Orthopaedic Emergencies 281INJURIES TO THE SHOULDER AND UPPER ARMMANAGEMENT
1 Give the patient morphine 2.5–5 mg i.v. with an antiemetic such as meto-
clopramide 10 mg i.v.
2 Perform the reduction using procedural sedation with diazepam 5–10 mg i.v.
or midazolam 2.5–5 mg i.v., provided that a second doctor is present, and
monitoring and resuscitation equipment are available.
(i) Apply traction to the arm abducted to 90°.
(ii) Gently externally rotate the arm.
3 Place the arm in a sling and repeat the shoulder X-ray to confirm reduction.
Occasionally, the reduction may be unstable and immediate orthopaedic
referral will be required.
4 Give the patient an analgesic and refer to the next fracture clinic.
Fractures of the upper humerus
DIAGNOSIS
1 These fractures usually occur in elderly patients following a fall onto the
outstretched hand and may involve the greater tuberosity, the lesser tuber-
osity, the anatomical neck or most commonly the surgical neck of the
humerus.
2 There is localized pain and loss of movement, often with dramatic bruising
gravitating down the arm.
3 Complications include:
(i) Dislocation of the humeral head.
(ii) Complete distraction of the humeral head off the shaft.
(iii) Axillary (circumflex) nerve damage causing anaesthesia over
the upper, lateral aspect of the upper arm and loss of deltoid
movement.
(iv) Axillary vessel damage with compromised vascular supply to the
humeral head or distal arm.
4 Confirm proximal head fracture and associated humeral head distraction or
comminution with plain X-rays of the shoulder.
MANAGEMENT1 Immediately refer to the orthopaedic team patients with:
(i) Gross angulation or total distraction of the humeral head.
(ii) Fracture associated with a dislocation.
(iii) Associated neurovascular damage.
2 Otherwise, use a collar and cuff to allow gravity to exert gentle traction. Give
the patient an analgesic such as paracetamol 500 mg and codeine phosphate
8 mg two tablets q.d.s.