Managing Common Upper Extremity Fractures

Emerg Med 36(5):26-36, 2004

Proceeding systematically from the proximal humerus to the distal radius, the authors discuss emergent treatment, referral considerations, and potential complications of fracture injury at the sites where it most often occurs.

By Susan Hendricks, MD, and Francis L. Counselman, MD

Upper extremity fractures not only are painful and traumatic but also threaten the patient's quality of life with the risk of significant loss of function. As clinicians, we have the opportunity to provide these patients with effective pain relief and start them on the road to recovery. With these injuries, a clear understanding of the structures involved in the upper extremities is imperative. Appropriate evaluation and initial management are key to minimizing complications. It is also important to know the indications for orthopedic consultation. This article will focus on common fractures of the arm and forearm, taking a systematic, proximal-to-distal approach.
 

GENERAL PRINCIPLES OF TREATMENT

Ice, elevation, analgesia, and immobilization are the mainstay of treatment for all fractures. With upper extremity fractures, because of the close proximity of the neurovascular structures, it is extremely important to document normal distal function. Usually, this can be done by checking the brachial and radial pulses, and the ulnar, median, and radial nerve functions (motor and sensory) of the hand. In general, immobilization is accomplished with a sling and swathe for proximal humerus fractures, a coaptation (sugar-tong) splint for humeral shaft fractures, a posterior splint for the elbow, and a double sugar-tong or long-arm anterior-posterior splint for forearm fractures.

Reduction of the fracture is imperative to align the bony fragments for optimal healing and to reduce soft tissue and neurovascular injury. Factors to consider in fracture reduction include: the physician's comfort level with the procedure; the acuity of the injury; the presence of neurovascular deficits; the degree of fracture displacement or angulation, or both; and the availability of an orthopedic surgeon.

For open fractures, intravenous (IV) antibiotics, such as 2 gm of cefazolin, should be administered. Also, the patient's tetanus status should be updated, if necessary, and an orthopedist consulted.
 

RELEVANT ANATOMY

The proximal humerus includes the humeral head and extends to the surgical neck. Just above the greater and lesser tubercles of the head is the anatomic neck. The humeral shaft begins at the insertion of the pectoralis major just below the surgical neck; it ends at the beginning of the supracondylar ridges.

The distal humerus consists of two columns of bone called condyles. The supracondylar ridges mark the beginning of these bones. They are held together by a thin piece of bone that expands distally and forms the coronoid fossa. The condyles form the two articular surfaces of the humerus in the elbow. The trochlea, which is the articular surface of the medial condyle, articulates with the olecranon of the ulna. The capitellum, the articular surface of the lateral condyle, articulates with the head of the radius. The nonarticular segments are the epicondyles.

The radius and ulna are held together by proximal and distal joint capsules and radioulnar ligaments. Down their shafts they are held together by a fibrous interosseous membrane. The proximal ligaments allow the radial head to rotate over the ulna, enabling supination and pronation.

The major neurovascular structures in the arm begin with the brachial plexus and axillary artery in the axilla. The axillary artery becomes the brachial artery in the arm and bifurcates into the radial and ulnar arteries in the elbow, which continue on their respective sides in the forearm. The median, ulnar, and radial nerves branch out of the brachial plexus. The median nerve runs anteriorly in the elbow with the brachial artery, then runs down the middle of the forearm and into the carpal tunnel to reach the hand. The ulnar nerve runs in the medial epicondylar fossa of the elbow (the so-called funny bone), then courses down the ulnar side of the forearm to the hand. The radial nerve wraps around the distal third of the humeral shaft, then around the lateral epicondyle to extend deep into the structures of the forearm.
 

PROXIMAL HUMERUS FRACTURES

Proximal humerus fractures are more common in the elderly and are most often the result of a fall on an outstretched arm. Less commonly, they can occur from a direct blow to the lateral arm. When they occur in the younger population, it is usually the result of trauma.

On examination, the patient will usually be holding the arm in an adducted position. There will be tenderness and swelling over the proximal humerus. Any deformity should be noted. The brachial plexus, axillary nerve, and vascular structures are in close proximity and are therefore easily injured. They are much more likely to be injured if the patient is holding the arm in an abducted position, since this suggests that a distal fragment is located in the axilla. Anteroposterior and lateral radiographic views will usually demonstrate these fractures, but an axillary view can be utilized if not all fragments are fully visualized.

