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Upper Limb Injuries


Proximal Humerus

Summary

Commonly in the elderly and their incidence is increasing.1, 2 Commonly non-displaced and often managed non-operatively using immobilisation methods.3 Immobilisation is achieved using either a sling, shoulder immobiliser or a splint, sling and swathe. Gentle range-of-motion exercises can begin after 7-10 days in most stable fractures depending upon pain and tolerance. Physical therapies may be initiated after 3 weeks, making sure that no aggressive range-of-motion exercises, whether passive or actively assisted occurs until bony union has occurred.4 With regards to unstable fractures, surgical stabilisation may be required to achieve stability and pain relief, however this is not without its own risks.3

Classification

A “one-part” fracture is one in which the fragment is not displaced at all, or is displaced 45 degrees. Neer additionally defined two, three and four-part fractures to indicate the number of main segments affected by displacement see figure below.

Neer’s classification system

Source: Wikiradiography - Neck of Humerus Fractures

Epidemiology

The majority of proximal humeral fractures occur in the elderly with ~70% occurring in women, presumably due to the greater incidence of osteoporosis.1 Most of these occur at home due to a fall, and in most cases they are an isolated injury.1,3

  • One-part fracture: These undisplaced/minimally displaced fractures account for over 70% of all proximal humeral fractures and are almost always treated conservatively.
  • Two-part fracture: Frequently seen in the setting of anterior shoulder dislocation.7 These fractures account for approximately 20% of proximal humeral fractures.8
  • Three-part fracture: These fractures account for approximately 5% of proximal humeral fractures.8
  • Four-part fracture: These fractures are uncommon.8 However, this pattern has poor non-operative results, and as the articular surface is no longer attached to any parts of the humerus which are attached to soft tissues, it has a high incidence of osteonecrosis.9

Presentation

There is usually marked swelling, pain, tenderness and bruising of the proximal portion of the arm, due to bleeding from the bone and soft tissues.

Imaging

Standard imaging studies of proximal humeral fractures consist of true anterior-posterior, outlet and axillary view. Additional CT imaging is recommended if fracture lines cannot be reliably detected, as seen in complex three and four-part fractures with multiple-fragmented involvement of the head and tuberosities.10 However, while CT imaging improves the reliability of fracture classification over radiographs alone, however there is no evidence that CT improves outcome.3

ED Management Options

For the majority of one-part fractures, these can be managed conservatively: analgesia, sling/sling and swathe and range of motion exercises.

Surgical intervention is generally needed for significantly displaced multi-part fractures and thus all displaced fractures should be referred to an orthopaedic surgeon for evaluation.11 Further indications for referral include fracture-dislocations and joint instability.12 Urgent orthopaedic referral is indicated for all nerve and vascular injuries, open fractures, and fracture dislocations.

Referral and Follow Up Requirements

Fracture Type

Management

Follow-up

One-part fracture

  • Analgesia
  • Sling or sling, splint and swathe13
  • Functional assessment:
    • Mobility
    • Personal care
  • Minimal trauma fracture in patients >50 years, arrange bone health assessment (i.e. bone density assessment)
  • Refer to falls clinic
  • Refer to physiotherapy consult

One-part fractures are almost always treated conservatively8,9

Orthopaedic outpatient follow-up in 3-4 days13

Two three and four-part fracture

  • Analgesia
  • Sling or sling, splint and swathe13
  • Orthopaedic consult in ED

Orthopaedic outpatient follow-up

Fracture dislocations

  • Analgesia
  • Secure in position of most comfort for the patient
  • Assess limb neurovascular status
  • Orthopaedic consult in ED

Orthopaedic outpatient follow-up

Potential Complications

Loss of shoulder mobility is among the more common complications of proximal humerus fractures. The decrease in motion ranges from clinically insignificant to adhesive capsulitis (i.e. frozen shoulder), in which shoulder movement is painful and limited in all orientations. The risk of developing diminished range of motion is more likely to occur in patients who do not perform range of motion exercises during recovery.

Although osteonecrosis of the humeral head is not common (7.9%), it can occur in patients with complex two, three and four-part fractures, especially in fractures involving the anatomic neck or severely displaced fractures. Other complications include nonunion and impingement from avulsed fracture fragments.14

Patient Advice

  • Sling required for 2-4 weeks depending on the patient and fracture. Usually should start gradual mobilisation at 2 weeks.
  • Pain from the fracture and restriction of movement is usual for 2-3 weeks and will require regular, then analgesia as required. See .
  • Refer to physio for advice and starting of mobilisation.
  • ECI patient factsheets

Further References and Resources

  1. Court-Brown, C. and Caesar, B., Epidemiology of adult fractures: a review, Injury, 2006, 37(8): p.691-697.
  2. Court-Brown, C. and Garg, A., The epidemiology of proximal humeral fractures, Acta Orthop Scand, 2001, 72(4): p.365-371.
  3. Doornberg, J. and Ring, D., Proximal Humerus Fractures, in Evidence-based orthopedics, Bhandari, M., Editor, 2012, BMJ Books, London, UK.
  4. McRae, R. and Esser, M., Practical Fracture Treatment, 5th Edition, 2008, Sydney, Churchill Livingston.
  5. Court-Brown, C. et al., Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment, Journal of Bone and Joint Surgery, 2002, 84(4): p.504-508.
  6. Murray, I. et al., Proximal Humeral fractures: current concepts in classification, treatment and outcomes, Journal of Bone and Joint Surgery, 2011, 93(1): p.1-11.
  7. Zuckerman, J. and Koval, K, Shoulder fractures: the practical guide to management, 2005, Thieme.
  8. Zhang, Y., Clinical epidemiology of orthopedic trauma, 2012: Thieme.
  9. Iannotti, J. and Williams, G., Disorders of the shoulder, diagnosis and management, 2007, Philadelphia: Lippincott Williams & Wilkins.
  10. Maier, D. et al., Proximal humeral fracture treatment in adults, The Journal of Bone and Joint Surgery, 2014, 4(96): p.251-261.
  11. Basset, R. Proximal humeral fractures in adults, 2014, cited 2015 March
  12. Kristiansen, B., et al. Functional results following fractures of the proximal humerus: a controlled clinical study comparing two periods of immobilization, Archives of Orthopedic Trauma Surgery, 1989, 108(6).
  13. Stone, C. and Humphries, R., Current diagnosis and treatment: emergency medicine, 2011: McGraw-Hill.
  14. Hanson, B. et al., Functional outcomes after non-operative management of fractures of the proximal humerus, Journal of Shoulder and Elbow Surgery, 2009, 18(4).

Clavicle

Summary

Fracture Type

Management

Follow up

Medial Third

Least common (5%), can be serious fractures.

Anterior or no displacement

(Always check medial third #s with senior ED/ortho)

GP or ortho clinic follow up in 1 week with repeat xray

Posterior displacement - Potential major vessel and airway compromise, manage initially as “trauma call” consult urgently

As per ortho

Middle Third

Most common (80%)

Non displaced - Broad arm sling for 2 days and then collar and cuff for comfort.

