William W. Forgey, MD
ORTHOPEDICS part 6 – Upper Arm Fracture, Elbow Trauma, Forearm Fractures
Updated: Nov 13, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Upper Arm Fractures (Near the Shoulder)
The humerus is the upper bone of the arm. Fractures of the upper part (or head) of the humerus are most common in elderly people. Again, the shoulder will be very painful. The classification of these fractures is made with X-rays, which indicate that not only has a fracture occurred but also shows the number of pieces in the fracture and whether angulation or displacement has transpired. Displacement or severe angulation frequently requires surgical repair, but often very conservative measures are followed by the orthopedic specialist. Without access to X-ray or an orthopedic specialist, we have to treat all injuries conservatively.
Fractures of the upper humerus are associated with swelling and eventual bruising of the shoulder and upper arm, with gravity slowly causing the swelling and bruising to appear lower and lower down the arm. Severe pain will prevent normal movement of the shoulder, but some movement is frequently possible. As fractures of the upper part of the humerus occur through bone that mends itself readily (cancellous bone), the final outcome is often more dependent upon limiting the length of time of immobilization and starting proper physical therapy than it is upon the number of pieces or the separation and angulation. Conservative treatment will consist of a sling and swathe (figure 7-3). It is important in older individuals to mobilize the shoulder as soon as possible; otherwise adhesions form and a frozen shoulder will result. An X-ray would help determine how much time should be allowed in the sling. This would range from only a few days to 4 or even 6 weeks for a four-part fracture with marked displacement. If the patient is over 30, the best rule of thumb when treating without an X-ray is to mobilize and start physical therapy at 2 weeks. A youngster’s arm can be left in a sling for 4 weeks. The therapy should consist of range-of-motion movements, such as circular elephant trunk motions while bending over and raising the arm in front, to the side, and toward the rear. Effort should be made to move the shoulder as if the patient were wiping his bottom. The patient should do this on his own, without someone forcing his arm through these motions.
Upper Arm Fractures (Below the Shoulder)
Fractures in the shaft beneath the head of the humerus will result in muscle spasm, causing an overriding of the shafts of bone. This is prevented by applying a hanging cast. This amounts to a weighted cast applied to the forearm, with a loop of cloth supporting much of the weight of the cast from around the victim’s neck. Mobilization and physical therapy should be started in 2 weeks. It is not practical in a setting without X-ray to properly design and follow the results of a hanging cast. Pain and apparent fracture of the humerus at the shoulder will probably have to be treated with a sling and swathe, with early mobilization as mentioned above.
Humeral shaft fractures take 2 to 4 months to heal. Located between the shoulder and the elbow, this type of fracture is best splinted with a cast that orthopedic surgeons call a sugar tong splint. It amounts to a U-shaped plaster extending from the armpit around the elbow back up to the shoulder, molded to the arm after reduction, and wrapped with an ace bandage. A SAM Splint can be used to construct a sugar tong splint, as in figure 7-7.
Complete fractures of the shaft of the humerus will be very painful, making a crunching feel when the bone is gently stressed. Incomplete fractures will be exquisitely tender to touch. Several days after the injury, swelling and bruising will appear at the elbow and forearm. Humeral shaft fractures at a point one-third of the way up from the elbow may cause damage to the radial nerve, thus causing numbness to the forearm, thumb, and index finger. This numbness generally lasts from 3 to 6 months and will commonly resolve on its own. Usually developing numbness is a serious consequence that reflects either a tear or compression on a nerve.This is an area where the development of such a numb feeling is less cause for panic.
Fractures of the humerus above the elbow are very treacherous, as bone fragments may seriously injure the nerves or blood vessels at this location. Fractures of the elbow itself are similarly dangerous due to the possible damage to nerve, blood vessel, or articular surfaces of the bones in this joint. The immense swelling associated with fractures or sprains at the elbow causes compression that frequently does more damage than sharp pieces of broken bone.
