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Common Upper Extremity Fractures in Cyclists

Clinical Scenario

You are patrolling your local trails, descending a set of gnarly switchbacks. As you come around the corner you encounter a rider who has just been thrown over the handlebars. She tried to brace her fall by extending her arms in front of her. She is now grasping her shoulder/wrist She is complaining of pain.

Clavicle (Collar bone) Fractures

Introduction

The clavicle or collarbone is the located at the front of the shoulder between the arm (humerus) and the chest (sternum). In fact, the clavicle is the only true attachment of the arm and the trunk of the body.

Mechanism of Injury

Usually a cyclist will fall onto an outstretched upper extremity. The force is then transmitted up the arm resulting in a clavicle fracture. Most fractures will occur in the middle aspect of the bone. This injury can also occur from a direct impact to the clavicle, such as hitting a rock or tree.

Patient Symptoms

The injured cyclist will complain of pain at the site of the fracture. He may also complain of swelling and grinding if the fracture is mobile (unstable). Very rarely, will the cyclist complain of numbness or tingling.

Physical Findings

Be sure to examine the entire shoulder. Bruising and abrasions may be common. Deep lacerations or wounds over the fracture site, suggest an open fracture in which the bone has protruded through the skin. This is a surgical emergency due to the high risk of infection. Usually, there is obvious deformity at the injury site; the clavicle may appear shortened or there may be a large bump present where the two bone edges are overlapping.

As with any good examination of the extremity, make sure the patient has good sensation and movement of the injured extremity. In this case, make sure the patient can feel your touch throughout the hand and make sure he can wiggle his thumb, fingers, and wrist. This is a crude and quick test to assess the function of nerves and muscles.

Treatment

Treatment in the field should include immobilization or splinting of the affected shoulder. Usually, this involves placing the arm in a sling to support the arm and minimize motion. Treatment in clinic setting usually involves continued use of the sling until pain is controlled followed by therapy for motion and strengthening. For severe fractures surgery is sometimes necessary.

Danger Signs

The following signs or symptoms should not be ignored and the patient must seek urgent medical attention:

 

  • Open fractures: as mentioned earlier, deep wounds or lacerations around a fracture suggest a bone that has exited the skin. These injuries have a high rate of infection if not treated urgently.

     

  • Fractures with a large bump causing excessive tension on the skin. If the fracture is severe and the bone fragments press against the skin, the skin will become thin and will eventually lose its blood supply.

     

  • Persistent numbness, tingling, or burning in the upper extrremity. These symptoms can indicate nerve or blood vessel injury.

Distal Radius Fractures

Introduction

The wrist consists of eight small bones called the carpals and the ends of two larger bones. These bones, called the radius and ulna, are actually the lower end of the forearm bones. The radius is the larger of these two bones. The word distal refers to this lower end (the end of the bone closes to the wrist).

Mechanism of Injury

This is a fairly common injury especially among mountain bikers. Generally, the cyclist will fall directly onto the wrist with the arm extended forward. Less commonly, the end of radius may be injured by a direct impact.

Patient Symptoms

The cyclist will complain of extreme pain at the wrist. She may notice an obvious bend (deformity at the wrist-usually the wrist is bent backward). She may complain of numbness and tingling of the fingers.

Physical Findings

If the fracture is bent (displaced-where the bones are not in their normal orientation), you will notice a deformity. There may be bruising or swelling at the fracture site. Again, look for open wounds, especially on the palm side of the wrist. Open fractures here are much more common than open fractures of the clavicle. Again, make sure the cyclist can wiggle the fingers and thumb. Make sure that she can feel sensation as you brush your fingers over her thumb, index finger, and small finger. Again, this is a quick and crude examination to test the major nerves of the hand and upper extremity.

Treatment

Field treatment will include splinting the fracture to prevent the injury from moving and causing more pain or damage. The ideal splint will run from the fingers to above the elbow. This will allow maximal immobilization of the fracture. If there are open wounds or lacerations, irrigate the site quickly and apply clean bandages before splinting. Treatment in the clinic setting will include reduction (pulling or pushing the fracture straight) with casting or surgery depending on the severity of the injury.

Danger Signs

The following signs or symptoms should not be ignored and the patient must seek urgent medical attention:

 

  • Open fractures: as mentioned earlier, deep wounds or lacerations around a fractures suggest a bone that has exited the skin. These injuries have a high rate of infection if not treated urgently.

     

  • Persistent numbness, tingling, or burning in the hand, especially if the thumb or index finger are involved. These symptoms can indicate nerve injury.

     

  • Coolness or blue/white discoloration of the hand. This can indicate a problem with blood flow or a blood vessel injury.

Article contributed by NMBP Medical Advisor Brian Fukushima, MD.

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