GP or ortho clinic follow up in 1 week with repeat xray

Displaced - Depending on degree, patient factors and surgeon availability - elective surgery more common now in active patients. Always refer where skin tenting.

As per ortho

Distal Third

10-15%

Can be complex and there is a 5 part classification link. Most common fracture for non-union, complex anatomy and requires ortho assessment in ED at time of presentation, or early follow up.

Ortho assessment in ED at time of presentation, or early follow-up arranged with orthopaedics

Source: Orthobullets - clavical fractures

Classification

By thirds.

Fractures of the clavicle can be classified by its anatomical location (as shown in the table below):

Source: The Royal Children’s Hospital, Melbourne

Classification of clavicle fractures by location.

Location

Frequency

Description

Lateral third

15%

Around and lateral to coracoclavicular ligaments

Middle third or midshaft

80%

Defined by shortening/comminution/angulation

Medial third

5%

  • Bony injury alone
  • Associated with sternoclavicular dislocation (may be a physeal sleeve separation)

Source: The Royal Children’s Hospital, Melbourne - Clavicle Fracture Clinical Guide

Epidemiology

Common presentation to the ED usually following direct blow to the lateral aspect of the shoulder of forces through the out-stretched arm, commonly from falling off bicycle, but also contact sports and skiing.

Can be associated with other serious injury depending on mechanism.

Presentation

After trauma with pain swelling and deformity, ranging from subtle to very obvious. If not in a sling the patient usually elects to hold the arm supported and close to the chest or sometimes hanging by the side. On examination deformity and tenting of the skin may be seen. Medial fractures may be associated with great vessel and airway compromise and are managed as per trauma protocols and systems when suspected.

Imaging

  • Radiographs
    • standard AP view
    • 45° cephalic tilt determine superior/inferior displacement
    • 45° caudal tilt determines AP displacement
  • CT
    • may help evaluate displacement, shortening, comminution, articular extension, and non union
    • useful for medial physeal fractures and sternoclavicular injuries

ED Management Options

The majority of clavicle fractures (middle third) can be managed with analgesia and initially a Broad Arm Sling (BAS) which can be changed to a collar and cuff after 24-48hrs. Even quite displaced fractures can be managed conservatively. There is a trend, particularly in athletes, to get fixation of the middle third fractures for more rapid return to sport or work. This can be managed as an outpatient between the patient their GP and orthopaedic doctor but should be discussed in the ED as a potential option.

Urgent referral/assessment by orthopaedics/senior ED should be sort for all fractures where there is neurovascular injury, significant tenting of skin, open fracture and for all medial and lateral third fractures with any displacement.

Special support such as figure 8 bandage is no longer used for clavicle fractures.

Referral and Follow Up Requirements

Fracture Type

Urgency

Follow-up

Medial Third

Immediate senior input for posteriorly displaced fractures.

If isolated non displaced fracture, review # clinic within week

If suspicion ask for help immediately

All other fractures managed through orthopaedic consultation

Middle Third

Non displaced isolated fractures can be managed by JMO/NP/physio as per their scope.

GP follow up 1 week

Distal Third

Non displaced fractures

# clinic within the week

Displaced fractures

Ortho assessment in ED at time of presentation, or early follow-up arranged with orthopaedics

Potential Complications

  • Non-union: depending on the fracture area and displacement, overall 1-5% but the majority from the lateral third fractures.
  • Cosmetic deformity, discuss with relevant patients.
  • If ORIF risk of infection and will need plate removal.

Patient Advice

  • Sling required for 2-4 weeks depending on the patient and fracture. Usually should start gradual mobilisation at 2 weeks.
  • Pain from the fracture and restriction of movement is usual for 2-3 weeks and will require regular, then prn analgesia.
  • Refer to physio for advice and starting of mobiliation.
  • Return to sport will depend on the sport.
    • Full contact sport >10-12 weeks
    • Non-contact sport as per pain 3-6 weeks, but increased risk of re-fracture
  • ECI patient factsheets

Further References and Resources

Elbow Dislocation

Summary

The elbow dislocation is common coming second to the shoulder. They generally occur in the younger patient involving complex mechanisms. There is invariably disruption of the capsule and ligament stabilisers.

Classification

By position of the olecranon: Posterolateral by far the most common.

Simple: No associated fracture (50%).

Complex: Associated fractures (50%) - radial head and coronoid.

Epidemiology

Predominantly 10-20 years of age, more likely related to mechanism, e.g. ski jumping, skateboarding, complex tackles in sport.

Presentation

Likely mechanism, obvious deformity and pain.

Examination should be done before and after reduction for:

  • skin integrity,
  • neurovascular assessment including radial pulse, capillary return to finger tips, and radial, median and ulnar nerve power/sensation in the hand. (particular risk of ulnar nerve and brachial artery injury),
  • assessment for forearm compartment syndrome.

Imaging

Plain X-rays: AP and lateral.

CT scan: Complex dislocations with fractures.

ED Management Options

Simple stable dislocations: Reduction and splinting 90 degrees for 7-10 days then mobilise under supervision. Alternative is hinged brace for 2-3 weeks.1

All other complex or unstable dislocation early referral ortho. Unstable may be evident during the reduction process and not remain reduced, if in doubt refer.

Immediate referral ortho/senior ED for skin integrity concerns, neurovascular issues or suspicion of compartment syndrome. Clear documentation of findings and urgent reduction may be indicated.

Referral and Follow Up Requirements

Simple: POP splint or hinged brace and review ortho 1 week.

All other: refer to ortho opinion in ED.

Neurovascular, skin or compartment compromise immediate referral and action senior ED and ortho.

Potential Complications

Immediate: Ulnar and Medial nerves, brachial artery injury, compartment syndrome.

Medium Term: Varus posteromedial instability, loss of ROM.

Long term: contracture and stiffness, chronic instability, articular surface damage.

Patient Advice

  • Pain from the fracture and restriction of movement is usual for 2-3 weeks and will require regular, then analgesia as required.
  • ECI patient factsheets

Further References and Resources


Olecranon

Summary

Painful and distressing injury often involving high speed or energy mechanisms or direct trauma in the young and low energy falls in the elderly. Non displaced fractures may be managed conservatively, there is risk to the ulnar nerve and in general consultation with orthopaedic partners is required. The injury is rare in children.

Classification

There are several classifications but from an ED point of view the Mayo classification suits our purposes of determining urgency requirements for othopaedic input.

Epidemiology

In the young adult as part of direct trauma or indirect large forces and in the elderly as a result of a fall and reduced bone stock. A common fracture in adults to the exposed nature of the elbow but uncommon in children due to the relative strengths of surrounding bone which breaks preferentially.

Presentation

Patients present with a likely mechanism and obvious pain and deformity. May be an isolated injury or part of poly-trauma from a mechanism such as an MVA. Isolated olecranon injuries occur commonly. Neurovascular examination must be done and a bony step may be palpated but rarely needed to drive you to the next step of imaging.

