Fall on the outstretched hand (FOOSH), when the forces transmitted up the upper limb may indirectly result in a fracture, or from a direct blow.

Pain occurs at the site of the fracture whenever the upper limb is moved. The patient often supports the injured arm at the elbow in an attempt to reduce movement of the limb. There is usually swelling at the site of the fracture, which typically occurs at the junction of the outer (lateral) third and inner (medial) two-thirds of the bone.

The upper limb should be immobilised in a broad arm sling. A collar and cuff should not be used, as this will act to separate the bony ends of the fracture due to the weight of the arm.

This is usually a straightforward injury to treat. The sling will often control the pain as it prevents movement at the fracture site. As with all limb injuries, there is a chance of damage to important vascular and neurological structures close to the fracture site. The subclavian artery and vein are in close proximity to the clavicle and although injury to them is rare, it can be serious. Similarly, the nerves that supply the upper limb may be injured, particularly when the fracture has been caused by direct rather than indirect force. Direct injury to this region may also result in chest injury and the assessment must not be confined to the clavicle.

Usually due to a direct blow, most commonly after a fall from a motorcycle, from a blunt weapon during an assault or accidentally during a sporting event with a stick or bat (e.g., a hockey stick). The scapula is surrounded by muscle and this is an unusual injury, considerable force being required.

Pain occurs over the site of the fracture and may be made worse with movement of the upper limb.

Immobilisation of the upper limb in a broad arm sling will reduce the discomfort.

There may be associated injuries to the thoracic cage and ribs and these need careful examination.

Fall on the outstretched hand (FOOSH) or by direct injury to the anterior aspect of the shoulder, levering the medial end of the clavicle away from its usual articulation with the manubrium of the sternum.

There is pain localised at the medial end of the clavicle, made worse by movement of the upper limb. There may be swelling and deformity over the sternoclavicular joint.

The vast majority of these injuries are subluxations or partial dislocations. They are best treated in a broad arm sling.

Occasionally there is severe displacement. If the medial end of the clavicle has been dislocated posteriorly, then the major vessels are in danger of injury. The patient should be examined for signs of chest injury and shock. If there is evidence of shock, they should be considered to have a severe, potentially life-threatening injury and evacuated to hospital immediately. Intravenous access can be achieved in transit and any delay in reaching hospital should be avoided. Occasionally posterior dislocation of the sternoclavicular joint may produce airway obstruction: the clavicle should be pulled forwards, as a matter of urgency.

Usually a fall onto the point of the shoulder. It is a common injury in rugby football. This injury results from partial or complete disruption of ligaments between the clavicle and the acromion and in severe cases also the ligaments between the clavicle and the underlying coracoid process of the scapula.

Pain at the lateral end of the clavicle, made worse by attempting to carry any weight with the affected arm. There will be a variable amount of local swelling and usually a step is visible between the lateral end of the clavicle and the acromion (this is the expanded anterolateral process of the scapula which forms a bony roof over the shoulder joint and muscles and normally articulates with the clavicle).

The upper limb should be immobilised in a broad arm sling.

The mechanism of injury should lead to a high level of suspicion of associated injuries to the cervical spine and nerves in the brachial plexus.

Usually caused by forced external rotation of the glenohumeral joint (the joint between the humerus and the glenoid process of the scapula). Typically, this results from a fall or a mistimed rugby tackle. If the shoulder has previously been dislocated, then less force is required to produce a recurrent injury.

The patient will be supporting the forearm with the elbow flexed. The shoulder will look abnormal (square contour) compared with the other side, with a loss of the usual rounded contour of the upper arm. The lateral edge of the scapula may well appear prominent. It is important to assess the sensory portion of the axillary nerve which provides sensation to the ‘regimental badge’ area of skin on the lateral aspect of the proximal arm.

Treatment should be directed at immobilising the upper limb during transfer to hospital for relocation of the joint. An acceptable method is to allow the patient to sit upright and support the arm, perhaps resting it on a pillow. The sooner the joint is relocated the better.

The longer the joint is dislocated, the more permanent damage is done to the articular surface of the bone and to the soft tissues. All the nerves of the upper limb can be at risk. Damage to the major blood vessels may occur and proper examination and reexamination of the distal limb circulation is essential. Severe fractures and fracture-dislocations of the surgical neck of the humerus may mimic simple anterior dislocation.

Often a fall on the outstretched hand with the arm internally rotated or a direct blow to the anterior aspect of the shoulder. An electric shock, epileptic fit or chronic muscle spasticity such as is seen in cerebral palsy can also cause posterior dislocation.

These are similar to those of anterior dislocation, with pain, swelling and local deformity.

The arm should be immobilised and the patient transported to hospital.

The nerves in the brachial plexus are particularly susceptible to damage due to pressure from the humeral head. Recognition and early relocation are essential. The X-ray changes are very subtle and this injury can be easily missed in hospital.

Inferior dislocation is extremely rare but can follow a violent convulsion or an electric shock.

The arm is held extended above the head and the injury is extremely painful. The condition is often bilateral.

Analgesia and support during the transfer to the hospital are all that is required.

Fitting the patient onto the stretcher may be difficult.

Usually either a fall onto the outstretched hand (FOOSH) or a direct fall onto the upper arm, particularly in elderly patients and those with osteoporosis. The fracture can occur in younger patients following direct violence.

There is pain at the upper end of the arm. The patient will usually be supporting the arm at the elbow with the other hand. There may be obvious deformity. Swelling is almost immediate, but the severe bruising which accompanies this injury may not be apparent for several days and can track distally down the lateral aspect of the arm.

The arm is supported in a broad arm sling initially. Once the diagnosis has been confirmed in the accident and emergency department, the sling should be changed to a ‘collar and cuff.’ This allows the weight of the arm to apply traction to the fracture and tends to reduce the fractured bone into its normal anatomical position.

As with all fractures, the surrounding nerves and blood vessels can be injured directly at the time of the fracture.

The shaft of the humerus may be fractured through direct injury such as a fall onto the arm or a blow from a blunt weapon. Indirect force can cause these fractures, although the fracture pattern may be different.

The arm is painful and may be supported at the elbow by the other hand. There may be obvious angular deformity, but rotational malalignment is not always obvious. There may be significant swelling and bruising. It is essential to examine the distal portions of the limb to exclude vascular and neurological injury.

The arm should be supported in a broad arm sling.

The radial nerve runs in a groove, closely applied to the humeral shaft posteriorly. It may be damaged directly or secondarily due to swelling (compartment syndrome). Loss of radial nerve function may lead to weakness of the muscles that extend the wrist and as a result the patient will demonstrate ‘wrist drop’ (inability to extend the wrist). The arterial blood supply to the upper limb is via just one vessel at this point, the brachial artery. This artery may suffer direct injury or may be constricted owing to a compartment syndrome.

Supracondylar fractures of the distal portion of the humerus just proximal to the elbow joint are common in childhood. They are typically caused by a fall onto the outstretched hand. The fractures can range from an undisplaced crack to a completely displaced injury with vascular and neurological damage.

There is pain at the elbow after a fall. The child will support the elbow with the other hand. There may be obvious swelling and deformity and serious interference with the blood supply to the distal part of the limb.

The arm should be immobilised in a broad arm sling in slight extension. Constant evaluation of the distal circulation is essential. If the circulation is compromised the elbow should be extended (straightened).