The most common classification system used for proximal humerus fractures is Neer's, which divides the humeral head into four parts: the anatomic neck, the lesser and greater tuberosities, and the surgical neck. If the fragments are more than one centimeter displaced or have more than 45 degrees of angulation, they are considered separate. A one-part fracture has no fragments that are considered separate. A two-, three-, or four-part fracture will have the corresponding number of separate fragments. There are also two-, three-, and four-part fracture-dislocations, where the articular portion of the humeral head is displaced either anteriorly or posteriorly.

About 80% to 85% of all proximal humerus fractures are one-part fractures. Successful treatment for all proximal humerus fractures depends on early mobility, because the major complication encountered is joint stiffness.

Surgical neck fractures. The normal angle between the humeral head and the shaft is 135 degrees. It is important to measure this angle in all proximal humerus x-rays. Using Neer's classification, this would mean that an angulation of less than 90 or more than 180 degrees would make the fracture a two-part fracture, which may mean that reduction is necessary (see image, below). Any displacement greater than one centimeter requires reduction. Similarly, any neurovascular compromise requires reduction, along with emergent orthopedic referral.

Surgical neck fracture. Angulation of less than 90 or more than 180 degrees between the humeral head and the shaft may mean that reduction is necessary. Displacement greater than one centimeter requires reduction.

Treatment includes ice, elevation (with the patient in an upright position), analgesia, a sling and swathe, and orthopedic referral. Patients with one-part fractures can safely be encouraged to begin circumduction exercises within five to seven days. This involves having the patient bend forward at the waist 90 degrees and allowing the arm to hang down and swing in a gentle circle. Active contraction of the shoulder muscles should be avoided. Complications include joint stiffness, malunion, and myositis ossificans (or localized intramuscular ossification).

Anatomic neck fractures. These are fractures that transect the epiphysis. They are classified as nondisplaced or displaced, which is more than a one-centimeter separation. Nondisplaced fractures can be treated with ice, analgesia, a sling and swathe, and early orthopedic referral. For displaced fractures or any anatomic neck fracture in a child, emergent orthopedic referral is required. These fractures can be complicated by avascular necrosis.

Greater tuberosity fractures. This fracture is seen in approximately 15% of all anterior shoulder dislocations and should be looked for closely in such situations. The supraspinatus, infraspinatus, and teres minor muscles of the rotator cuff insert at the greater tuberosity and typically cause upward displacement of the fracture fragment. This makes abduction of the shoulder difficult and painful for the patient.

Greater tuberosity fractures are classified as nondisplaced (including compression fractures) or displaced. Treatment for all of these fractures is ice, analgesia, a sling and swathe, and orthopedic referral. Urgent referral is especially important if the patient is young or active, or both, and has a displaced fracture, since this scenario is almost always associated with a tear of the rotator cuff. The patient may be a candidate for early surgical correction. Complications include chronic tenosynovitis, nonunion, and myositis ossificans.

Lesser tuberosity fractures. These fractures are less common and tend to occur with posterior shoulder dislocations. The subscapularis muscle inserts here and tends to displace the fragment. These fractures are not usually associated with any complications and can be treated with ice, analgesia, a sling and swathe, and orthopedic referral.

Combination fractures. These are Neer's three- and four-part fractures. Often, there will be a dislocation in addition to the fracture itself. These fractures result from severe forces, such as those involved in a motor vehicle accident. Associated injuries include rotator cuff tears, injuries to the brachial plexus, and injuries to the axillary vessels and nerve. Acute management consists of ice, analgesia, a sling and swathe, and emergent orthopedic consultation for admission. These fractures usually require surgical repair and may even call for a prosthesis. Even with proper management, they may be complicated by humeral head avascular necrosis and nonunion, along with the potential for neurovascular damage.

Articular surface fractures. These fractures include impression fractures of the humeral articular surface and also "head-splitting" comminuted fractures of the humeral head. A comminuted fracture is only considered a Neer three- or four-part fracture if the fragments are displaced more than one centimeter or angulated more than 45 degrees. Impression fractures include the Hill-Sacks deformity commonly seen with anterior shoulder dislocation. These fractures are typically difficult to visualize on x-ray, and secondary signs of hemarthroses should be sought, such as the fat fluid level seen on an anteroposterior view or inferior pseudosubluxation of the humeral head, in which the head is pushed down by the hemarthrosis.

