Upper Limb Fractures

Objectives

To provide guidance on the assessment and management of suspected upper limb fractures in the deployed setting.

Scope

This guideline includes the diagnosis and immediate management of suspected or confirmed upper limb fractures. The core content covers key principles of fracture management and should be followed in conjunction with fracture specific guidance. 

Hand injuries and fractures are out of scope for this guideline and are covered in a separate CGO.  

Fractures in the deployed setting are commonly high energy-transfer injuries, including ballistic and blast injuries. Where required, treating clinicians should use these guidelines in conjunction with separate guidance on:

Open Fractures
Tetanus Prone Wounds 
Gunshot injuries to extremities  
Wound Excision

This guideline does not include guidance on additional interventions that might be considered by specialists. Definitive treatment is covered in specialist guidelines. 

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in forward medical locations or in an Emergency Department on deployed operations.

Initial Assessment & Management

Assessment of upper limb fractures will follow completion of the primary survey using a systematic approach (MARCH) which will have included the control of significant haemorrhage. Also ensure adequate analgesia has been administered.

Neurovascular Assessment Neurological and vascular status of the limb distal to the injury should be assessed and recorded including:

Temperature 
Pulses 
Capillary refill time  
Sensation and movement

Comparison should be made to the non-injured limb.  

If there are concerns regarding perfusion or neurological status distal to the injury, management should be anatomical alignment of the limb and splinting.

"Rock, paper, scissors, OK" provides a useful tool for assessing neurological status in upper limb injuries – see accordion content below.

Open Fractures

Refer to Open Fracture CGO and Tetanus Prone Wounds CGO

  • Remove gross contamination
  • Administer appropriate antibiotics
  • Assess tetanus risk
  • Cover wounds with saline soaked gauze or non-adhesive dressings prior to splinting

Manipulation / Reduction

If there is clear deformity of the limb, or concerns regarding neurovascular status distal to the injury, manipulation to achieve anatomical alignment may be required prior to immobilisation (see fracture specific guidance below).

Assess and document neurovascular status prior to attempting reduction.

Ensure adequate analgesia or ideally utilise procedural sedation (if equipped and trained) as per the relevant CGOs.

Apply manual traction until approximate anatomical reduction is achieved.

Reassess and document neurovascular status post-reduction.  

Immobilisation

Immobilise the limb in anatomical alignment (see fracture specific guidance below for appropriate immobilisation).

Temporary splintage with a SAM splint and bandages is appropriate. Alternatively, a Plaster of Paris (POP) backslab provides more definitive splintage if available.

Compartment SyndromeCompartment syndrome can develop secondary to swelling within a fascial compartment leading to tissue hypoperfusion with subsequent risk of ischaemia and necrosis.  

High energy injuries are particularly at risk.  

Compartment syndrome should be a consideration following any upper limb fracture, but mid-shaft forearm fractures are most at risk.  

Assess and monitor for: 

  • Pain out of proportion to the injury OR refractive to appropriate analgesia  
  • Pain on passive stretching of the muscles within the affected compartments  
  • Reduced power of the muscles in the affected compartment
  • Altered sensation in the distribution of the nerves travelling through the affected compartments  

The presence of a distal pulse does not exclude compartment syndrome  

Management of suspected compartment syndrome:  

  • Ensure any deformity is re-aligned and immobilised  
  • Review circumferential dressings and splintage. Remove circumferential dressings where possible or split down to the skin
  • Elevate the limb to the level of the heart  
  • Urgent evacuation to a surgical facility is required

Further guidance contained in the Compartment Syndrome CGO is aimed at deployed surgical teams.

