Fracture and Dislocation of the Forearm, Wrist, and Hand

Humerus Fracture | Elbow Fracture | Nursemaid's Elbow | Ulna Fracture | Colles' Fracture | Scaphoid Fracture | Boxer Fracture | Bennett Fracture | References

Humerus Fracture

Definition: A humerus fracture is a break in the upper arm bone. It can occur at the proximal humerus (near the shoulder), the shaft, or the distal humerus (near the elbow).

Aetiology: Common causes include falls, direct trauma, or high-energy impacts such as car accidents. Osteoporosis increases the risk of humeral fractures, particularly in older adults.

Key Findings/Symptoms:

• Severe pain in the upper arm, often with visible deformity.
• Swelling, bruising, and tenderness over the fracture site.
• Inability to move the shoulder or arm.
• Numbness or tingling if the radial nerve is involved, particularly in midshaft fractures.

Investigations:

• X-rays: AP and lateral views of the humerus to assess the fracture pattern and displacement.
• CT scan: May be used for complex fractures, particularly around the shoulder or elbow.

Management:

• Primary Care: Immobilisation with a sling or shoulder immobiliser, analgesia, and referral to orthopaedics/fracture clinic.
• Specialist Care: Open reduction internal fixation (ORIF) for displaced or unstable fractures, conservative management with a functional brace for non-displaced fractures, and physiotherapy post-immobilisation.

Elbow Fracture

Definition: Elbow fractures can involve the distal humerus, the radial head, or the olecranon (part of the ulna).

Aetiology: Often caused by falls onto an outstretched hand (FOOSH), direct trauma, or high-energy impacts.

Key Findings/Symptoms:

• Severe pain and swelling around the elbow.
• Limited range of motion in the elbow joint.
• Visible deformity in cases of displaced fractures.
• Numbness or tingling in the fingers, indicating possible nerve involvement.

Investigations:

• X-rays: AP and lateral views of the elbow to assess the fracture and joint alignment.
• CT scan: Useful for evaluating complex fractures or intra-articular involvement.

Management:

• Primary Care: Immobilisation with a posterior splint, analgesia, and urgent referral to orthopaedics.
• Specialist Care: ORIF for displaced fractures or those involving the joint, conservative management with a hinged brace for stable fractures, and physiotherapy to restore function.

Nursemaid's Elbow

Definition: Nursemaid's elbow, or radial head subluxation, is a common injury in young children where the radial head slips out of its normal position at the elbow joint.

Aetiology: Typically occurs when a child's arm is pulled suddenly, such as when lifting or swinging a child by the hands.

Key Findings/Symptoms:

• Immediate pain and refusal to use the affected arm.
• The arm is held slightly flexed at the elbow and close to the body.
• No obvious swelling or deformity is usually present.

Investigations:

• Clinical Diagnosis: Based on history and physical examination. X-rays are generally not required unless the diagnosis is unclear.

Management:

• Reduction: Gentle manual reduction using the supination-flexion or hyperpronation technique. Most children will resume using the arm immediately after successful reduction.
• Post-reduction: Education for parents to avoid similar injuries and reassurance that this is a common and easily treated condition.

Ulna Fracture

Definition: An ulna fracture, commonly known as a "nightstick fracture," typically occurs in the midshaft of the ulna, often as a result of direct trauma.

Aetiology: Caused by direct blows to the forearm, such as during a fall, sports injury, or in self-defence against a blunt object.

Key Findings/Symptoms:

• Pain and tenderness along the ulna, especially over the site of the fracture.
• Swelling and bruising in the forearm.
• Inability to rotate the forearm or bear weight.
• Visible deformity if the fracture is displaced.

Investigations:

• X-rays: AP and lateral views of the forearm to assess the fracture pattern and any associated injuries.

Management:

• Primary Care: Immobilisation with a splint, analgesia, and referral to orthopaedics.
• Specialist Care: ORIF for displaced fractures, conservative management with a functional brace for non-displaced fractures, and physiotherapy post-immobilisation.

Colles' Fracture

Definition: A Colles' fracture is a fracture of the distal radius with dorsal displacement of the distal fragment, often caused by a fall onto an outstretched hand (FOOSH).

Aetiology: Commonly occurs in older adults with osteoporosis, but can also occur in younger individuals following trauma.

Key Findings/Symptoms:

• Severe pain in the wrist, with a "dinner fork" deformity.
• Swelling and bruising around the wrist.
• Limited range of motion in the wrist and hand.
• Numbness or tingling in the fingers, particularly if the median nerve is involved.