Treatment of these fractures includes ice, analgesia, a sling and swathe, and early orthopedic referral. A head-splitting comminuted fracture or any fracture involving more than 20% of the articular surface may require surgical repair or prosthesis. Complications include joint stiffness, arthritis, and, if the fracture is comminuted, avascular necrosis of the humeral head.

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HUMERAL SHAFT FRACTURES

Humeral shaft fractures occur more frequently in patients over age 50. They result from two different mechanisms: a direct blow from a fall or motor vehicle accident typically results in a transverse fracture; an indirect force, such as a fall on an elbow or outstretched arm, will cause an oblique or spiral fracture. Anteroposterior and lateral views of the humerus will usually identify these fractures.

As with all fractures, displacement of the fragments will be largely determined by the muscular forces applied to them. This will vary with humeral shaft fractures, depending on the location of the fracture along the shaft. Because of the extensive musculature of the humerus, reduction is often difficult and unsuccessful. Examination of the radial nerve and brachial artery is critical, especially with fractures involving the middle and distal thirds of the humerus. Midshaft humeral fractures are frequently associated with a radial nerve palsy, characterized by wristdrop. Also important is a thorough examination of the shoulder and elbow, because humeral shaft fractures are often associated with occult injuries of these joints.

Treatment depends on the presence of displacement or neurovascular injury, or both, and the degree of angulation. If none of these exists, the fracture is managed with a coaptation splint, ice, analgesia, and an orthopedic referral. For the displaced or angulated fracture, referral is needed and the appropriate treatment will vary. Typically, a hanging cast or olecranon pin traction is used. Any neurovascular damage also warrants emergent orthopedic consultation and reduction.

Complications include shoulder adhesive capsulitis with subsequent limited range of motion, myositis ossificans, and nonunion or delayed union. There is also a 5% to 10% incidence of delayed radial nerve palsy, especially in spiral fractures of the distal third of the humerus.
 

ELBOW FRACTURES

Elbow fractures include distal humerus fractures and proximal forearm fractures. The mechanism of injury is usually a direct blow to the elbow or a fall on an outstretched hand. An anteroposterior view with the elbow in full extension and a lateral view with the elbow in 90 degrees of flexion are usually sufficient for the diagnosis. An oblique view with the elbow in extension may help in diagnosing occult fractures of the radial head or coronoid fossa.

Occult fractures of the elbow are not uncommon, and indirect signs on x-ray that suggest intra-articular injury should prompt the physician to treat the injured elbow as a nondisplaced fracture. These signs include the anterior fat pad "sail" sign and the posterior fat pad sign. The anterior fat pad is just superior to the coronoid fossa and is occasionally seen in a normal radiograph as a thin lucency. With intra-articular injury, it will be larger than normal and displaced anteriorly and away from the distal humerus—the sail sign. A posterior fat pad sign is never normal and if seen just above the olecranon fossa should always suggest a fracture with accompanying hemarthrosis.

Neurovascular injury is a real concern with elbow fractures. All patients with proximal forearm fractures should have a thorough wrist examination, because injuries to the distal radioulnar joint are common.

Distal humerus fractures. Supracondylar fractures are horizontal extra-articular fractures of the distal humerus. These are very common fractures, with 90% to 98% being an extension type of fracture, with the distal fragment displaced posteriorly. When nondisplaced, these fractures can be difficult to diagnose with certainty; the diagnosis is often assumed by the presence of a posterior or large anterior fat pad sign. An abnormal distal humerus may also be found by utilizing the anterior humeral line. A line is drawn on the lateral radiograph along the anterior surface of the humerus through the elbow. This line should normally transect the middle of the capitellum; if it does not, a fracture should be assumed.

Neurovascular injuries are common, even in a nondisplaced injury. The median nerve tends to be the most frequently injured nerve. The brachial artery is also easily injured, and if the injury goes undetected, it can cause Volkmann's ischemic contracture.

Treatment includes ice, analgesia, and immobilization in a posterior long arm splint. Controlling the swelling is key, because it can cause delayed neurovascular compromise. Orthopedic consultation is recommended for all supracondylar fractures, even if they are nondisplaced. This is a common injury in children, and most pediatric patients will be admitted to the hospital. If there is posterior displacement or more than 20 degrees of posterior angulation, reduction will be necessary. Other complications include deformities due to malalignment and decreased range of motion.

