Clavicle Fractures
These injuries are also known as a broken collarbone. The most common cause is a fall onto the shoulder. The majority occur in the middle third; 15% are observed lateral and only 5% medial. The mid third fractures are prone to displacement as the shoulder muscles tend to pull the two fragments apart.
Initially immobilisation in a sling and pain medication are the first steps of treatment. Currently it is controversial whether to operate on these fractures but there is consensus that all fractures that are 100% displaced and shortened more than 2 cm should be surgically fixed.
Distal Clavicle Fractures
These fractures typically occur in older people and the mechanism is similar to a midshaft fracture. Often the coraco – acromial ligaments that stabilize the acromioclavicular joint are partially or completely torn resulting in instability. The preferred treatment option is surgery. Multiple surgical techniques have been described and we have recently summarized the more contemporary options in a review article. Our preferred technique is the use of a low profile plate typically used in forearm fractures with additional stabilization of the coraco-acromial ligaments.
Acromioclavicular Joint Injury
This injury is also known as a shoulder separation. It is either caused by a direct blow to the shoulder such as a tackle injury in Rugby or a fall onto the shoulder. Treatment depends on the severity of the injury
In type one and two type injuries supportive treatment with a sling, pain medication, early movement and physiotherapy is sufficient whilst in type four to six injuries surgery is always required. For type three injuries treatment is controversial but should be considered in active people, workers and individuals who perform overhead activities frequently.
Proximal Humerus
These fracture are more commonly seen in older patients and involve approximately 5% of all fractures. They are more common in females. The fractures are categorized according to how many parts of the proximal humerus are involved and range from one part to four part with or without involvement of the articular part of the bone
Most fractures which are displaced less than 5 mm and where the bone fragments are not rotated can be treated non-operative with sling immobilisation. Severely displaced fractures generally require surgical fixation and in severe fractures involving the joint surface occasionally joint replacement is the best choice.
Humerus Shaft
Humerus shaft fractures are either seen in the young and active population or elderly osteoporotic patients.
In the young population the fracture is usually caused by high energy injuries whereas in the elderly, simple falls and low energy injuries are more common. If they are not displaced they can be treated with a functional brace with good success. When displaced operative treatment is preferable. Surgical fixation should also be considered for transverse fractures as these type of injuries have a high non-union rate. This can either consist of a plate and screws or an intra-medullary nail. Recently percutaneous minimal invasive surgery combines the best of both worlds and is our preferred option MIPO.
Distal Humerus
These fractures include supracondylar, single- and bicolumn fractures involving the joint surface of the bone or so called coronal shear fractures.
Treatment of these fractures are complex and almost always require surgery. The goal is to restore motion but successful outcome is defined as elbow motion from 30-130 of flexion which is considered the functional range of this joint. Unfortunately the outcome is not satisfactory in up to 25% of patients.
Olecranon Fractures
An indirect blow or a fall onto the outstretched upper extremity usually causes a transvers fracture and a direct blow results in a comminuted fracture. The triceps muscle inserts onto the olecranon which often causes displacement. In general these injuries require surgery.
Radial Head and Neck Fractures
The radius communicates with the humerus at the elbow joint. The proximal end is called radial and and neck. The head also provides stability and comminuted fractures or fractures associated with an elbow dislocation can cause instability.
Nondisplaced fractures can be treated with a very short period of immobilisation followed by early range of motion exercises. Displaced fractures or fractures with a mechanical block requires surgery. Severely comminuted fractures occasionally require resection and replacement with a metallic implant.
Monteggia Fractures
These are rare injuries and consists of a proximal fracture of the ulna with an associated radial head dislocation.
They are often part of more complex injuries including radial head fractures, olecranon fractures, lateral collateral ligament injuries or the terrible triad of the elbow. Early surgery is important as delays can increase the complication rates significantly.
Galeazzi Fractures
These are fractures of the distal third of the radius and an associated injury to the radioulnar joint.
If the radius fracture is close to the joint these are unstable injuries. The mechanism of injury is typically a fall onto the outstretched hand with the forearm in pronation. The treatment is always almost surgical and early surgery is superior to late reconstruction.
Distal Radius Fractures
Distal radius fractures are amongst the most common injuries.
They account for nearly 18% of all orthopaedic injuries and tend to occur in older patients. In younger patients they are associated with high energy trauma. Osteoporosis and female gender is a major risk factor. Bone density scans are recommended in women with distal radius fractures. Treatment is still controversial. If the fractures do not involve the joint surface, is shortened less than 5 mm and angulated less than 5 degrees conservative treatment in a cast is appropriate. All other fracture patterns tend to have better outcomes with surgical treatment.
Scaphoid Fracture
The scaphoid is the most commonly broken carpal bone.
One problem with this bone is the blood supply as it enters the bone distally resulting in non-healing and even necrosis.
Early treatment is important. Many fractures can be treated with long periods of cast immobilisation but often early surgical treatment results in more predictable outcomes. Pain in the anatomic snuffbox following a fall is the main presentation. Early radiographs are often normal and follow-up with MRI is advised. Another option is cast treatment and repeated Xrays two weeks later.
Metacarpal Fractures
These fractures are divided into head, shaft and neck.
The most common mechanism of injury is a direct blow to the hand or a rotational injury with axial loading. Careful clinical examination is compulsory as the overlying tendons or neurovascular structures may have also been injured. Conservative treatment is indicated if the fracture is stable with no rotational component. For shaft fractures in the index and long finger up to 20 degrees of angulation is acceptable; in the ring finger up to 30 degrees and in the little finger up to 40 degrees. For neck fractures slightly higher angulation is acceptable.