Upper Limb Fractures – shoulder/elbow/forearm/wrist/hand
The forearm is made up of 2 bones namely the radius and ulna. The primary function of your forearm is rotation i.e., the ability to turn your palms up and down. The fracture of the forearm affects the ability to rotate your arm, as well as bend and straighten the wrist and elbow. The breaking of the radius or ulna in the middle of the bone requires a strong force and it is most commonly seen in adults. In most of the cases, both bones are broken during a forearm fracture.
The forearm bones can break in several ways. The bones can crack slightly or can break into many pieces. Forearm fractures are generally due to automobile accidents; direct blow on the forearm or fall on an outstretched arm during sports, climbing stairs, etc.
The symptoms of a forearm fracture include intense pain in the arm, bruises and swelling. Your fractured forearm may appear bent and shorter compared to your other arm. You may experience numbness or weakness in the fingers and wrist. You may be unable to rotate your arm. Rarely, a broken bone sticks out through the skin or the wound penetrates down to the broken bone.
Your doctor may conduct a physical examination and record your medical history initially. Your doctor may feel your arm thoroughly to determine tenderness. You may be asked to get an X-ray done to determine displaced or broken bones.
Usually people with forearm fractures are immediately rushed to the emergency room for treatment. Treatment of forearm fracture aims at putting back the broken bones into position and preventing them from moving out of place until they are completely healed.
In case only one bone is broken and is not out of place, your doctor might treat it with a cast or brace and provide a sling to keep your arm in position. Your doctor will closely monitor the healing of the fracture. If the fracture shifts in position, you may be advised to undergo surgery to fix the bones back together.
When both forearm bones are broken, surgery is usually required. During surgery, the cuts from the injury will be cleaned and the bone fragments are repositioned into their normal alignment. They are held together with screws and metal plates attached to the outer surface of the bone. The incision is sutured firmly and a sling is provided to facilitate healing.
The clavicle or the collarbone is the bone that connects your sternum or breastbone to your shoulder. Clavicle fracture, also called broken collarbone is a very common sports injury seen in people who are involved in contact sports such as football and martial arts as well as impact sports such as motor racing.
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.
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.
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 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.
Plates and Screws fixation
During this surgical procedure, your surgeon will reposition the broken bone ends into normal position and then uses special screws or metal plates to hold the bone fragments in place. These plates and screws are usually left in the bone. If they cause any irritation, they can be removed after fracture healing is complete.
Placement of pins may also be considered to hold the fracture in position and the incision required is also smaller. They often cause irritation in the skin at the site of insertion and have to be removed once the fracture heals.
An elbow fracture results from a break or crack in one or more of the bones that make up the elbow joint. There are two types of elbow fractures:
- Extra-articular fractures that include intercondylar fractures, supracondylar fractures, epicondylar fractures, and condyle fractures
- Intra-articular fractures that include trochlea and capitellum fractures, radial head, and proximal ulnar fractures
The elbow is a complex hinge joint formed by the articulation of three bones- humerus, radius, and ulna. The upper arm bone or humerus connects the shoulder to the elbow forming the upper portion of the hinge joint. The lower arm consists of two bones- the radius and the ulna. These bones connect the wrist to the elbow forming the lower portion of the hinge joint. A joint capsule surrounds the elbow joint which contains lubricating fluid called synovial fluid.
The three joints of the elbow are
- Ulnohumeral joint, the junction between the ulna and humerus
- Radiohumeral joint, the junction between the radius and humerus
- Proximal radioulnar joint, the junction between the radius and ulna
The elbow is held in place with the support of various soft tissues including
- Blood vessels and
The various movements of an elbow joint are
Elbow fractures can be caused by:
- A direct hit or blow to the elbow joint
- Falling on an outstretched arm
- A twisting injury of the elbow
The differential diagnoses of elbow fracture include sprains, strains, or dislocations.