A transcondylar fracture is one that is horizontal and transects both condyles. These fractures lie within the joint capsule but do not involve an articular surface. Treatment is the same as for supracondylar fractures, except in the case of a Posadas fracture, which is a transcondylar fracture caused by a direct blow to the elbow while it is in a flexed position. This results in the condyles being displaced anteriorly to the proximal humeral segment. A Posadas fracture should be splinted with the arm in the position of presentation; flexion or extension of the elbow could result in vascular compromise. Emergent orthopedic consultation is needed.

An intercondylar fracture is essentially a supracondylar fracture with a vertical component that extends into an articular surface. These usually appear to be a comminuted fracture, and they typically occur in patients over age 50 who have sustained a direct blow that causes the olecranon to become impacted in the distal humerus. With these fractures, fragments will frequently be rotated and displaced because of multiple muscular forces.

Only patients with the most benign nondisplaced intercondylar fractures can be sent home. All other patients require emergent orthopedic consultation. Treatment includes ice, analgesia, and immobilization in the position of presentation. The most common complication is loss of range of motion of the elbow, making it functionally useless.

Condylar fractures include a portion of a condyle and the corresponding epicondyle. The lateral condyle is the most commonly injured. A long-arm posterior splint is used for immobilization. If the lateral condyle is injured, the forearm should be supinated and the wrist placed in extension. This relieves tension on the wrist extensors, which all originate from the lateral epicondyle. If the medial condyle is injured, the opposite positioning is used to relieve tension on the wrist flexors.

In the case of nondisplaced fractures, the patient may be sent home with orthopedic follow-up. However, an orthopedic surgeon should be consulted for any condylar fractures with displacement, because these fractures require reduction and possible surgical fixation. Complications include cubitus valgus or varus deformity, lateral transposition of the forearm, arthritis, malunion, and delayed ulnar nerve palsy.

An epicondylar fracture does not include the corresponding condyle, and an injury is more common on the medial side. This fracture is frequently associated with a posterior dislocation of the elbow. In adults, it is usually the result of a direct blow. In children, this is called "Little League elbow," resulting from repeated valgus stress with subsequent avulsion of the flexor pronator tendon. It is essential to assess ulnar nerve function before initiating therapy. Treatment is a posterior splint, ice, analgesia, and orthopedic referral. If there is associated dislocation, a reduction should be performed first, with post-reduction x-rays to determine the new location of the fracture fragment. If the fragment is in the joint space, the patient will require open reduction.

Olecranon fractures. Olecranon fractures are often associated with complications. All of these fractures are considered intra-articular and need near-perfect reduction for the patient to regain full range of motion. Displaced fractures almost always have either a rupture of the triceps aponeurosis or the periosteum. A high incidence of ulnar nerve compromise occurs, especially in comminuted fractures. Other associated injuries include elbow dislocation, anterior dislocation of the radioulnar joint, and fractures of the distal humerus and radial head or shaft.

If the fracture is nondisplaced and without ulnar nerve injury, treatment is with ice, analgesia, and immobilization in a posterior long-arm splint. The elbow should be flexed at 50 to 90 degrees with the forearm in the neutral position. If the fracture is displaced or ulnar nerve injury is present, emergent orthopedic referral is required for surgical repair. Other complications include shoulder arthritis and elbow immobility.

Radial head and neck fractures. These are common injuries that are frequently associated with avulsion of the lateral epicondyle or injury to the capitellum. Radiographs can be deceiving, and oblique views are often required to confirm the diagnosis. Also, it is sometimes helpful to get multiple views with varying degrees of radial rotation.

Occult fractures can be detected by evaluating the radiocapitellar line, which is a line drawn through the shaft of the radius and center of the capitellum on the lateral 90-degree view. The line should cut the radial head in half; if it does not, this suggests a slip of the head, especially in children before the epiphysis has closed. The previously mentioned fat pad signs can be useful in evaluating for this type of injury.

Treatment includes ice, analgesia, and immobilization in a posterior long-arm splint. Early aspiration of the hemarthrosis is advocated by many clinicians, because it can alleviate pain significantly and help the patient with mobilization. Early orthopedic referral is needed for all patients with radial head and neck fractures. Those with displacement of more than one millimeter will need reduction. If there is involvement of more than one third of the articular surface, a depression of more than three millimeters, angulation of a neck fracture of more than 30 degrees, or severe comminution, surgical excision may be required.

