Extremity fractures are a common reason for Emergency Department
visits. If there is no neurologic or vascular compromise, most closed
fractures can be managed conservatively in the Emergency Department
with splinting and Orthopedic Surgeon follow-up. This chapter addresses
four common fractures of the upper extremity that may require reduction
by the Emergency Physician. These include clavicular fractures,
Colles fractures, displaced surgical neck fractures of the humerus,
and supracondylar fractures of the humerus. The
reduction of fractures in the Emergency Department should involve
consultation with an Orthopedic Surgeon prior to performing the
procedure. The only exception to this is if neurologic or vascular
compromise exists in the extremity.
Clavicular fractures are common and represent approximately 5
percent of all fractures.1–3 Most of these occur
at the junction of the middle and distal third of the clavicle,
just medial to the coracoclavicular ligament. The clavicular fracture
is the most common fracture encountered in childhood and occurs
most often as a result of a fall. These fractures are usually detectable
clinically, with plain radiographs helping to confirm the diagnosis.
Although these fractures are relatively common, there is a small
but definite risk of associated complications.
Anatomy and Pathophysiology
The clavicle is the only bony attachment of the upper extremity
to the axial skeleton. It serves as a strut to support the shoulder
girdle. It provides support and stabilization of the upper limb
while allowing a broad range of movements. The clavicle is securely
attached at both the acromioclavicular and sternoclavicular joints
by ligaments (Figure 75-1). The great vessels of the upper extremity
and nerves of the brachial plexus pass posteriorly to the clavicle
at its midportion where it overlies the first rib. The proximity
of these neurovascular structures, as well as the underlying lung,
accounts for most of the potential complications of clavicular fractures.
The clavicle serves as a strut between the torso and
upper extremity; it is held firmly by the acromioclavicular and
sternoclavicular ligaments. The brachial plexus and great vessels
pass behind the middle third of the clavicle.
The most commonly used classification for clavicular fractures
was proposed by Allman.4 This simple classification is
useful clinically and mechanistically to the Emergency Physician. Group
I fractures are midclavicular and account for approximately 80 percent
of clavicular fractures. These most often result from a shearing
force applied to the lateral aspect of the shoulder. Group II fractures
involve the distal third of the clavicle and account for approximately
15 percent of all clavicular fractures. These most often result
from a direct blow to the top of the shoulder. Several additional
subclassifications have been proposed for these fractures based
on the location of the fracture and associated ligamentous injury.
Operative repair is suggested for some of these subtypes. All distal