Clavicle Fractures:
- Most common sites: middle (80%) > distal (15%) > proximal (5%)
- Look for skin tenting -> results in open fracture by perforating the skin or creating a necrotic area
- X-ray: AP, 45° cephalic tilt (shows sup\inf displacement)
- NVS (brachial plexus) of the UL runs below the clavicles -> evaluate it!
- Treatment:
- Non-operative: if non-displaced -> sling
- Operative: ORIF w\ plate & screws more commonly, IM nailing
- Absolute indications: open fractures, neurovascular
- Relative indications: skin tenting, shortening of 2 cm, 100% displacement, interfragmentary piece, ligament injury
Shoulder Dislocations:
- Anterior: (most common)
- MOI abduction, extension, ext rotation of the arm
- O\E: pt’s arm will be abducted and externally rotated (can’t internally rotate), “squared off” shoulders
- Posterior:
- MOI: 3E’s: epilepstic seizures, EtOH, electrocution
- O\E: pt will present w\ the arm locked in internal rotation (can’t externally rotate)
- Inferior: aka “luxiatio erecta” (rare)
- O\E: pt will be in saluting position
- Clinical evaluation: apprehension test, axillary N exam (sensory patch over deltoid + abduction)
- Hill-sachs lesion: indentation of humeral head against glenoid edge
- Anterior dislocation -> Hill-sachs in the back
- Posterior dislocation -> Hill-sachs in the front
- Bankart lesion: tear in the labrum of the glenoid rim -> associated w\ high recurrence rate of shoulder dislocations esp in young pts. While in elderly, shoulder dislocations are associated w\ rotator cuff tears
- X-ray:
- “True” AP view
- Axillary view -> lateral arm abduction (most imp, esp to dx post dislocation)
- Trans-scapular Y “Mercedes-Benz sign”
- Hill-sachs (done after 2-3 wks, not acutely)
- Treatment methods: kocher’s (method of choice), traction-countertraction, Stimson (hanging the arm), Hippocratic method

Proximal Humerus Fractures:
- Neer classification: a part is a piece w\:
- > 1 cm displacement
- > 45° angulation
- Anatomic neck is closer to the head -> higher incidence of AVN
- Examine the axillary N!
- What’s the difference of an impression fx and Hill-sachs? Position. Impression fx is directly on the articular surface which indicates a high energy mechanism, Hill-sachs is either post or ant
- Treatment:
- Non-\minimally displaced: sling immobilization for 2-3 wks
- Two or three-part fracture: ORIF
- Four-part fracture: ORIF in young, hemiarthroplasty in elderly

Humeral Shaft Fractures:Â
- Examine the radial N!
- Treatment:
- Non-operative: initially sugar tong\hanging cast followed by Sarmiento functional brace 2 wks later
- Operative: ORIF (open fx, neurovascular, unacceptable alignment, segmental, obesity):
- Plate & screws most commonly
Distal Humeral Fracture; Holstein-Lewis Fracture:Â
- May entrap or lacerate radial N (fix it even if no radial N sx)
Forearm Fractures:
- Contralateral X-ray are a must esp in bone loss? to recreate the normal side while fixation: alignment, length, and rotation -> it becomes your template
- How to check rotation? Supination\pronation
- Ulna can be negative, positive, neutral
Ulna: Nightstick:
- Isolated ulnar fx w\out radial head dislocation
- Direct blow to forearm -> holding up arm to protect face
Ulna: Monteggia:
- Prox ulnar fx + radial head dislocation (PRUJ injury)
- Bado classification:
- Type I: anterior radial head dislocation
- Type II: posterior radial head dislocation
- Type III: lateral radial head dislocation
- Type IV: both ulna and radius are fractured
Radial: Galeazzi:
- Distal radial fx + DRUJ dislocation
- Reverse Galeazzi: ulnar fx + DRUJ dislocation
- MOI: FOOSH on pronation
Distal Radial Fractures:
- Most common upper limb fx
- Clinical evaluation: check ipsilateral elbow and shoulder, carpal tunnel syndrome
- X-ray: AP (radial inclination and radial length) + lateral (volar tilt)
- Treatment:
- Non-operative:
- Manual closed reduction under hematoma block
- Traction w\ finger traps -> ulnar deviation volar flex to max length of radius to use the force on the radial column
- Sugar tong, full circular cast
- Operative: if open fx, neurovascular, failed closed reduction, loss of reduction
- Non-operative:
Scaphoid Fractures:Â
- Most common carpal bone fx
- Site: waist > proximal (worst prognosis, highest risk of AVN) > distal
- MOI: hyper-extended + radially diverted wrist
- Blood supply:Â
- Dorsal: radial A -> dorsal carpal branch (80%, retrograde)
- Volar: radial A -> superficial palmar branch (20%)
- Clinical evaluation:
- Dorsally: snuff box tenderness
- Volarlly: scaphoid tubercle tenderness
- Pain w\ resisted pronation
- X-ray: AP, lateral, scaphoid-specific views (wrist ext w\ ulnar deviation -> shows fx in a clear line)
- Treatment:
- Non-operative: usually non-displaced -> long-arm thumb spica cast for 4 wks then short arm cast until radiological evidence of healing (2-3 mo)
- Operative:
- Minimal displacement -> percutaneous fixation w\ headless (countersink) screw
- Severe displacement, humpback deformity -> ORIF w\ headless (countersink) screw
- If the pt’s presenting w\ a clinical picture of scaphoid fracture but no radiological signs? Manage it as scaphoid fx. Bc it might be a hairline fx which doesn’t appear until 2-3 wks when bone resorption happens, so treat as scaphoid fx and repeat X-ray 2 wks later to r\o fx. (or do CT from the beginning and you can see it clearly)
Download the PDF version: here
References:
- Dr. Khalid Alsheikh’s lecture
- Toronto notes
- Orthobullets