An Essex-Lopresti fracture is a radial head or neck fracture in which the force has been transmitted down the interosseous membrane, rupturing it and the distal radioulnar joint. This makes the examination of the wrist very important. This type of fracture requires a more urgent orthopedic consultation. Complications include myositis ossificans, restricted range of motion, and malunion.

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FOREARM SHAFT FRACTURES

Forearm shaft fractures include radial shaft fractures, ulnar shaft fractures, and combined radial and ulnar shaft fractures.

Radial shaft fractures. The radius can be broken down into three segments when discussing fractures. Displacement of fragments will vary with each segment because of the different muscular attachments. Proximal fractures occur just distal to the insertion of the supinator and biceps, and as a result there will be supination of the proximal fragment. In middle and distal fractures, the fragments tend to be pronated due to the force of the pronator teres and pronator quadratus, respectively. These are the segments most commonly injured because of the decreased muscle mass in this area. The mechanism is usually a direct blow.

A thorough examination of the proximal and distal joints is important; these are frequently associated with occult elbow and wrist injuries. Examination of the distal radioulnar joint, which can be tender due to subluxation or dislocation, is especially important. The Galleazzi fracture is a distal radial shaft fracture with dislocation of the distal radioulnar joint. Nondisplaced fractures, which are relatively rare, require ice, analgesia, immobilization in a double sugar-tong or anteroposterior long-arm splint, and urgent orthopedic referral. Displaced fractures or those with involvement of the distal radioulnar joint require emergent consultation. Complications include delayed separation of nondisplaced fragments, compartment syndrome if there is significant soft tissue injury, malunion or nonunion, and rotational deformities.

Ulnar shaft fractures. Classification of ulnar shaft fractures includes nondisplaced, displaced, and Monteggia's fractures. The mechanism is usually a direct blow to the forearm. Typically, the patient raised the forearm to protect the face, giving these fractures the nickname "nightstick fractures." Since accompanying elbow and wrist injuries are common, these joints should always be examined. The distal neurovascular examination is again important, because there can be a temporary injury to the deep branch of the radial nerve. Nondisplaced fractures can be treated with ice, analgesia, a double sugar-tong or anteroposterior long-arm splint, and orthopedic referral. Displaced fractures should have a more urgent orthopedic referral; these fractures may need open reduction and internal fixation.

Monteggia's fracture is a displaced fracture of the proximal third of the ulna, with radial head subluxation or dislocation. This fracture requires complete rupture of the annular ligament. Most patients will have anterior dislocation of the radial head with anterior angulation of the distal ulna fragment. Posterior and lateral dislocations are less common. Monteggia's fractures are important because they are associated with many complications. Paralysis of the deep branch of the radial nerve is quite common with these fractures, as is nonunion and recurrent dislocation or subluxation of the radial head. Emergent orthopedic consultation is needed because surgical correction is usually required.

Combined radial and ulnar shaft fractures. The radius and ulna are frequently injured at the same time, usually as a result of a direct blow. These fractures are typically classified as nondisplaced, displaced, displaced with shortening, comminuted, or torus/greenstick. Nondisplaced fractures can be treated with ice, analgesia, a double sugar-tong splint, and urgent referral. Delayed displacement is common. Any displacement, shortening, or comminution requires emergent orthopedic consultation for reduction and probable surgical intervention.

Torus and greenstick fractures can be treated more conservatively with immobilization and orthopedic follow-up. A greenstick fracture with more than 15 degrees of angulation needs more urgent orthopedic follow-up because it may require completion of the fracture and reduction. Complications may include neurovascular damage (especially with open fractures), compartment syndrome, impaired supination or pronation, and synostosis of the radius and ulna.
 

DISTAL FOREARM FRACTURES

Distal forearm fractures include extension-type distal radial fractures, flexion-type distal radial fractures, and push-off-type distal radial fractures.

Colles' fracture. The distal radial fracture with dorsal displacement, or Colles' fracture, needs early reduction to minimize the risk of complications, which occur at a rate of 20% to 30%.

