Upper Limb Fractures

Clavicle & Scapula Fx - Collar & Blade Breaks

• Clavicle Fractures:

  • Common: Middle 1/3 (Allman I, ~80%). MOI: FOOSH, direct.
  • N/V check: Subclavian vessels, brachial plexus.
  • 📌 Allman: I (Mid), II (Lat - nonunion risk if CC ligs torn), III (Med).
  • Rx:
    • Non-op: Sling, Fig-8 (undisplaced).
    • ORIF: Displaced >2cm / shortening >1.5cm, skin tenting, open, N/V injury, floating shoulder.

• Scapula Fractures:

  • High-energy; check associated injuries.
  • Types: Body (commonest), neck, glenoid, acromion, coracoid.
  • Rx:
    • Non-op (most): Sling, early ROM.
    • ORIF: Glenoid step >3-5mm / >20% involved; Neck angulation >40° / translation >1cm; Open fx.

  ⭐ Floating Shoulder: Ipsilateral clavicle + scapular neck/glenoid fx. Causes glenohumeral instability. Usually requires ORIF of one/both.

• Management Flowchart (Clavicle Fx):

Humerus Fx (All Parts) - Arm Bar Busters

• General Nerve Risks (📌 ARM-U):

  • Axillary n.: Surgical Neck.
  • Radial n.: Mid-Shaft (Spiral Groove).
  • Median n.: Supracondylar.
  • Ulnar n.: Medial Epicondyle.

• Proximal Humerus Fx:

  • Elderly, osteoporosis. Neer's Classification (4-parts; displaced if >1cm or >45°).
  • Nerve: Axillary n. (deltoid, regimental badge). Vascular: Circumflex arteries (↑AVN risk).
  • Tx: Sling (undisplaced) vs. ORIF/Arthroplasty (displaced).

  ⭐ Axillary nerve is most commonly injured in surgical neck of humerus fractures.

• Humeral Shaft Fx:

  • Nerve: Radial n. (wrist drop); Holstein-Lewis Fx (distal 1/3 spiral).
  • Tx: Sarmiento brace (if <20° ant, <30° varus/valgus angulation) vs. ORIF/IMN.

• Distal Humerus Fx (Supracondylar - Peds):

  • FOOSH. Gartland Classification.
  • Nerve: Median n. (AIN), Radial n. Vascular: Brachial a. (⚠️ Volkmann's Ischemia).
  • Complication: Cubitus varus (Gunstock deformity).

Elbow & Forearm Fx - Joint & Shaft Jumbles

• Elbow Region Fx:
  • Supracondylar Humerus (SCH): Child, FOOSH. Gartland I-III.
    • Complications: Brachial art., AIN (no 'OK' sign), Median n., Cubitus varus, Volkmann's.
    • Tx: Cast (I), CRPP (II/III).
  • Radial Head: FOOSH. Mason I-IV (Type II: >2mm disp.).
    • Essex-Lopresti: Radial head Fx + DRUJ injury + IOM tear.
  • Olecranon: Direct blow. Displaced: TBW.
• Forearm Shaft Fx:
  • Both Bones: Adults: ORIF plates. Child: Cast/Nails.
  • Nightstick Fx: Isolated ulna.
• Fx-Dislocations (Unstable):
  • 📌 MUGR: Monteggia (Ulna Fx + Radial Head Disloc.); Galeazzi (Radius Fx + DRUJ Disloc.).
  • Monteggia: Bado types. Type I (Ant. RH disloc.) common.
  • Galeazzi: "Fx of necessity" (adult ORIF).

⭐ Monteggia fracture-dislocation: Fracture of the proximal ulna with dislocation of the radial head. Bado Type I (anterior dislocation of radial head) is the most common.

Wrist & Hand Fx - Distal Damage Detail

• Scaphoid Fx Complications:
  • Avascular Necrosis (AVN): Risk ↑ proximal pole (up to 100% if displaced) > waist > distal pole.
  • Non-union: Common, especially if diagnosis delayed or fracture displaced.
  • Treatment: Herbert screw often used for fixation.
• Kienbock's Disease: AVN of the lunate bone.
• Nerve Injuries:
  • Median N.: Acute Carpal Tunnel Syndrome (CTS) post-Colles' Fx, lunate dislocation. 📌 Tinel's/Phalen's signs.
  • Ulnar N.: Guyon's canal syndrome (e.g., hook of hamate Fx).
  • Superficial Radial N.: Injury with styloid fractures (Chauffeur's Fx), tight casts/handcuffs.
• Compartment Syndrome: ⚠️ Forearm/hand. Key signs: Pain out of proportion, Paresthesia, Pallor, Paralysis, Pulselessness (late). Requires urgent fasciotomy.
• Malunion & Stiffness: Common after metacarpal/phalangeal fractures; can impair hand function.

⭐ Tenderness in the anatomical snuffbox is highly suggestive of a scaphoid fracture, even if initial X-rays are negative. Immobilize and repeat X-ray in 10-14 days or consider MRI/CT for early diagnosis.

High‑Yield Points - ⚡ Biggest Takeaways

• Anterior shoulder dislocation is most common, risking axillary nerve injury.
• Clavicle fractures: Middle third most common; managed with sling or figure-of-8.
• Supracondylar humerus fractures (children) risk Volkmann's contracture (median nerve, brachial artery).
• Colles' fracture: Dorsal angulation ("dinner fork"); Smith's fracture: Volar angulation.
• Scaphoid fractures: Anatomical snuffbox tenderness; high risk of avascular necrosis.
• Monteggia: Proximal ulna fracture with radial head dislocation. Galeazzi: Distal radius fracture with DRUJ dislocation.