Imaging

Plain X-rays: AP and true lateral usually sufficient for management.

CT may be required in complex comminuted fractures.

ED Management Options

Type I fractures need POP long arm slab immobilisation at 45-90 degrees and review with repeat X-ray at one week in fracture clinic. Aim for beginning of mobilisation at 3-4 weeks. Neurovascular documentation essential.

All other (Type II and III fractures) require orthopaedic input and surgical planning. Long arm slab for comfort and documentation of neurovascular state.

Referral and Follow Up Requirements

At one week for Type I and same day for all other fractures.

Potential Complications

Ulnar nerve injury, other missed fractures which require intervention.

Patient Advice

  • Pain from the fracture and restriction of movement is usual for 2-3 weeks and will require regular, then analgesia as required.
  • Refer to physio for advice and starting of mobilisation
  • Monitor for compartment syndrome
  • ECI patient factsheets

Further References and Resources

Radial Head and Neck

Summary

Fracture Type

Management

Follow-up

Type 1 – un-displaced

Sling, RICE, Analgesia

GP within 1 week

Type 2 – displaced >2mm

Sling or Above Elbow Backslab

RICE

Analgesia

Refer to the nearest orthopaedic on call service. Requires reduction (closed or open)

Type 3 – comminuted

Sling or Above Elbow Backslab

RICE

Analgesia

Refer to the nearest orthopaedic on call service. Requires reduction (closed or open)

Type 4 – associated elbow dislocation

Sling or Above Elbow Backslab

RICE

Analgesia

Refer to the nearest orthopaedic on call service. Requires reduction (closed or open)

RICE: Rest, Ice, Compression, and Elevation.

Classification

Fractures of the proximal radius can be classified according to:

  • anatomical location: radial neck (extrarticular) or radial head (intrarticular).
  • degree of displacement.
  • presence of other injuries of the elbow/forearm (ligamentous and/or bony).
  • presence of elbow joint dislocation/relocation.

It is important to distinguish between these as the treatment and outcome can vary significantly.

The Mason classification is as follows:

  • Mason Type I – Nondisplaced fractures (displacement ≤2mm)
  • Mason Type II – Displaced fractures >2mm
  • Mason Type III – Comminuted fractures
  • Mason Type IV – Radial head fracture with associated elbow dislocation.

Epidemiology

Radial head and neck fractures are common and are present in about 30% of all elbow fractures.1,2 They represent between 1.7-5.4% of all fractures in adults.3 On average, fractures in men occur seven years earlier than in women.5 Radial head fractures occur throughout adulthood; the mean age at the time of injury is approximately 45 years. Fractures of the radial neck occur most often in children and are much less common in adults.1

Presentation

The most common mechanism for radial head and neck fractures is a fall onto an outstretched hand leading to axial impaction of the radius on the capitellum.1

Injuries suffered as a result of sports and falls from a height often entail more severe fracture patterns. Fractures can also occur due to direct trauma or from a radial head dislocation in association with a Monteggia fracture (ulnar fracture with radial head fracture) or elbow dislocation.1

Associated injuries (fractures, dislocations, and soft tissue injuries) are common with more severe fractures (Mason type 2, 3, and 4).

Imaging

Anterior and lateral views required.

If unclear, diagnosis may be aided by the presence of a posterior fat pad, or an abnormally large anterior fat pad.

ED Management Options

Mason Type 1

Nondisplaced (Mason Type I) radial head fractures with full motion can be treated with a sling for comfort for 24-48 hours.1 A posterior splint (above elbow backslab) may be applied in the acute setting but should not be used for more than a day or two.2 Range of motion exercises should be started as early as possible. Ice is applied during the first 24 hours. Paracetamol or nonsteroidal antiinflammatory drugs (NSAIDs) are generally adequate for acute pain control; opioids are usually unnecessary.

Range of motion exercises consist primarily of extension and flexion of the elbow with the emphasis on fully straightening and flexing the joint. Additionally, the patient performs pronation and supination with their arm at their side and their elbow held at 90 degrees. In this position, the patient simply rotates the forearm so the palm faces up and then down.

Mason Type 2 and 3

Place the patient in a sling or posterior splint (above elbow backslab) for comfort, ice, analgesics, and orthopedic referral within several days for further care. The treatment of Mason Type II radial head fractures remains controversial and should be determined by an orthopaedic surgeon.

The majority of Mason Types III and IV radial head fractures require operative intervention, often with radial head resection and prosthetic replacement.

Referral and Follow Up Requirements

Fracture Type

Urgency

Follow-up

Mason Type 1

Non urgent

GP within 1 week

Mason Type 2-3

Semi Urgent

Orthopaedic Surgeon 48 hours

Mason Type 4

Urgent

Immediate Orthopaedic Review

Potential Complications

The most common complication from radial head and neck fractures is decreased elbow range of motion, particularly loss of full extension. Early, active range of motion exercise is the most important factor in mitigating this complication.1

Elbow instability is infrequent but can occur with concomitant injuries to the lateral or medial collateral ligaments or the coronoid process. These inevitably require reconstruction, and specialised orthopaedic care should be sought.

Patients reporting continued pain at the elbow may have occult soft tissue injuries, a capitellar fracture, or an osteochondral lesion. Traumatic osteoarthritis is another cause of elbow pain following fracture of the radial head; the likelihood of osteoarthritis increases with the severity of the fracture.

Associated hand, wrist, and shoulder injuries can also occur with elbow injuries.

Patient Advice

Non displaced fractures, conservative management:

  • For comfort keep in a sling for 1-2 days. Then start mobilising your elbow by bending it up and down as much as you can several times a day.
  • Also with your elbow by your side and bent at 90 degrees rotate your hand facing up and down.
  • Do these exercises in conjunction with a physio or your doctor for best results and they should be done within the limits of acceptable pain.
  • ECI patient factsheets

Further References and Resources

  1. Royal Children's Hospital Melbourne - Radial Neck Fractures Clinical Guidelines for the Emergency Department (accessed 6/3/15)
  2. Radial head and neck fractures in adults (internet). UpToDate, 2015 (cited 6/3/15)
  3. Conn, J., and Wade, PA. Injuries of the elbow. A ten-year review, J Trauma, 1961, 1:248.
  4. Mason, ML Some observations on fractures of the head of the radius with a review of one hundred cases, Br J Surg 1954; 42:123
  5. van Riet, RP, et al., Associated injuries complicating radial head fractures - a demographic study, Clin Orthop Relat Res 2005; 441:351.