Advanced Assessment & Management

The principles of care in the deployed hospital environment are similar to those outlined above:

  • Re-assess and document neurovascular status.  
  • Assess/monitor for compartment syndrome.  
  • Request appropriate imaging for suspected fractures (see fracture specific guidance below).  
  • Assess whether further anatomical reduction is required and whether immobilisation with non-invasive methods such as casting or bracing is likely to be adequate.  
  • If temporary immobilisation has been utilised, consider more definitive immobilisation with Plaster of Paris. Re-assess neurovascular status and re-image after POP application.  
  • In case of open fractures, ballistic trauma, compartment syndrome, or where anatomical alignment with non-invasive methods is inadequate, specialist assessment for consideration of deployed surgical care is required.

Prolonged Casualty Care

Re-assess neurovascular status following reduction and immobilisation and regularly whilst awaiting evacuation.

Ensure regular analgesia.  

If any change in neurovascular status or increasing pain despite appropriate analgesia, assess for compartment syndrome - if identified, this diagnosis warrants prioritisation for evacuation.

Paediatric Considerations

Initial assessment and management of paediatric upper limb fractures is the same as for adults. Where there is limb deformity, intra-nasal analgesia can be considered to facilitate assessment and immobilisation.

Advanced assessment and management: See Principles of Paediatric Extremity Trauma in the Deployed Setting CGO

Neurovascular Assessment (including "Rock, paper, scissors, OK" tool)

  Median Nerve Radial Nerve Ulnar Nerve Anterior Interosseus Nerve
Motor Assessment

Finger flexion

'Rock'

Extension of wrist and MCP joint

'Paper'

Small muscles of the hand (finger abduction & adduction)

'Scissors'

Thumb flexion at IP joint; index finger flexion at DIP joint

'OK'
Sensory Region Volar surface of the hand including thumb, index, middle, and radial half of ring fingers, and the tip of the dorsal surfaces Dorsal surface of hand including thumb, index, middle and radial half or ring fingers, as far as PIPJ Both dorsal and volar surfaces of the ulnar half of the ring finger and the fifth digit.  

Note that the sensory regions described are "classical" but often vary between individuals.

 

(Image from Aberdeen Virtual Hand Clinic, made freely available at https://aberdeenvirtualhandclinic.co.uk/)

Scapula

Initial Management 

There is usually a history of high-energy trauma. Have a high index of suspicion and assess for associated injuries to the thorax.  

Neurovascular Status: Brachial plexus and large thoracic vessels are at risk 

Reduction: Not indicated 

Immobilisation: Broad-arm sling OR collar and cuff  

Advanced Assessment and Management 

As per initial management 

Imaging: AP Chest X-Ray (assists with assessing other thoracic and shoulder girdle injuries). Low threshold for considering Trauma CT if available

In-Theatre Specialist Assessment: Consider early if there is a high suspicion of, or confirmed scapula fracture 

Clavicle

Initial Management

Assess integrity of the skin overlying any deformity. If there is significant skin tenting, assess whether the skin is tethered to the fracture spike. Any concerns regarding skin integrity requires early specialist assessment.  

Neurovascular Status: Assess for subclavian vessel and brachial plexus injuries  

Reduction: Closed reduction is not indicated and may increase the risk of underlying neurovascular injury.  

Immobilisation: Broad-arm sling OR triangular bandage, ensuring the elbow is supported 

Advanced Assessment and Management 

As per initial management 

Imaging: X-Ray Clavicle 

In-Theatre Specialist Assessment: Indicated if any of:

  • Open fracture / Neurovascular compromise  
  • Significant skin tenting or skin breakdown over fracture site  

Proximal Humerus

Initial Management

In a military population, fractures will usually occur following direct trauma and may be associated with glenohumeral joint dislocation.

Neurovascular Status: The brachial plexus, axillary nerve, and axillary artery are at risk of injury. Careful assessment of sensation over the ‘Regimental Badge’ area.

Reduction: Anatomical alignment is usually achieved with gravitational traction following application of a collar and cuff.

