Extremity fractures are a common reason for Emergency Department (ED) visits. If there is no neurologic or vascular compromise, most closed fractures can be managed conservatively in the ED 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 (EP). 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 ED 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% 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 90-1). 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 EP. Group I fractures are midclavicular and account for approximately 80% 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% 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 clavicular fractures ...