct blow to the shoulder. Shoulder joint is the most flexible joint of the body. It allows different motions of the hands making it possible for us to do a vast array of different activities. However its flexibility makes it more prone to injuries. The type of shoulder fracture depends of the age of the patients. Clavicle fractures are more common in children. A fracture of the upper part of the arm (proximal humerus) is more common in elderly individuals and its frequency increases with age.

Clavicle fractures

A clavicle fracture, also called broken collarbone is a common fracture that happens to people of all ages. The collarbone, also called the clavicle, is the bone that connects your sternum or breastbone to your shoulder.

Causes

A broken collarbone normally occurs after a fall onto the shoulder or a motor vehicle accident. The most common sports associated with clavicle fractures include football, hockey, and skiing.

Symptoms

A broken collarbone most often causes pain, swelling and bruising over the collarbone.  Pain increases with shoulder movement. Your shoulder may be slumped downward and forward. You may also have a bump around the area of the break. You may hear a grinding sound when you try to raise your arm.

Diagnosis

To diagnose a broken collarbone, your doctor will take a brief history, about the injury, and perform a physical examination of your shoulder. An X-ray of the clavicle is taken to identify the location of the fracture. Your doctor may also recommend a computerized tomography (CT) scan in some cases.

Conservative Treatment Options

Most broken collarbones heal without a surgery. An arm sling may support the arm and hold the bones in their normal position. You may also be given pain medications to relieve the pain.  After your pain reduces your doctor may recommend gentle shoulder and elbow exercises to minimize stiffness and weakness in your shoulder. Follow up with your doctor until your fracture heals.

Surgery

Surgery may be required in case of displaced fractures. Surgery is performed to re-align the fractured ends and stabilize them during healing. Surgery often involves use of pins or plates and screws to maintain proper position of the bone during healing.

Proximal Humerus Fractures

Humerus is the upper arm bone and it forms two joints – shoulder joint and elbow joint. The proximal humerus refers to the upper end of the arm bone, which forms shoulder joint.

Causes

Fractures of proximal humerus are common in elderly individuals, suffering from osteoporosis. Fractures may be caused by traumatic injuries such as a fall on outstretched hand, from greater heights or motor vehicle accidents. In younger individuals a severe trauma can cause these fractures.

Proximal humerus fractures can be categorized into 4 groups:

  • Greater tuberosity fractures: Greater tuberosity is the insertion site for attachment of rotator cuff tendons. Greater tuberosity fractures are less common and are seen in cases of shoulder dislocations and in those with osteoporosis
  • Lesser tuberosity fractures: These fractures often caused by posterior shoulder dislocations or traumatic muscle contractions by electrical shock or convulsions. If left untreated, these fractures cause subscapularis muscle (stabilizer and mobilizer muscle) deficiency and requires a major muscle transfer procedure
  • Surgical neck fractures: Fractures of the surgical neck are most common in patients with osteoporotic bone. These fractures also damage the axillary nerve that carries sensory impulses to the shoulder
  • Humeral head fractures: Humeral head fractures are very often in elderly individuals and chances are more in those with osteoporotic bone. These fractures occur in younger individuals by significant trauma whereas a mild traumatic injury can cause fracture in elderly individuals with osteoporosis

In addition to above, another type of proximal humerus fractures is two, three, and four part fractures, a fracture that cause multiple fragmentation of the proximal humerus.

Symptoms

Patients with proximal humerus fracture experience severe pain, swelling, and restricted motion of the shoulder.

Diagnosis

Proximal humerus fracture is diagnosed by physical examination, X-ray of the affected area and/or computerized tomography (CT) scan.

Conservative Treatment Options

Most proximal humerus fractures are minimally displaced and can be treated with conservative approaches such as use of sling to immobilize and early physical therapy to improve the functional outcome.

Surgery

Surgery may be necessary in displaced fractures. The multiple fragments are fixed with plates, screws, or pins and in severe cases a shoulder replacement surgery is performed.

Scapula Fracture

Scapular fractures are uncommon but do occur and require a large amount of force to fracture. They are usually the result of intense trauma, such as a high speed motor vehicle accident or a fall from height onto one’s back. They can also occur from a fall on an outstretched arm if the humeral head impacts on the glenoid cavity.

