Emergency Medicine

282 Orthopaedic Emergencies

INJURIES TO THE SHOULDER AND UPPER ARM

3 Remember that the elderly patient may now need social services support

in the form of ‘meals on wheels’, a home help, and possibly a community

nurse.

(i) Inform the GP by fax and letter so he or she may visit the patient.

4 Refer the patient to the fracture clinic for follow-up.

Fractures of the shaft of the humerus

DIAGNOSIS

1 These fractures are caused by direct trauma or a fall on to the outstretched

hand.

2 Upper-third fractures result in the proximal fragment being adducted by the

pectoralis major, whereas in middle-third fractures the proximal fragment is

abducted by the deltoid.

3 Clinically the diagnosis is usually evident, with obvious local deformity and

loss of function of the arm. Examine the affected arm for neurovascular

complications, which are common.

4 Complications are usually seen in middle-third fractures, including:

(i) Compound injury.

(ii) Radial nerve damage in the spiral groove, causing weak wrist

extension and sensory loss over the dorsum of the thumb.

5 Always include views of the shoulder and elbow, remembering the old adage

to ‘X-ray the joint above and the joint below any fracture’.

MANAGEMENT

1 Immediately refer to the orthopaedic team patients with:

(i) Grossly angulated or comminuted fracture.

(ii) Compound fracture.

(iii) Radial nerve palsy.

2 Otherwise, support the arm for comfort in a U-slab plaster or hanging cast.

This should not require analgesia to apply.

(i) Pad the arm well with cotton-wool and apply a 10–15 cm wide

plaster slab medially under the axilla, around the elbow, and up

over the lateral aspect of the upper arm on to the shoulder.

(ii) Hold the slab in place with a crêpe bandage, and support the arm

in a sling.

3 Give the patient analgesics and review in the next fracture clinic. Social

services support is needed for the elderly, who may require admission if they

are unable to cope.