Upper Limb Trauma
I have a high volume general trauma practice at the Norfolk and Norwich University Hospital. I also offer a specialist upper limb trauma service.
Generally speaking the majority of upper limb fractures may be managed without surgery and any operative intervention carries with it an inherent risk. As always therefore it is a case of weighing the risks and benefits of each case on its own merit.
Clavicle (Collar bone) Fractures
Clavicle fractures are common. The majority will heal well given enough time with little residual functional problems. They may well take several months to fully unite. Some particular patterns of fracture are more likely to have prolonged healing times and in these types of fracture I have a lower threshold to offer initial fixation.
If the clavicle fracture fails to heal in a reasonable length of time (a clavicle non-union) then I also offer fixation of the non-union.
Acromio-clavicular joint (ACJ) Injuries
The joint at the outer end of the collar bone is known as the ACJ. It is also relatively commonly injured. The majority of injuries are low grade sprains to the ligaments around the joint. More significant injuries may cause the ACJ to 'spring' with the outer end of the collar bone becoming prominent. Even in this situation the shoulder is likely to settle to an excellent functional level without any need for any intervention other than physiotherapy.
Surgical stabilisation is therefore reserved for those minority of very severe acute injuries or for those whose moderate injury fails to settle.
Dislocations of the Shoulder Joint
Acute management of traumatic shoulder dislocation should consist of reduction of the dislocation with appropriate pain-killers or sedation.
Following the reduction a sling should be worn.
The risk of recurrent dislocation depends on the presence of fractures around the shoulder and the age of the patient.
If this is a first time dislocation then it is reasonable to pursue a non-operative course of management with appropitiate physiotherapy. If however the joint has dislocated several time it may be worth considering surgical stabilistaion
Fractures of the proximal humerus
Fractures of the shoulder are generally managed non-surgically in a sling. This course of action safely results in healing for most fractures. Unfortunately there is often a functional loss but even with surgery the function following these injuries is often impaired. Surgical fixation may offer an earlier return of movement but after a year the difference is slight.
In some fracture patterns early surgery is advocated as it does make a difference to long term outcomes and this may consist of fixation of the fracture or replacement of the shoulder.
Fractures and dislocations around the elbow
The elbow is a complex joint consisting of two parts.The part that allows the elbow to bend and the part that allows the forearm to rotate. Either or both may be injured. Additionally the ligaments around the elbow may be injured
The principles of management are to allow early movement to prevent elbow stiffness. For minor fractures it may be enough to simply get the arm moving after a few days rest in a sling. More significant injuries may require surgery to fix the fractures and/or repair the ligaments.
Distal radial fractures are amongst the most common fractures that present to fracture clinics.
If the fracture is well reduced they may be managed non surgically in a plaster for 5-6 weeks. Some wrist stiffness is to be expected after immobilistaion but generally settles with appropriate therapy.
If the fracture is unstable or has a fracture into the joint itself surgical fixation may be advocated and this commonly includes a plate and screws.
Fixation of distal radial fractures does also have the benefit of early mobilisation.