Extremity fractures are common injuries and often necessitate an Emergency Department (ED) visit. Most closed fractures can be managed conservatively in the ED with splinting and follow-up if there is no neurologic or vascular compromise. This chapter addresses four common fracture patterns of the upper extremity that may require reduction by the Emergency Physician (EP). These include clavicular fractures, dorsally angulated distal radius or Colles fractures, displaced surgical neck fractures of the humerus, and supracondylar fractures of the humerus. The reduction of fractures in the ED should involve consultation with an Orthopedic Surgeon prior to performing the procedure. The only exception to this is the existence of neurologic or vascular compromise and the Orthopedic Surgeon is not immediately available.
Clavicular fractures are common and represent approximately 5% of all fractures.1-4 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 from a fall.4 These fractures are usually detectable clinically (Figure 112-1) with plain radiographs (Figure 112-2) helping to confirm the diagnosis.5 These fractures are relatively common and have a definite risk of associated complications.
Middle third clavicle fracture with soft tissue swelling. (From Sherman SC, et al: Simon’s Emergency Orthopedics, 7th ed. New York: McGraw-Hill; 2014. Courtesy of Northwestern Emergency Medicine teaching file with permission.)
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 112-3). The subclavian vessels and nerves of the brachial plexus pass posterior and inferior to the clavicle at its midportion where it overlies the first rib. The proximity of these neurovascular structures and 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. 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.6 This simple classification is useful clinically and mechanistically but it does not predict outcomes. Group I fractures are midclavicular and account for ...