Radius and Ulna Shaft

Summary

  • OTA classification
  • radial and ulna diaphyseal fractures (see below)
    • Type A
    simple fracture of ulna (A1), radius (A2), or both bones (A3)
    • Type B
    wedge fracture of ulna (B1), radius (B2), or both bones (B3)
    • Type C

Classification

Epidemiology

  • 1 to 10 per 10,000 persons per year
  • Bimodal distribution:
    • Highest incidence among young males aged 10-20 years (10:10,000)
    • Females over 60 years (5:10,000)
  • Far less common than distal radius fractures
  • Midshaft forearm fractures commonly occur in association with one or more concomitant injuries, particularly if high energy trauma is involved
  • 33-82% of midshaft radius and ulna fracture cases are isolated injuries
  • 50 percent involve multisystem trauma

Uptodate - Midshaft ulna and radius fractures

Presentation

  • High Energy Trauma
    • Motor vehicle accident, fall from height, sports injuries
    • Tend to be younger mailes
  • Low Energy Trauma
    • Primarily falls from standing height
    • Tend to be in post-menopausal osteoporotic females
  • Direct Injuries: often a defensive injury protecting their head or from an object
  • Indirect Injury: most frequently from falls onto the wrist or hand
  • Evaluate the elbow and wrist for associated injuries
  • Evaluate for neurovascular injury as compartment syndrome more common.

Imaging

  • Forearm X-ray which includes the wrist and elbow are required
  • Occasionally dedicated views of the elbow and wrist (true lateral and AP) are required to evaluate the alignment of the radius and ulna to exclude Monteggia and Galeazzi fracture dislocations.
  • The radial head must be aligned with the capitellum on all views
  • Comparison views to the opposite arm are sometimes necessary to evaluate axial rotation of either the ulna (rare) or radius (more common)
    • Seek senior advice if uncertain (orthopaedic registrar, ED staff specialist, nurse practitioner).
  • Never accept a single forearm bone fracture as an entity until a Monteggia or Galeazzi injury has been eliminated.

ED Management Options

  • Conservative treatment: (elbow back slab)
    • Isolated non displaced or distal 2/3 ULNA shaft fracture ('nightstick' fracture) with:
      • <50% displacement and
      • <10o of angulation (any direction)
  • Outcomes
    • unionrates >96%
    • acceptable to fix surgically due to long time to union
  • Orthopaedic referral for operative management
    • displaced distal 2/3 isolated ulna fractures
    • proximal 1/3 isolated ulna fractures
    • all radial shaft fractures (even if non displaced)
    • both bone fractures (radius and ulna)
    • all open fractures should be treated with primary ORIF.

Referral and Follow Up Requirements

Fracture Type

Urgency

Follow-up

Isolated distal 1/3 ulna fracture

Non urgent

1 week orthopaedic review

All other fractures

Urgent – same day

Refer to orthopaedic team

Potential Complications

  • Synostosis (adjacent bone fusion)
    • uncommon with an incidence of 3-9%
    • associated with ORIF using a single incision approach
  • Infection
    • 3% incidence with ORIF
  • Compartment syndrome increased risk with:
    1. high energy crush injury
    2. open fracture
    3. low velocity Gun Shot Wounds
    4. vascular injuries
    5. coagulopathies (DIC and anticoagulant use - warfarin)
  • Nonunion
    • commonly result from technical error or use of intramedullary fixation
  • Malunion
    • direct correlation between restoration of radial bow and functional outcome
  • Neurovascular injury
    • uncommon except
      • posterior interosseous nerve (PIN) injury with Monteggia fractures and middle and upper third radial diaphysis
      • open fractures
    • observe for three months to see if nerve function returns
      • explore if no return of function after 3 months
  • Refracture
    • increased risk with
      • removing plate too early
      • large plates (4.5mm)
      • comminuted fracture
      • persistent radiographic lucency
    • do not remove plates before 15 months
    • wear functional forearm brace for 6 weeks and protect activity for 3 months after plate removal

Further References and Resources

  • Allen, D (2015) Radius and Ulnar Shaft Fractures, Orthobullets, Accessed 03/09/2015.
  • McRae, R. (2006) Pocketbook of orthopaedics and fractures. Elsevier Health Sciences.
  • Nye, N. and Buetler, A. (2015) Midshaft ulna and radius fractures in adults, UpToDate, Accessed 3/9/2015.


Galeazzi Fracture - Dislocation

Summary

Fracture Type

Management

Follow-up

Dorsal Galeazzi (Common)

Volar Galeazzi (Rare)

All require urgent orthopedic consultation

Analgesia

Rule out compound injury

Check neurovascular status

Long Arm Splint (POP) and elevation

Reduction

All adult fractures require open reduction and internal fixation (ORIF)

Closed reduction is preferred in children

Follow up post operatively in the fracture clinic 7-14 days

Classification

Galeazzi fracture-dislocation there is a fracture of the distal third and middle third of the shaft of the radius in association with a subluxation or dislocation of the distal radio-ulna joint (DRUJ). The closer the fracture is to the DRUJ, the more likely that it will be unstable.

They are classified by the direction of the ulna displacement, hence:

  • Volar Galeazzi
  • Dorsal Galeazzi

Epidemiology

In 1934, Ricardo Galeazzi, an Italian surgeon in Milan, reported on his experience with 18 fractures with the above-described pattern as a compliment to the Monteggia lesion. In 1941, Campbell termed the Galeazzi fracture the "fracture of necessity" because it necessitates surgical treatment. In adults, nonsurgical treatment of the injury results in persistent or recurrent dislocations of the distal ulna.

Galeazzi Fractures account for an estimated 7% of all forearm fractures of all fractures in adults and most commonly seen in males. Rare in children.

Presentation

It is usually associated with a fall causing an axial load to be placed on a hyper pronated forearm.

Symptoms include pain and soft tissues swelling at the distal-third fracture site and at the wrist, joint with associated deformity.

Examination includes point tenderness over fracture site, skin integrity, ROM; forearm instability on supination and pronation, motor nerve injury including ulna nerve damage and anterior interosseous nerve (AIN) palsy. The AIN is a division of the medial nerve and damage may cause paralysis of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger.

Imaging

Radiographs

The views should include the entire radius and ulnar as well as the elbow joint.

AP.

Widening of the distal radio-ulnar joint maybe seen.

An associated fracture of the ulnar styloid may be seen.

Lateral.

The ulna does not overlie the radius (volar or dorsal displacement is seen).

The ulna styloid is not aligned with the dorsal triquetrum.

ED Management Options

  • Splint/long arm plaster of paris
  • Analgesia as required
  • Reduction (if indicated)
  • Ulnar nerve neuropraxia usually resolve spontaneously
  • Urgent referral to orthopaedic consultant
  • Preparation for theatre
  • Reduction in theatre by means of ORIF for adults and preferably closed for children.

Referral and Follow Up Requirements

Fracture Type

Urgency

Follow-up

Volar Galeazzi &

Dorsal Galeazzi

Immediate referral for orthopedic consultation and planning for ORIF in adults and possible closed reduction in children.

7-14 Days; post-surgery review in the orthopedic clinic, the wound is examined. The sutures are removed at 10-14 days after surgery, radiographs are obtained at each visit, and replace the splint with an above-elbow cast brace in supination.

4 weeks; further radiographs are obtained to recheck alignment and reduction of the radius and DRUJ, remove pins if present, recheck radiographs to confirm maintenance of reduction, and replace the cast brace in supination.