Signs and symptoms:
The common symptoms of an elbow fracture include
- Swelling, tenderness, stiffness, and bruising around the elbow joint
- Restricted movement of the elbow
- Pain at the elbow joint while stretching
- Possible damage to nerves and/or artery
- Decreased range of motion
- Possible numbness in finger, hand or forearm
- Popping or cracking sound may be felt in the elbow
Healing of a fracture depends on the type and severity of the fracture sustained as well as the age and health status of the individual.
Your doctor diagnoses elbow fracture by performing a physical examination. Other investigations that help diagnose an elbow fracture include:
- X-ray of the elbow is a radiological test carried out to look for abnormalities in bone structures of the joint
- CT (Computerized tomography) scan of the elbow is done to obtain detailed views of the bone
- MRI (Magnetic resonance imaging) of the elbow is done to view the bone and surrounding soft tissues
Treatment varies according to the severity of the fracture and involves the following:
- Rest the elbow until the fracture has healed completely which may take about 8-10 weeks.
- Non-surgical or conservative treatment such as a cast or splint may be used to stabilize the joint if the bones are not displaced. Generally, casts are used to treat fractures in paediatric patients as they experience less muscle stiffness compared to adults.
- Your doctor may prescribe pain medications to keep you comfortable, and antibiotics to prevent infection.
- Physical therapy will be recommended by your doctor to increase range of motion and to strengthen your elbow muscles.
- Surgery is considered in cases of displaced bones or unstable fractures, which require realignment and stabilization of the bone fragment.
Fracture of the Shoulder Blade (Scapula)
The scapula (shoulder blade) is a flat, triangular bone providing attachment to the muscles of the back, neck, chest and arm. The scapula has a body, neck and spine portion.
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 of a scapular fracture 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.
Scapular fractures should be evaluated by an orthopaedic surgeon for proper diagnosis and treatment.
Your surgeon will perform the following:
- Medical History
- Physical Examination
Diagnostic Studies may include:
- X-rays: A form of electromagnetic radiation that is used to take pictures of bones.
- CT scan: This test creates images from multiple x-rays and shows your physician structures not seen on regular x-ray.
- MRI: Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments.
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.
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 how well you heal.
- 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.
Fractures of the scapula involving the neck or glenoid or with severe displacement have been associated with poor outcomes when treated non-operatively. Will usually require surgical intervention to realign the bones properly and restore a functional, pain free range of motion to the shoulder joint.
Scapular fracture repair surgery has historically been performed through a large, open incision. Newer, minimally invasive techniques have evolved and surgery to repair scapular fractures can now be performed through arthroscopy.
Olecranon (Elbow) Fractures
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. 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.
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.
Symptoms of an olecranon fracture include pain, swelling, bruising, stiffness in and around the elbow, a popping or cracking sound, and deformity of the elbow bones.
To diagnose olecranon 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.
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 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.
Radial Head Fractures
The elbow is a junction between the forearm and the upper arm. The elbow joint is made up of 3 bones namely the humerus bone in the upper arm which joins with the radius and ulna bones in the forearm. The elbow joint is essential for the movement of your arms and to perform daily activities. The head of the radius bone is cup-shaped and corresponds to the spherical surface of the humerus. The injury in the head of the radius causes impairment in the function of the elbow. Radial head fractures are very common and occur in almost 20% of acute elbow injuries. Elbow dislocations are generally associated with radial head fractures. Radial head fractures are more common in women than in men and occur more frequently in the age group of 30 and 40 years.
The most common cause of a radius head fracture is breaking a fall with an outstretched arm. Radial head fractures can also occur due to a direct impact on the elbow, a twisting injury, sprain, dislocation or strain.
The symptoms of a radial head fracture include severe pain, swelling in the elbow, difficulty in moving the arm, visible deformity indicating dislocation, bruising and stiffness.
The treatment of a fracture depends on the type of fracture.
- Type 1 fractures are usually very small. The bone appears cracked, but remains fitted together. The doctor might use a splint (casting) to fix the bone and you might have to wear a sling for a few days. If the crack becomes intense or the fracture gets deep then your doctor might suggest surgical treatment.
- Type 2 fractures are characterized by displacement of bones and breaking of bones in large pieces and can be treated by surgery. During surgery, your doctor will correct the soft-tissue injuries and insert screws and plates to hold the displaced bone together firmly. Small pieces of bone may be removed if it prevents normal movement of the elbow.