Immobilisation: Collar and cuff - ensure the wrist is supported and the elbow hangs to allow gravitational traction

Advanced Assessment and Management

As per initial management

Imaging: X-Ray Shoulder (AP and axial); check for congruency of the glenohumeral joint 

In-Theatre Specialist Assessment: required if any of:

  • Open fracture / Neurovascular compromise  
  • Fracture-dislocation of the humeral head  

Humeral Shaft

Initial Management

Neurovascular Status: The radial nerve is most at risk of injury, and a radial nerve palsy may be present at initial assessment. Arterial injury is rare but may present as a pulsatile expanding haematoma3

Reduction: Anatomical alignment can usually be achieved with splinting  

Immobilisation: May be difficult due to inherent instability of the injury  

SAM splint: Create a U-shaped sugar-tong splint to immobilise the upper arm, secure above and below the fracture site with fabric ties or bandages. Support the arm with a sling or collar and cuff.

If there is a radial nerve palsy, add a forearm splint to support the wrist in dorsiflexion

Advanced Assessment and Management

As per initial management

Imaging: X-Ray Humerus (AP and Lateral)  

Immobilisation: U-slab Plaster of Paris. Support the arm with a sling or collar and cuff. Use a functional humeral brace if available  

In-Theatre Specialist Assessment: required if any of:

  • Open fracture / Neurovascular compromise  
  • Expanding haematoma  
  • Severe displacement or failure of non-invasive immobilisation  

Elbow: Distal Humerus

Initial Management 

Neurovascular Status:  Careful neurological assessment of the median, radial, ulnar, and anterior interosseous nerves is required - see above (Rock, Paper, Scissors, OK)  

Injury to the brachial artery may result in the presence of an expanding haematoma 

Reduction: Aim for anatomical alignment with splinting  

Immobilisation: Use a SAM splint to immobilise above and below the elbow with the elbow in a flexed position and secure with bandages. Support with a triangular bandage sling  

Advanced Assessment and Management 

As per initial management 

Imaging: X-Ray Elbow (AP and Lateral)  

Immobilisation: Above elbow backslab. Support with a broad arm sling / triangular bandage.  

In-Theatre Specialist Assessment: required if any of:

  • Open fracture / Neurovascular compromise 
  • Severe displacement 

Elbow: Olecranon

Initial Management

Inspect the skin carefully for any breach – high risk of open fracture from direct trauma to the olecranon. 

Neurovascular Status: Ulnar and anterior interosseous nerves most at risk.

Reduction: Not indicated for isolated olecranon fractures

Immobilisation: SAM splint immobilisation in 45 – 90 degrees flexion

Advanced Assessment and Management

As per initial management

Imaging: X-Ray Elbow (AP and Lateral)

Reduction: Anatomical reduction indicated for displaced fracture-dislocation of the elbow

Immobilisation: Above elbow backslab with collar and cuff.

In-Theatre Specialist Assessment: required if any of:

  • Open fracture / Neurovascular compromise
  • Elbow fracture-dislocation 

Elbow: Radial Head

Initial Management

Confirm whether there was any sensation of elbow dislocation at the time of injury – the combination of radial head fracture and elbow dislocation increases the possibility of an unstable elbow.
Carefully examine the wrist – pain at the distal radio-ulnar joint may indicate disruption of the interosseous membrane with fracture-dislocation of the distal radio-ulnar joint.

Neurovascular Status: Assess and document distal neurovascular status. Low risk of neurovascular injury with isolated radial head fracture.

Reduction: Not indicated for isolated radial head fracture

Immobilisation: Collar and cuff for comfort but advise simple movement of the elbow to prevent stiffness. If clinical concerns for elbow dislocation, ulnar fracture, or wrist injury, fully immobilise the forearm and elbow with a SAM splint

Advanced Assessment and Management

As per initial management

Imaging: X-ray Elbow (AP and Lateral); additionally X-ray forearm/wrist if there is clinical concern about a distal injury

In-Theatre Specialist Assessment: required if any of:

  • Open Fracture / Neurovascular compromise  
  • Involvement of the proximal ulnar (Monteggia fracture) or distal radio-ulnar joint (Essex-Lopresti injury).