Symptoms

Symptoms of a scapular fracture can include the following:

  • Pain: Usually severe and immediate following injury to the scapula
  • Swelling: The scapular area quickly swells following the injury
  • Bruising: Bruising occurs soon after injury
  • Impaired Mobility: Decreased range of motion of the joint occurs, often with inability to straighten the arm
  • Numbness: Numbness, tingling, or coldness of the hand and forearm can occur if blood supply is impaired or nerves are injured
  • Popping Sound: A cracking or popping sound, also referred to as crepitus, can often be heard or felt at the time of the fracture

Diagnosis

Scapular Fractures should be evaluated by an Orthopaedic surgeon for proper diagnosis and treatment.

Conservative Treatment Options

Most scapular fractures are not significantly displaced due to the strong supporting soft tissue structures surrounding it. Therefore, a majority of scapular fractures are treated conservatively and with early motion to reduce the risk of stiffness and will usually heal without affecting shoulder movement. The conservative treatment options include:

  • Immobilization: A sling is used for comfort and to support the shoulder to allow healing to take place. This is usually worn about 3-6 weeks depending on the type of fracture and
  • Prescription Medications: Pain medications will be prescribed for your comfort during the healing process
  • Physical Therapy: Early progressive range of motion exercises is essential in restoring full shoulder function. Your physician will most likely refer you to a Physical Therapist for instruction on proper exercises and early motion of the shoulder to prevent complications

Surgery

Fractures of the scapula involving the neck or glenoid or with severe displacement have been associated with poor outcomes when treated non-operatively. Scapula fracture repair can be performed through a minimally invasive approach. Minimally invasive ORIF (open reduction internal fixation) surgery uses smaller incisions than a traditional “open” surgery. Minimally invasive incisions are limited to where surgical plates will be placed instead of a traditional incision which can be large. The benefits of minimally invasive surgery include smaller incisions, faster healing, a more rapid recovery, and less scarring.

 

Wrist Fracture

The wrist is comprised of two bones in the forearm (the radius and the ulna) and eight other tiny bones. The bones meet to form multiple large and small joints. Awrist fracture refers to a break in one or more bones in the wrist. Wrist fracture can be caused due to a fall on the outstretched arm or an injury due to accidents such as a car accident or workplace injuries. A wrist fracture is more common in people with osteoporosis, a condition marked by brittleness of the bones.

Common symptoms of a wrist fracture include pain, swelling, and deformity at the wrist site, as well as movement constraint in hand and wrist. More commonly, fracture in radius is seen in many fractures exhibiting deformity of the wrist. Deformity may not be apparent in the case of fractures of the smaller bones such as the scaphoid.

Wrist fractures are simple if the pieces of the fractured bone are well aligned and stable; and unstable if the broken bone fragments are misaligned and cause wrist deformity. Some fractures result in breaking of the joint surface and some don’t. Open (compound) fracture is one in which the broken bone can be seen through the skin. In such a fracture the risk of infection is higher. Misalignment of the bone fragments in a healed fracture might permanently limit motion, cause pain, or arthritis.

Your doctor will perform a preliminary examination followed by an X-ray of the wrist to diagnose a fracture and the state of alignment of the bones. Sometimes a CT scan may be used to gather more details of the fracture and the associated injuries. Injuries to ligaments (the structures that hold the bones together), tendons, muscles, and nerves may also occur when the wrist is broken. In such cases these injuries also need to be treated concurrently.

Factors such as age, activity level, hand dominance, previous injuries, and arthritis of the wrist besides other medical conditions, and possible predisposing causes in hobbies and occupation of the patient are considered before treating a wrist fracture. Fractures that are not displaced are treated with either a splint or a cast to hold the wrist in place. For displaced fractures surgery may be needed to properly set the bone and hold it in place, sometimes using external devices, with pins, screws, rods, or plates. These implants are placed deep inside through an incision on the lower or upper side of the wrist.

If the wrist fracture is treated externally, pins are fixed above and below the fracture site and these pins are held in place by an external frame outside the body. This keeps the bone stable until healing occurs.
Sometimes, if the bone is crushed or missing, surgical treatment such as bone grafting may be required. Bone grafting involves taking the bone from another part of the body or a bone bank or using a bone graft substitute to treat the fracture.

During the period of healing, fingers and shoulder are allowed to remain flexible unless there are other injuries that require their immobilization. When the fracture heals and the limb is stable, you may be asked to do some motion exercises to keep the wrist flexible. In many cases, hand therapy may be indicated to restore flexibility, function, and strength. There is no standard wrist fracture recovery time. While some fractures take a few weeks, some others may take several months to heal.