- Type 3 fractures are characterized by multiple broken pieces of bone. Surgery is considered the compulsory treatment to either fix or to remove the broken pieces of bone, sometimes including the radial head. An artificial radius head may be placed to improve the function of the elbow.
Shoulder injuries most commonly occur in athletes participating in sports such as swimming, tennis, pitching, and weightlifting. The injuries are caused due to the over usage or repetitive motion of the arms.
Shoulder injuries cause pain, stiffness, restricted movements, difficulty in performing routine activities, and popping sensation.
Some of the common shoulder injuries include sprains and strains, dislocations, tendinitis, bursitis, rotator cuff injury, fractures, and arthritis.
- Sprains and strains: A sprain is stretching or tearing of ligaments (tissues that connect adjacent bones in a joint). It is a common injury and usually occurs when you fall or suddenly twist. A strain is stretching or tearing of muscle or tendon (tissues that connect muscle to bone). It is common in people participating in sports. Strains are usually caused by twisting or pulling of the tendons.
- Dislocations: A shoulder dislocation is an injury that occurs when the ends of the bone is forced out of its position. It is often caused by a fall or direct blow to the joint while playing contact sport.
- Tendinitis: It is an inflammation of a tendon, a tissue that connects muscles to bone. It occurs as a result of injury or overuse.
- Bursitis: It is an inflammation of fluid filled sac called bursa that protects and cushions your joints. Bursitis can be caused by chronic overuse, injury, arthritis, gout, or infection.
- Rotator cuff injury: The rotator cuff consists of tendons and muscles that hold the bones of the shoulder joint together. Rotator cuff muscles allow you to move your arm up and down. Rotator cuff injuries often cause a decreased range of motion.
- Fractures: 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.
- Arthritis: Osteoarthritis is the most common type of shoulder arthritis, characterized by progressive wearing away of the cartilage of the joint.
Early treatment is necessary to prevent serious shoulder injuries. The immediate mode of treatment recommended for shoulder injuries is rest, ice, compression and elevation (RICE). Your doctor may also prescribe anti-inflammatory medications to help reduce the swelling and pain.
Your doctor may recommend a series of exercises to strengthen shoulder muscles and to regain shoulder movement.
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. A wrist 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.
Fractures of the Hand and Fingers
The hand is one of the most flexible and useful parts of our body. Because of overuse in various activities, the hands are more prone to injuries, such as sprains and strains, fractures and dislocations, lacerations and amputations while operating machinery, bracing against a fall and sports-related injuries.
A fracture is a break in the bone, which occurs when force greater than the bearable limit is applied against a bone. The most common symptoms of any fracture include severe pain, swelling, bruising or bleeding, deformity, discoloration of the skin, and limited mobility of the hand.
Fingers are fine structures of the human body that assist in daily routine activities through coordinated movements. Any abnormality affecting the fingers can have a huge impact on the quality of life. A finger fracture is not a minor injury, and if left untreated can lead to stiffness, pain, disruption of the alignment of the whole hand and interference with specialized functions such as grasping or manipulating objects. Finger fractures commonly occur during sports activities, when you break a fall or while operating machinery.
The diagnosis of a hand or finger fracture is based on history, physical examinations and X-ray imaging to determine the type and severity of the fracture. X-rays are the most widely used diagnostic tools for the evaluation of fractures.
The objective of early fracture management is to control bleeding, provide pain relief, prevent ischemic injury (bone death) and remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after the fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical methods.
The bones can be realigned by manipulating them into place. Following this, splints, casts or braces made up of fibre glass or plaster of Paris material are used to immobilize the bones until they heal. The cast is worn for 3 to 6 weeks.
During surgery, the fracture site is adequately exposed, the bones realigned and reduction of the fracture is done internally using wires, plates and screws and intramedullary nails.
Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of the cast or brace so that the bone becomes solid enough to bear stress. Rehabilitation program involves exercises and gradual increase in activity levels to strengthen the muscles and improve range of motion.