Avoid splinting the elbow near a 90-degree angle. Allow the elbow to droop in the sling with a posterior padding. Never wrap the elbow joint at the front aspect—leave this area open to the air. It is compression in the front of the elbow joint, an area called the antecubital fossa, that frequently results in serious injury to the blood vessels and nerves. Surgical intervention with X-ray assistance is required, so back to the grid with you for this one to ensure normal elbow function. Allowing the injured elbow to freeze into a 120-degree position may be the only treatment you can offer under long-term off-grid conditions.
Dislocation of the elbow is most common in young adults. Fractures of the tip of the elbow (the coronoid process) frequently are involved but generally do not cause future problems.
Forearm fractures in children can generally be treated by reducing under X-ray and plaster casting, while in adults they frequently are treated surgically. Neither option is available to the isolated wilderness inhabitant if evacuation is not possible. The position of splinting on forearm fractures differs depending upon the location along the two bones, due to different forces upon these bones from tendon and muscle attachments. This positioning can only be held properly with tight-fitting plaster splints. Bone alignment can only be followed through repeated X-rays. Therefore, it is obvious that a completely fractured, unstable condyle can cause severe problems, as indicated above, primarily due to compression from associated bleeding on the neurovascular bundle. Reduction obviously should not be attempted if there is a chance of being treated properly by an orthopedic specialist with X-ray equipment. The appearance of the dislocated elbow is obvious when compared to that person’s other elbow. Some people have a sharper-looking elbow tip than the average individual. However, swelling and a particularly prominent, hard point behind the elbow would indicate that a dislocation has transpired.
Pain medication should be given to the victim to relax the muscles prior to attempting to reduce the dislocation. Figure 7-8 demonstrates the technique of reducing an elbow dislocation.
The ideal position after reduction of the elbow is at 90 degrees with a posterior plaster splint. However a 90-degree position is potentially dangerous, as swelling may compromise the circulation. If the pulses at the wrist are decreased, then allow the elbow to droop as necessary to relieve this compression, possibly to a 120-degree position as described above. The reduction of a simple elbow dislocation is best maintained in the posterior splint for 3 weeks, then start range-of-motion exercises. Soaking the elbow in warm water about 15 minutes prior to starting a gentle exercise program is helpful. If unusual deformity has resulted, or if the elbow is frozen, this may have to be accepted under survival conditions until definitive surgery can be accomplished. Full and proper use of this elbow will probably never again be reestablished; even after delayed surgery a fracture of the forearm will very likely not heal properly when treated by crude techniques in an off-grid setting.
Most fractures of the forearm are not complete and unstable, however. They will heal nicely with protective splinting being the only required therapy. A stable crack can be suspected from swelling and point tenderness to gentle finger palpation by the examiner along the radius and ulna, the two forearm bones. Under this circumstance a splint must be manufactured that will provide stability so that this fracture can heal without danger of further trauma, as in figure 7-9. The bone will weaken during the healing process and additional trauma may turn this non-displaced fracture into an angulated mess. Pad the splint well and provide a sling for at least 3 weeks. Keep splinted for a total of 6 weeks, longer if point tenderness is still present. If point tenderness disappears within a few days or at most 2 weeks, the injury was not a fracture, but simply a contusion, and the splint may be safely removed at that time.
Fractures associated with deformity in the forearm provide the physician with two challenges: first, reducing the fracture, and second, maintaining its position with proper casting. Reduction of forearm fractures is generally done by traction, increasing the angulation to engage the fracture ends, then straightening the bones prior to casting. This is done with anesthesia. The survivalist had best splint deformed fractures of the forearm after straightening gross angulation with in-line traction. The splinted position will have to be maintained for 8 weeks or longer, depending upon the disappearance of local tenderness. A well-padded splint may generally be applied in a firm manner, immobilizing the elbow and wrist joints. Corrective surgery can be performed later. It is best to avoid a manipulation that will be extremely painful and unstable anyway.
Next week's Orthopedic post will cover wrist fractures, thumb sprains and fractures and hand fractures.