6 weeks; remove the cast, obtain radiographs, and initiate physical therapy for elbow, wrist, and digital motion. Application of a functional forearm brace is appropriate at this time.

Radiographs are re-examined at 6 week intervals until healing is apparent.

Potential Complications

The overall complication rate in the treatment of Galeazzi fractures approaches 40%. Complications include the following:

a) Neurovascular compromise

  • Ulna nerve damage

b) Compartment syndrome

c) Chronic disability of the DRUJ

d) Physeal Injury

e) Malunion of the radius

f) Nonunion

g) Infection

h) Refracture following plate removal

i) Posterior interosseois nerve (PIN) injury.

Patient Advice

  • The majority of these types of fractures do well
  • Elevation and ice application for reduction of selling
  • Compartment syndrome advice
  • There may be nerve injury usually ulna which normally resolves spontaneously through observation.
  • ECI patient factsheets

Further References and Resources


Monteggia Fracture - Dislocation

Summary

Monteggia Fracture (Bado Classification)

Management

Follow-up

Type I

Type II

Type III

Type IV

All require urgent orthopaedic consultation

Reduction of dislocation under sedation in ED or OT within 6-8 hours

Adults: most require open reduction and internal fixation techniques

Paediatric: most are managed conservatively with closed reduction and long arm cast

Consultation with the Orthopaedic team after their reduction and stabilization of the injury. Follow up in fracture clinic needs to be in 7 days with an X-ray

Isolated proximal ulna fractures are rare - always examine for Monteggia Fracture-dislocations

Classification

Giovanni Battista Monteggia in 1814 first described the injury consisting of a fracture of the proximal third of the ulna with anterior dislocation of the radial head from both the proximal radioulnar and radiocapitellar joints. Bado in 1967, subsequently redefined the Monteggia lesion as a group of traumatic lesions having in common a dislocation of the radiohumeral joint, associated with a fracture of the ulna at various levels.

Bado Classification

Type I

Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (the most common in children and young adults, up to 70%)

Type II

Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70-80% of adult Monteggia fractures)

Type III

Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head

Type IV

Fracture of the proximal or middle third of the ulna with dislocation of the radial head in any direction

Epidemiology

Rare in adults – The predominant lesion in adults is the posterior Monteggia fracture associated with osteoporosis. Anterolateral diaphyseal proximal radioulnar joint fracture-dislocation are not commonly seen in adults.

This type of injury is more common in children with peak incidence between 4 and 10 years of age where there is a different treatment protocol for children. It accounts for less than 5% of all forearm fractures with published literate supporting 1-2%.

Presentation

Primarily associated with falls on an out stretched hand with forced pronation (low energy) and in some cases a direct blow to the forearm or trauma such as a motor vehicle collision (high energy) can result in similar injuries.

Symptoms

Elbow pain, swelling, crepitus and paraesthesia or numbness. May not have severe pain but limited elbow flexion and forearm rotation.

Physical Exam

Inspection; may or may not be obvious dislocation at radiocapitellar joint and skin integrity should be evaluated.

Palpation; tenderness over radial head in an anterior, antero-lateral, or postero-lateral location.

ROM and instability; loss of ROM due to dislocation.

Neurovascular; posterior interosseous nerve neuropathy; radial deviation of hand and wrist extension, weakness of thumb extension and weakness of MCP extension. Weakness or paralysis of extension in the fingers or thumb.

Imaging

  • Radiography - AP and Lateral (true) elbow, wrist and forearm.
  • CT scan - Helpful in fractures involving coronoid, olecranon, and radial head.

ED Management Options

Radial head dislocation should be reduced emergently. Closed reduction should be performed within 6-8 hours. This is usually achieved with supination of the forearm but may require traction and direct pressure on the radial head. If the closed reduction is unsuccessful, the patient should be taken to theatre within this same timeframe for open reduction. A delay in reduction of the radius may lead to permanent articular damage or further nerve damage or both. All management is aimed at maintaining length of ulna and alignment.

Most adult fractures require open reduction and internal fixation techniques where most paediatric patterns can be managed conservatively with closed reduction and long arm casting.

All Monteggia fracture-dislocations should be splinted in a long arm cast and urgent on call orthopedics should be consulted.

Referral and Follow Up Requirements

Fracture Type

Urgency

Follow-up

Monteggia fracture-dislocations

All require an urgent orthopedic assessment

After reduction and stabilisation of the injury either by non-operative or operative should be reviewed within 7 days at the fracture clinic.

Potential Complications

  • Delayed diagnosis is the most frequent complication
  • Nerve injury - radial nerve and posterior interosseous nerve (10%) injury due to proximity to the radial head with neuropraxia common treatment involves observation for 2-3 months and usually spontaneous resolves and and if no improvement nerve studies are obtained.
  • Malunion with radial head dislocation. Usually caused by failure to obtain anatomic alignment of ulna with treatment involving ulnar osteotomy and open reduction of the radial head.
  • Compartment Syndrome
  • Infection
  • Plate loosening is common in adults
  • Proximal radioulnar synostosis is common for posterior monteggia injuries.
  • Ulnohumeral instability
  • Recurrent radial head dislocation.

Patient Advice

Children - parents can be advised these injuries do well with 90% of children having good result.

Adults - these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.

  • Pain from the fracture and restriction of movement is usual for 2-3 weeks and will require regular, then prn analgesia.
  • ECI patient factsheets

Further References and Resources

  • Konrad GG et al. (2007) Monteggia fractures in adults: long-term results and prognoistic factors, J Bone Joint Surg, 89(3), p.354-60.
  • Orthobullets - Monteggia Fractures.
  • Putigna, F. (2014) Monteggia fracture, accessed on Medscape.
  • Ring, David (2013) Monteggia Fractures, p. 59-66, accessed online.
  • Victorian Paediatric Orthopedic Network Online (2015) Clinical Practice Guidelines: Monteggia fracture-dislocations, The Royal Children’s Hospital Melbourne.

    Colles

    Summary

    Dorsally angulated, distal radius fractures (colles fractures) are a relatively common ED presentation. They are most commonly caused by a fall onto an outstretched hand. ED assessment should include pain, neurovascular and radiographic assessment. Whilst the majority of fractures can be managed in a short arm backslab and referred to an orthopaedic fracture clinic, significantly displaced or open fractures should be referred to orthopaedics straight away and closed reduction in ED may be indicated.

    Classification

    Although several classification models exist (Frykmanns, AO etc.), it is often easier and more useful to classify the fracture using the following descriptors:

    • Open vs closed
    • Intra articular vs extra articular
    • Simple vs comminuted
    • Fracture line orientation
    • Degree of angulation
    • Degree of impaction
    • Degree of displacement
    • Other concomitant fracture (e.g. ulna styloid).

    Epidemiology

    Distal radius fractures account for almost 17% of all fractures that occur in adults. They occur most often in the following two groups:

    1) Elderly individuals with osteoporotic bone who sustain these fractures from low energy trauma, and

    2) Young adults following high energy trauma.

