Bones • THEME Early management of upper limb fractures in general practice eneral practitioners are frequently confronted with BACKGROUND Upper limb injuries are very G injuries to the upper limb, most commonly from falls. David Spain, common and patients frequently present to general practitioners for treatment. Circumstances This article focusses on upper limb fractures and the MBBS, FRACGP, important issues relevant to correct early management. FACEM, is Director, of the injury and varied patient factors are critical Allamanda 24 Hour to assessment. Outcome of these injuries involves History of injury Emergency Care short term pain control and diagnosis; fracture Centre, Allamanda immobilisation, comfort and function in the A careful history should consider in detail the circum- Private Hospital, Senior Staff Specialist, treatment device medium term; and longer term, stances of the accident or fall (Table 1). This helps predict Emergency the best functional outcome. likely injury and is essential to distinguish simple slip falls Department, Gold OBJECTIVE This article aims to guide GPs from medical causes of collapse. Isolated injury must be Coast Hospital, and Clinical Senior Lecturer, through the initial assessment and early distinguished from an injury as a part of actual or potential the University of management of fractures and provides a logical, multiple trauma. Patients with a severe dramatic and Queensland. simple structure for this process. Understanding painful injury can be distracted, often resulting in other of different injury patterns and patient injuries of significance being initially overlooked. Simple characteristics to assist correct overall enquiry about other possible injury often unearths management is emphasised and the correct unusual replies. ‘My neck is also a bit sore’ may be the timing for early follow up is discussed. only clue to an otherwise unsuspected spinal injury. DISCUSSION Many upper limb fractures can be Other history comprehensively managed in general practice. Bad outcomes from injuries are not uncommon Hand dominance, occupation, pastimes and home circum- and most commonly occur due to relatively minor stances are critical information that may affect early errors in early decision making. These ‘second management decisions. Socially isolated people with minor accidents’ are often completely preventable. dominant hand injuries frequently need extra community sup- ports or brief hospital admission. Past medical history, medication and allergy history are important to assist deci- sions especially regarding appropriate analgesia. Analgesic requirement should always be explored individually. Pain per- ception, self administered analgesics before consultation and prior experience with pain and analgesics often influence decisions of type, strength and method of administration. Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004 105 Theme: Early management of upper limb fractures in general practice Table 1. History of injury Table 2. Examination of isolated upper limb trauma Why the fall occurred? ‘Simple slip’, medical causes, intoxication When the injury occurred? Delay may change management or suspect child abuse 1. Any swelling or deformity? Where the injury occurred?Home, work, high speed car accident 2. Intact skin? How the injury occurred/ This often predicts likely injury and its consistency 3. Define likely site of fracture mechanism of injury? with stated cause 4. Look for possible second injury in same limb What force was involved? Large force increases risk of more severe 5. Examine joint above and below area of likely injury orthopaedic injury 6. Check circulation Have you any other injury from the fall/incident? 7. Check sensory and motor function Table 3. Analgesic options Figure 1. Classic examination Temporary splints of anatomical Elevation snuff box for Drugs scaphoid tenderness Paracetamol 15–20 mg/kg orally Codeine 1 mg/kg orally Ibuprofen 10 mg/kg orally Figure 2. Morphine 0.2 mg/kg intramuscularly Palpating in Pethidine 1 mg/kg intramuscularly another direction for scaphoid tenderness on volar aspect Table 4. Recommended early referral to hospital of hand • Compound fractures • Amputations Figure 3. • Grossly deformed fractures requiring manipulative reduction Compressing for • Suspected fracture dislocations (eg. Monteggia fracture) scaphoid tenderness by • Actual or suspected high risk vascular compromise (eg. elbow swelling pushing thumb possible supracondylar with absent radial pulse) and first • Neural compromise (especially where exploration or reduction can metacarpal toward radius improve outcome) • Patients who will not manage in the community for social reasons Examination Table 5. Causes of failure to diagnose fractures