Investigations:

• X-rays: AP and lateral views of the wrist to confirm the fracture and assess the degree of displacement. The "dinner fork" deformity is typically seen in Colles' fractures.
• CT scan: May be used for complex or comminuted fractures to plan for surgical management.

Management:

• Primary Care: Immediate immobilisation with a splint, analgesia, and referral to orthopaedics for further management. Patients with minimal displacement may be managed conservatively with a plaster cast.
• Specialist Care: Closed reduction followed by casting for displaced fractures. ORIF may be required for fractures with significant displacement or comminution. Physiotherapy is crucial for regaining function post-treatment.

Scaphoid Fracture

Definition: A scaphoid fracture is a break in the scaphoid bone, one of the small carpal bones in the wrist, commonly occurring due to a fall onto an outstretched hand.

Aetiology: Falls or trauma that cause hyperextension of the wrist, particularly in younger adults.

Key Findings/Symptoms:

• Pain and tenderness in the anatomical snuffbox (the triangular depression on the radial, dorsal aspect of the hand).
• Swelling around the wrist.
• Pain with gripping or wrist movements.
• Often mistaken for a simple sprain if not properly evaluated.

Investigations:

• X-rays: PA and lateral views, along with scaphoid views, are essential to visualise the fracture. Initial X-rays may appear normal, so repeat imaging or MRI may be necessary if clinical suspicion remains high.
• MRI or CT scan: Useful for detecting occult fractures and assessing the blood supply to the bone, which is crucial due to the scaphoid’s risk of avascular necrosis.

Management:

• Primary Care: Immobilisation with a thumb spica splint or cast, analgesia, and referral to orthopaedics. Repeat imaging may be necessary after 10-14 days if the initial X-rays are negative.
• Specialist Care: ORIF may be required for displaced fractures or fractures at risk of non-union. Conservative management includes long-term immobilisation with a thumb spica cast, and follow-up imaging to ensure healing.

Boxer Fracture

Definition: A boxer fracture is a break in the neck of the fifth metacarpal, often resulting from a direct impact with a clenched fist, such as punching an object.

Aetiology: The fracture commonly occurs during fistfights or from striking a hard object with a closed fist.

Key Findings/Symptoms:

• Pain and tenderness over the knuckle of the fifth metacarpal.
• Swelling and bruising of the hand.
• Visible deformity with loss of the knuckle contour (a "dropped knuckle").
• Limited motion and grip strength in the hand.

Investigations:

• X-rays: AP, lateral, and oblique views of the hand to assess the fracture and angulation.

Management:

• Primary Care: Immobilisation with a splint or cast, analgesia, and referral to orthopaedics. Minimal angulation may be managed conservatively.
• Specialist Care: Closed reduction and casting for significant angulation. Surgical intervention may be necessary for severely displaced fractures or those affecting hand function.

Bennett Fracture

Definition: A Bennett fracture is an intra-articular fracture of the base of the first metacarpal (thumb), which involves a dislocation or subluxation at the carpometacarpal (CMC) joint.

Aetiology: Caused by a forceful axial load on a partially flexed thumb, often occurring in contact sports, falls, or during a fistfight.

Key Findings/Symptoms:

• Severe pain and swelling at the base of the thumb.
• Visible deformity and instability at the base of the thumb.
• Limited range of motion and weakness in the thumb, particularly in opposition and gripping.
• Crepitus (a grating sound or sensation) may be felt at the fracture site.

Investigations:

• X-rays: AP, lateral, and oblique views of the thumb to assess the fracture and degree of dislocation.
• CT scan: May be used for complex fractures to better visualise the injury.

Management:

• Primary Care: Immediate immobilisation with a thumb spica splint or cast, analgesia, and urgent referral to orthopaedics.
• Specialist Care: Closed reduction and percutaneous pinning for unstable fractures. ORIF may be necessary for complex or displaced fractures. Post-operative physiotherapy is crucial for restoring thumb function.

References

1. NHS (2024) Fractures of the Forearm, Wrist, and Hand. Available at: https://www.nhs.uk/conditions/fractures/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Fractures (Complex): Assessment and Management. Available at: https://cks.nice.org.uk/topics/fractures-complex/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Management of Hand and Wrist Injuries: Clinical Guidelines. Available at: https://www.bmj.com/content/350/bmj.h4300 (Accessed: 24 June 2024).
4. American Academy of Orthopaedic Surgeons (2024) Hand, Wrist, and Forearm Fractures. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/hand-and-wrist-fractures/ (Accessed: 24 June 2024).

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