    Distal radius fractures occur most often in older postmenopausal women, and four times as often in females than in males, and most often between the ages of 60-69 years.

    Presentation

    The most common cause of distal radius colles type fractures is from a fall onto an outstretched hand with wrist in extension. The classic appearance is dorso radial swelling/dinner fork deformity of the wrist. In addition to pain, the patient may also experience parasthesia secondary to nerve compression.

    Imaging

    Plain radiographs should be ordered if suspicious of fracture. The series should include AP, true lateral and oblique views. The AP view allows measurement of radial height, radial inclination and ulnar variance while the lateral view allows measurement of volar tilt. Definitions, normal values and acceptable criteria are as follows:

    • Radial height: the distance between two parallel lines drawn perpendicular to the long axis of the radial shaft — one from the tip of the radial styloid and the other from the ulnar corner of the lunate fossa. Normal value = 12mm (acceptable loss of height with fracture is 3mm in young and 5mm in elderly populations).
    • Radial tilt/inclination: the angle between two lines—one drawn perpendicular to the long axis of the radius at the ulnar corner of the lunate fossa and the other between that point in the lunate fossa and the tip of the radial styloid. Normal value = 23°.
    • Ulnar variance: a measurement of the relative lengths of radius and ulna at the wrist. The distance between two parallel lines drawn perpendicular to the long axis of the radius at the distal articular surface of the ulna and the ulnar corner of the sigmoid notch of the radius. Normal values: 0 (neutral) to 2mm.

    • Volar tilt/Palmar inclination: the angle between two lines—one drawn perpendicular to the long axis of the radius and the other between the dorsal and palmar lips of the distal radial articular surface normal value ~11°.

    CT may be indicated to evaluate intra articular involvement and for preoperative planning.

    MRI is not usually indicated in the acute context but may be useful in the medium term to evaluate soft tissue structures of the wrist.

    ED Management Options

    Neurovascular assessment should be performed and include the following:

    • Radial pulse
    • Capillary return to finger tips
    • Radial, median and ulnar nerve power/sensation in the hand.

    Closed injuries where there is no neurovascular compromise and the fracture is minimally displaced should be immobilised in a neutral wrist position with a short arm backslab. The affected limb should be placed in a sling and finger range of motion exercises should be encouraged to prevent stiffness and assist with oedema management. Education regarding cast care and monitoring of neurovascular status should be provided. Appropriate analgesia may also be prescribed.

    Fractures that exhibit any of the following criteria warrant orthopaedic review in the ED

    • Metaphyseal comminution with >5mm radial shortening
    • Ulnar variance >5mm
    • Intra-articular component
    • Large ulna styloid fractures
    • Suspicion of associated scaphoid fracture or scapholunate ligament injury
    • Open fractures
    • Articular step off >2mm.

    ?

    Fractures that exhibit any of the following criteria warrant closed reduction AND orthopaedic review in the ED

    • Greater than 20 dorsal angulation
    • Fracture dislocation
    • Fracture displacement in any direction greater than two thirds the width of the radial shaft
    • Acute neurovascular compromise.

    ?

    Referral and Follow Up Requirements

    Stable colles fractures can be followed up in a fracture clinic or equivalent approximately one week post injury. This will allow time for the initial swelling to subside so that a full circumferential cast can be applied.

    Potential Complications

    Complications can manifest acutely or in the medium to long term.

    The most common acute complication is median nerve neuropathy associated with carpal tunnel compression. The incidence can be reduced by elevating the limb, moving the fingers and avoiding immobilisation in excessive wrist flexion.

    Common medium term complications include rupture of the Extensor Pollicus Longus tendon (caused by mechanical attrition of the tendon), skin irritation/blisters/pressure areas (secondary to ill fitting plaster cast) and development of complex regional pain syndrome (CRPS).

    Common long term complications include fracture malunion and osteoarthritis of the wrist.

    Patient Advice

    Discharge advice should include information relating to the following:

    • Monitoring for compartment/compression syndromes eg increasing pain/analgesia use
    • Appropriate analgesia dosage/frequency
    • Finger/elbow range of motion exercises
    • Contra indicated activity (i.e. lifting heavy objects).
    • ECI patient factsheets

    Further References and Resources


    Smiths

    Summary

    Most commonly an extra-articular distal radius fracture which has palmar angulation, giving a so called garden spade deformity compared to the diner fork of the Colles which has dorsal angulation. The fracture can be intra articular and can be part of wrist dislocation. The mechanism can be falling on a flexed wrist.

    Classification

    • Type I: extra articular
    • Type II: crosses into the dorsal articular surface
    • Type III: enters radiocarpal joint
      • Volar Barton's Fracture = Smith's type III
      • Both involve volar dislocation of carpus associated with intra articular distal radius component

    Epidemiology

    Bimodal distribution:

    • younger patients - high energy
    • older patients - low energy/falls
    • 50% intra-articular
    • radial styloid fracture - indication of higher energy.

    Presentation

    Pain and deformity of the wrist with appropriate mechanism.

    Imaging

    • Radiographs – wrist:

    View

    Measurement

    Normal

    Acceptable Criteria

    AP

    Radial height

    10-13mm

    < 5mm shortening

    Radial inclination

    21-25 degrees

    change

    Articular stepoff

    Congruous

    < 2 mm stepoff

    LAT

    Volar tilt

    11-13 degrees

    Dorsal angulation < 5° or within 20° of contralateral distal radius

    Table Source: Orthobullets - distal radius fractures

    • CT Scans:
      • Important to evaluate intra-articular involvement and for surgical planning.
    • MRI useful to evaluate for soft tissue injury such as:
      • TFCC injuries
      • Scapholunate ligament injuries (DISI)
      • Lunotriquetral injuries (VISI).

    ED Management Options

    Adequate analgesia.

    Closed reduction and cast immobilisation is adequate most undisplaced or minimally displaced extra articular fractures.

    Where there is more significant angulation.

    Reduction involves reducing by reversing fracture deformity with longitudinal traction applying a long arm cast with the forearm in supination and wrist in neutral or a degree of extension.

    A sandwich or tongs type POP slab may maintain reduced position of the fracture.

    Referral and Follow Up Requirements

    Fracture Type

    Urgency

    Follow-up

    Undisplaced extra articular

    Non urgent, POP dorsal slab, or sandwich slab if thought unstable

    If isolated non displaced fracture, review fracture clinic within week

    Significant displacement or encroaching or involving the articular surface

    Ortho review, closed reduction, and POP slab

    Follow next day if none available at first presentation

    Barton’s fracture, joint involvement , radiocarpal involvement

    Ortho review and advice, for ORIF planning

    As per ortho advice

    Potential Complications

    Non-union and mal-union often where there are underlying complex medical problems.

    If significant volar displacement risk to median nerve.