with imaging Defining the likely injury and its location by examination is Failure to X-ray critical (Table 2). Localisation of pain by the patient may Failure to image the joint above and below the suspect area be significantly above or below the injury, eg. forearm or Failure to get adequate views elbow with shoulder injury. Localisation of bony tender- Failure to see fractures - obvious or subtle ness is important to ensure imaging of the correct area. Failure to recognise soft tissue changes suggesting fracture (eg. sail sign at When gross deformity suggests an obvious fracture, the elbow from effusion) direct palpation of the deformed area is not necessary, as Acceptance that normal X-ray equals no fracture management is not changed. When absent, look at and Failure to repeat X-rays with persistent pain palpate the whole limb comparing to the opposite side if Failure to image both sides in cases of doubt, eg. epiphyseal injury near necessary. Specifically seek bony tenderness to assist the elbow in child decision to X-ray. Palpating the bone in different directions Failure to seek advanced imaging if persistent doubt can assist doubtful bony tenderness. This technique can be used on most bones but is demonstrated and particularly 106Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004 Theme: Early management of upper limb fractures in general practice Figure 4. Figure 8. Active extension Temporary wrist of wrist testing splint from radial nerve magazine and motor function crepe bandage Figure 5. Active opposition of thumb and Early management forefinger testing median nerve Appropriate analgesia tailored to the individual patient motor function and injury should be given (Table 3). Intravenous titration of parenteral narcotics is considered ideal in a hospital environment but is not practicable in a busy general prac- tice. Compound wounds ideally should be irrigated with Figure 6. sterile water or normal saline to remove gross contami- Abduction of nation and covered with a sterile dressing. fingers testing ulna nerve motor Temporary splinting greatly improves patient function comfort and may prevent conversion of closed to com- pound fracture during transport. This may be a simple sling or a temporary splint (Figure 8). Ice is variably reported by patients to assist pain and is of proven benefit for soft tissue injuries. An early decision on whether to image locally and helpful in assessment of the scaphoid bone (Figure 1–3). continue management by the GP should be made. This Palpate and evaluate the joint above and below any sus- will depend on the local medical environment, time of pected fracture closely. Assess circulation by presence of day and expertise of the GP. Recommendations for pulses and capillary return distal to the injury. Sensory and early referral are listed in Table 4. motor function for radial, ulna and median nerves tested in Imaging the hand is usually sufficient for most injuries distal to the shoulder area (Figure 4–6). Axillary nerve function should A low threshold to imaging is necessary with plain also be tested when the shoulder and upper humerus are X-rays the usual modality. Failure to diagnose occurs for involved (Figure 7). Use of a wooden spatula that has been several reasons and these are listed in Table 5. On X-rays broken in two is a suitable clean tool for sensation testing. the fracture should be sought. Fractures are not always In infants and young children who present visible in all planes so a line visible in a single film may be extremely distressed but with no obvious deformity or all that is seen. A clear disruption of the continuity of the swelling, clinical localisation is often almost impossible. cortex is usually diagnostic. Greenstick fractures in adoles- Parenteral analgesia with narcotics followed by a cents are often more subtle and may only be evident as a deferred examination looking for reproducible tender- minor irregularity or ‘buckle’ in the area of tenderness. ness in one area can often assist in this situation. X-rays are not always diagnostic in the first few days postinjury and if there is a clinical suspicion of fracture then management should be as if a fracture is present. Figure 7. Testing Repeat examination for bony tenderness and repeat X- axillary nerve sensation ray at 7–10 days postinjury will usually confirm (chevron patch) previously suspected fractures. By this time, resorption over insertion of deltoid of bone from the fracture site makes any fracture visible. If a fracture is seen, always consciously examine the rest of the film looking at other bones for fractures or dislo- cations. Fractures in more than one bone and associated dislocations are common in the forearm and the carpus Reprinted from Australian Family