Extension-type distal radial fractures. More commonly known as a Colles' fracture, this is a very common injury that occurs as a result of a fall on an outstretched hand with the wrist in extension. This forces the distal fragment or fragments to be dorsally displaced, giving the wrist and hand the classic "dinner fork" deformity (see image, left). Any supinating force incurred during the fall may cause a concomitant fracture of the distal ulna.

Colles' fractures are classified according to the presence of intra-articular involvement or any distal ulnar fractures. About 60% of Colles' fractures will have an associated ulnar styloid fracture, and about 60% of those fractures will have an associated fracture of the ulnar neck. Therefore, when examining the x-ray, the clinician must determine if there is any ulnar, radiocarpal joint, or radioulnar joint involvement. The normal radiocarpal joint is angled 1 to 20 degrees volarly. Further volar displacement of this joint with a Colles' fracture will usually result in a good recovery of function. However, with dorsal angulation of this joint there tends to be poor functional recovery if the fracture is not reduced.

It is also important to examine the angulation of the ulna in relation to the radiocarpal joint. Normally, the ulna is angulated 15 to 30 degrees. Loss of this normal angulation can occur with a Colles' fracture and can lead to loss of ulnar hand motion if the fracture is not reduced.

There are many associated injuries with Colles' fractures. The median nerve is the most commonly injured and is usually impinged on by the angulation of fragments. Proximal radioulnar joint subluxation or dislocation may also occur, making examination of the elbow important. Carpal fractures, flexor tendon injuries, and ulnar nerve impingement may also be found.

Colles' fractures are associated with a 20% to 30% incidence of complications, including median and ulnar nerve impairment, extensor pollicus longus tendon rupture, post-reduction swelling with development of compartment syndrome, stiffness, cosmetic defects, malunion or nonunion, and chronic pain. Early reduction is key to avoiding these problems. Only patients with fractures that are totally extra-articular and have minimal angulation should be discharged without orthopedic consultation. Ice, analgesia, and a double sugar-tong splint with the wrist in 15 degrees flexion and 15 degrees ulnar deviation are appropriate initial treatment for this group of patients. Urgent orthopedic follow-up is important, however. All other patients need emergent orthopedic consultation for reduction and probable surgical intervention.

Flexion-type distal radial fractures. These are called reverse Colles' fractures because they occur in the same distribution but have volar displacement of the distal fragments. (They are also known as Smith's fractures.) They tend not to have ulnar involvement. The mechanism of injury is a fall on a dorsiflexed wrist or a direct blow to a closed fist with the wrist slightly flexed. The radial artery and median nerve can be injured on occasion and should be examined.

These fractures tend to be highly unstable, and most will require reduction under anesthesia with subsequent pinning. Treatment includes ice, analgesia, and immobilization in a long-arm anteroposterior or double sugar-tong splint. Emergent orthopedic consultation is always advised. Smith's fractures tend to do very well once reduction is maintained, but some may involve tendon damage or arthritis.

Push-off-type distal radial fractures. These are Barton's and Hutchinson's fractures, both of which are considered intra-articular. Barton's fracture involves the dorsal rim of the distal radius and typically results from extreme dorsiflexion of the wrist. On the lateral wrist x-ray, a triangular fragment will be visible dorsally. Sensory branches of the radial nerve may be injured, with subsequent paresthesias over the corresponding areas of distribution. Other associated injuries include carpal bone fracture or dislocation.

Nondisplaced Barton's fractures can be treated with ice, analgesia, immobilization with a double sugar-tong splint, and orthopedic follow-up. Displaced fractures need reduction and immobilization and should have emergent orthopedic consultation; open reduction and internal fixation are usually required. The most common complication is arthritis.

Hutchinson's fracture is a radial styloid fracture. The mechanism of injury here is a fall on an outstretched hand, in which the force is transmitted up the scaphoid and out the radial styloid. It is therefore common to see associated scaphoid fractures and scapholunate dislocation with this fracture. Treatment includes ice, analgesia, immobilization in a thumb spica or double sugar-tong splint, and orthopedic follow-up. Displaced or unstable fractures may require fixation.
 

PRESERVING MOBILITY AND FUNCTION

The arm and forearm provide the human body with enormous mobility and function. Fractures in this area are common and can result in significant disability. A clear understanding of the anatomy, mechanism of injury, and associated complications are essential for all physicians, since appropriate initial management is key to full recovery of function.

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