    Patient Advice

    Further References and Resources


    Hand Injury Guidelines

    A quick reference guide to assist Emergency clinicians with the diagnosis and emergency
    management of common hand presentations to the ED


    Metacarpals and Phalanges

    Summary

    Management of each form of metacarpal fracture is based upon which metacarpal is involved, location, angulation and mal-rotation. Treatment is primarily conservative followed by closed reduction under sedation or local anaesthesia. Goals of management are to obtain alignment and stability so as to encourage finger and wrist motion as soon as possible.

    Management of phalanges fractures when closed and minimally displaced with good alignment is also conservative. Unstable fractures, open fractures and joint injuries (usually dislocations) are often best managed by referral to orthopaedic teams, hand specialist and physiotherapy.

    Non operative management is acceptable in phalange and metacarpal fractures generally when the fracture is stable, has no deformity and acceptable degrees of angulation and shortening. Immobilisation should suffice.

    Operative intervention is usually necessary with intra articular fractures, rotation malalignment of digit, significant displacement and multiple metacarpal shaft fractures.

    Recovery is improved with early motion and removal of ORIF hardware and casts no greater than 4 weeks post injury.

    Fracture Type

    Management

    Follow-up

    Metacarpal base fractures

    Require reduction if >2mm of articular surface displacement or significant angular deformity or dislocation of CMC exist.

    Immobilisation for minimum of 3 weeks.

    Active finger IP joint motion exercise during MC immobilisation

    1 follow up X-ray to check alignment

    Physiotherapy.

    Metacarpal shaft

    If closed, are mostly treated non operatively

    Acceptable angulation 10% for 2nd MC. 20% for 3rd and 4th MCs. And 30% for 5th MC.

    Reduction of MC fractures can be best accomplished using the Jahss technique.

    Immobilization should be no longer than 4 weeks.

    1 follow up X-ray to check alignment

    Physiotherapy.

    Metacarpal neck

    Minimally angulated or displaced fractures can be managed with simple immobilisation for 3-4 weeks.

    No rotation is acceptable and operative intervention may be required if Jahss technique is not effective.

    Immobilization 3-4 weeks

    1 follow up X-ray to check alignment

    Physiotherapy

    Metacarpal Head fractures

    Non displaced fractures can be managed conservatively with splinting for 3 weeks then gentle ROM exercises

    >1-2mm articular surface displacement should be managed operatively

    Splinting of MC head fractures should involve the MCP joint. Gutter splints on 4th and 5th MC fractures are very effective.

    1 follow up X-ray to check alignment

    Physiotherapy.

    Fracture Type

    Management

    Follow-up

    Proximal phalanx

    Up to 3 weeks immobilisation in safe position

    Begin active exercises early.

    Orthopedic review if intra articular surface >30%, unstable, rotation, excessive angulation, multiple fingers

    1 follow up X-ray to check alignment

    Middle Phalanx

    Up to 3 weeks immobilisation with IPJ extension.

    Begin active exercises early.

    Orthopedic review if intra articular surface >30%, unstable, rotation, excessive angulation, multiple fingers

    1 follow up X-ray to check alignment

    Volar plate avulsion fracture

    1 week of slight flexion immobilisation

    Flexion exercises at 1 week, with splinting between.

    Extension exercises at 3 weeks

    Large avulsion fragments, or fragment within joint space require orthopedic review.

    Distal phalanx

    2-3 weeks splinting

    Large loss of soft tissue, nail bed injuries and >30% intra-articular surface involvement require orthopedic review.

    Mallet fracture

    6-8 weeks of DIP in slight hyperextension

    Avulsion fractures and >30% intra-articular surface require orthopedic review.

    Classification

    Fractures of the metacarpal are classified by location - base, shaft, neck or head and by type:

    • Head - sub capital, intra-articular, transverse
    • Shaft - transverse, oblique and multi-fragmentary
    • Base - intra-articular.

    Fractures of proximal phalanges are classified according to location distal-articular, distal-metaphyseal, shaft, proximal–metaphyseal, and proximal–articular and by type:

    • Distal Articular - oblique, unicondylar, bicondylar
    • Distal Metaphyseal - transverse, oblique, multi-fragmentary
    • Shaft - transverse, oblique, multi-fragmentary
    • Proximal Metaphyseal - transverse, oblique
    • Proximal Articular - avulsion, shearing, multi-fragmentary.

    Fractures of the middle phalanx are classified according to location, distal, shaft, and proximal and type:

    • Distal – unicondylar, bicondylar
    • Shaft - oblique, transverse, multi-fragmentary
    • Proximal - multi-fragmentary, avulsion and dislocation.

    Fractures of the distal phalanges are classified according to location distal, shaft and proximal and type of fracture:

    • Distal and shaft - transverse, multi-fragmentary
    • Proximal - avulsion and dislocation.

    Thumb fractures are classified according to location distal phalanx shaft, distal phalanx base, proximal phalanx articular, proximal phalanx metaphyseal, proximal phalanx base/shaft and metacarpal and type of fracture:

    • Distal Phalanx - Distal Shaft – Transverse, Multi-fragmentary
    • Distal phalanx - Base – dislocation, avulsion
    • Proximal phalanx - Articular – oblique, unicondylar with dislocation, bicondylar
    • Proximal phalanx - Metaphyseal – transverse, oblique, multi-fragmentary
    • Proximal phalanx – Base/Shaft – skiers thumb, Pilon, Multi-fragmentary
    • Metacarpal - Base, Bennett, Rolando

    Additional to phalanges fractures IPJ and MPJ injuries may occur with injury to flexor and/or extensor tendons with or without fracture. Appropriate management will prevent chronic deformities.

    Epidemiology

    Metacarpal fractures account for ~40% of all hand injuries and are the second most common fracture presentation to emergency departments after distal radius fractures. Men have the highest incidence of metacarpal fracture presentation accounting for 85% of presentations. The metacarpal neck is the most common site of fracture and the 5th metacarpal is the most commonly injured. (Punching injury)

    Finger phalanx fractures are reported as the 4th most common fracture presentation to emergency departments. Many phalanx fractures will not present for any medical intervention.

    Presentation

    Physical exam for hand injuries encompasses inspection, deformity, motor and neurovascular checks.

    Open wounds and associated injuries should always be deemed high risk of compound fracture, when fight associated wounds exist over MCPJ potential for osteomyelitis is increased with or without fracture. Wounds on the dorsal surface of the hand with metacarpal fracture are almost always open.

    Deformity in metacarpal injury is indicative of location of injury. Deformity at the proximal metacarpal should increase suspicion of carpal metacarpal dislocation. Shortening is best assessed by contralateral comparison, and mal-rotation is shown in misalignment of fingernails in partial and full flexion of fingers compared to opposite uninjured hand.

    Motor examination by assessment of ROM in active and passive motion should be compared to the uninjured hand. Results may be affected by swelling, pain and skin surface wounds, if open wounds exist check integrity of extension and flexor tendons.

    Neurovascular exam should be assessed prior to any local anesthetic, sensation and circulation by light touch and cap refill assessment usually suffice.

    Imaging

    When serious injury is suspected imaging should be attended prior to physical testing:

    • Most hand fractures are usually detected by anteroposterior, lateral, and oblique views of the specific injured joint/limb rather than the entire hand.
    • Direct posterior-anterior (PA) and lateral views of the thumb should be obtained if the thumb is suspected of injury. Fractures of the middle and proximal phalanx may angulate palmar or dorsally.
    • Post-reduction radiographs should show no more than 10° of angulation and rotational displacement.

    ED Management Options

    As per fracture type see above in summary.

    Splinting is by aluminium and foam strips cut to size, thermoplastic as available or pre made plastic splints for example for mallet finger.

    Referral and Follow Up Requirements

    See summary above.

    Potential Complications

    Open metacarpal fractures increase the likelihood of tendon laceration and/or neurovascular injury and potential for osteomyelitis. Closed and crush injuries, especially when multiple fractures or dislocations occur have the potential for compartment syndrome.

    In management prolonged immobilisation increases the probability of loss of joint range of motion. Where possible avoiding immobilising unnecessary joints is preferred.

    Patient Advice

    May be a place for a handout allowing for local variation and availability of hand services, care of the splint etc.

    Further References and Resources

    • Blomberg, J. (2014) Metacarpal Fractures: Orthobullets. Cited 1 May 2015.
    • Court-Brown, C.M., and Caesar, B. (2006) Epidemiology of adult fractures: A review, Injury, 37(8), pp.691-697.
    • Eddy, M. (2012) Hands, Fingers, Thumbs. Assessment and management of common hand injuries in general practice. Australian Family Physician Vol. 41(4).

      Scaphoid


    Summary

    Scaphoid is the most frequently fractured carpal bone, accounting for to 15% of wrist fractures.

    The most common mechanism of injury is axial load across hyper-extended and radially deviated wrist, occurs in falls in the elderly and common in contact sports. Transverse fracture patterns are considered more stable than vertical or oblique oriented fractures

    Fracture Type

    Management

    Follow-up

    Proximal third

    Common (25%) higher risk for avascular necrosis

    Due to increased risk with these fractures seek opinion form orthopaedic referral colleagues

    Waist (65%)

    Most common (65%)

    Undisplaced fractures NV intact thumb spic and follow up fracture clinic/ortho the following week

    Distal Third

    10% overall , more common in children due to growth plate evolution

     

    Source: Orthobullets - trauma

    Classification

    Herbert Classification System

    A

    Acute/stable

    A1

    Tubercle

    A2

    Non-displaced waist crack

    B

    Acute/unstable

    B1

    Oblique/distal third

    B2

    Displaced waist

    B3

    Proximal pole

    B4

    Fracture dislocation

    B5

    Comminuted fracture

    C

    Delayed union

    D

    Established non-union

    D1

    Fibrous

    D2

    Sclerotic

    Epidemiology

    • Males > Femailes
    • 10-19 years of age
    • Annual incidence of 23/100,000

    Presentation

    Physical examination:

    • anatomic snuffbox tenderness dorsally
    • pain on compression of the thumb
    • scaphoid tubercle tenderness volarly
    • pain with resisted pronation.

    Imaging

    • Radiographs recommended views:
      • Wrist AP and lateral.
      • Scaphoid views, 30 degree wrist extension, 20 degree ulnar deviation 45° pronation view.
      • if negative and high clinical suspicion should repeat radiographs in 14-21 days.
    • Bone scan, effective to diagnose occult fractures at 72 hours
      • specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72 hours.
    • MRI
      • most sensitive method to diagnose of occult fractures within 24 hours.
      • allows immediate identification of fractures and ligamentous injuries in addition to assessment of vascular status of bone (vascularity of proximal pole).
    • CT scan with 1mm cuts
      • less effective than bone scan and MRI to diagnose occult fracture.
      • can be used to evaluate location of fracture, size of fragments, extent of collapse, and progression of nonunion or union after surgery.

    ED Management Options

    Where there is a fracture or a lingering strong suspicion without radiological evidence immobilisation should be provided. An alternative path is go straight to CT of wrist for strong clinical suspicion of scaphoid fracture. More sensitive test and allows for early mobilisation where there is no fracture. There is otherwise a often significant economic or other cost to being immobilised for 7-10 days needlessly. There is also risk for decreased mobility and ongoing wrist problems. This option will be site specific.

    Immobilisation and bone scan at 72 hours where there is a very strong suspicion, highly sensitive (up to 100%) also reduces the wait to diagnosis time, over the 10 day wait for repeat X-rays which may be still difficult to interpret.

    Thumb spica cast immobilisation.

    • indications
      • stable nondisplaced fracture (majority of fractures)
      • duration of casting depends on location of fracture
        • distal-waist for 3 months
        • mid-waist for 4 months
        • proximal third for 5 months
        • athletes should not return to play until imaging shows a healed fracture
    • outcomes
      • scaphoid fractures with

    Referral and Follow Up Requirements

    Fracture Type

    Urgency

    Follow-up

    Medial Third

    Immediate senior input for posteriorly displaced fractures.

    If isolated non displaced fracture, review fracture clinic within week

    If suspicion ask for help immediately

    All other fractures managed through orthopaedic consultation

    Middle Third

    Non displaced isolated fractures can be managed by JMO/NP/physio as per their scope.

    GP follow up 1 week

    Distal Third

    Non displaced fractures

    Fracture clinic within the week

    Displaced fractures

    Ideally assessment in ED or early follow-up arranged with orthopaedic

    Potential Complications

    Avascular necrosis (AVN) is a common and concerning complication of a scaphoid fracture. It occurs as a result of disruption in the blood supply, which enters through the distal pole and travels to the proximal pole. Risk of AVN depends on the location of the fracture;

    Proximal third > middle third > distal third

    The most frequent fracture site is the middle third; however, the proximal third has the highest rate of AVN (~30%).

    Non union can also occur from undiagnosed or undertreated scaphoid fractures, secondary to disruption of the blood supply. If not treated correctly non-union of the scaphoid fracture can lead to wrist osteoarthritis.

    Arthritis of the wrist can occur over time due to the above pathologies. Symptoms may include aching in the wrist, decreased range of motion of the wrist, and pain during activities such as lifting or gripping. Arthritis is treated with anti-inflammatory medications and in some cases wearing a splint when an individual feels pain in the wrist. In severe cases, that don’t respond to initial treatment regimes, steroid injections to the wrist may help alleviate pain. Should these treatments not work, surgery may be considered.

    Patient Advice

    Further References and Resources

    • Orthobullets - clavicle fractures
    • Wheeless - scaphoid fracture
    • Owens BD, Wolf JM, Incidence estimates and demographics of scaphoid fracture in the US population, J Hand Surg Am, August 2010, 35(8): 1242-5.
    • Duckworth, AD et al. Scaphoid Fracture Epidemiology, J Trauma and Acute Care Surgery, October 2011, Vol 72(2): 41-45.

    Proximal Interphalangeal Joint (PIPJ)

Watch this video from Hand and Wrist Surgeon, Tanya Burgess on the assessment, management and commonly missed signs of a PIPJ injury.

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