Definitive management of these injuries is surgical.  

Forearm Shaft

Initial Management

Forearm fractures are commonly the result of a high-energy mechanism. Skin should be assessed carefully for open fracture.  
The radius and ulnar are mechanically linked, and as such it is important to consider that both bones may be fractured at different levels – carefully examine along the length of the forearm, including the wrist and the radial head to assess for associated injuries. For initial management it should be assumed that both bones are fractured and managed as such.  

Neurovascular Status: Assess and document motor and sensory function of the radial, median and ulnar nerves  Palpate and document the presence of both radial and ulnar pulses and check capillary refill time of the fingers. Assess for compartment syndrome

Reduction: Visible forearm deformity should be reduced to anatomical alignment prior to immobilisation

Immobilisation: SAM splint immobilisation from the metacarpal heads to the upper arm. Elbow in flexion.

Advanced Assessment and Management

As per initial management

Advanced assessment should include consideration of specific injury patterns with management varying based on the injury pattern identified. Forearm fractures have an increased risk of compartment syndrome, and this must be considered and assessed for.  

Imaging:   X-Ray Forearm (AP and Lateral). Ensure elbow and wrist are included on imaging. Request joint specific x-rays if required

Isolated Radial Shaft Fracture: Carefully examine the distal radio-ulnar joint to assess for associated injury 

Galeazzi Fracture-Dislocation: Radial shaft fracture with disruption of the distal radio-ulnar joint. Definitive management is surgical.  

Isolated Ulnar Shaft Fracture: Carefully examine the radial head to assess for associated injury  

Monteggia Fracture-Dislocation: Proximal ulnar fracture with associated radial head dislocation. Definitive management is surgical  

Both-bones Forearm Fracture: Often a high energy injury with high risk of open fractures and compartment syndrome. Definitive management is surgical  

Immobilisation: Above elbow backslab with collar and cuff. Ensure careful reassessment of neurovascular status after POP application and monitor for signs of compartment syndrome  

In-Theatre Specialist Assessment: required if any of:

  • Open fracture / Neurovascular compromise  
  • Severe displacement or failure of non-invasive immobilisation  
  • Compartment syndrome

Wrist: Distal Radius

Initial Management

Neurovascular Status: Assess and document motor and sensory function of the radial, median and ulnar nerves. A median nerve palsy suggests acute traumatic carpal tunnel syndrome 

Reduction: Indicated for deformity with neurovascular compromise. Aim for anatomical alignment. 

Immobilisation: SAM splint immobilisation from palmar crease to elbow OR wrist splint. Consider sling for elevation and comfort.  

Advanced Assessment and Management 

As per initial management 

Imaging: X-Ray Wrist (AP and Lateral). Assess for angulation and articular involvement of the fracture: 

Colles Fracture: Dorsal angulation, extra-articular fracture  

Smiths Fracture: Volar angulation, extra-articular fracture. Inherently unstable and definitive management is surgical  

Barton’s Fracture: Intra-articular fracture, classically with volar displacement. Inherently unstable and definitive management is usually surgical 

Reduction: Indicated for deformity with neurovascular compromise. Consider early anatomical reduction if resources allow or if evacuation is likely to be delayed  >72 hours 

Immobilisation: Below elbow backslab. Consider sling for elevation and comfort.

In-Theatre Specialist Assessment: required if any of:

  • Open Fracture / Neurovascular compromise 
  • Failure of non-invasive immobilisation 
  • Compartment syndrome  

Wrist: Scaphoid

Initial Management

Scaphoid fractures most commonly occur following a high-energy fall onto an outstretched hand.

Examine carefully for the following features:

Anatomical snuffbox pain on ulnar deviation of the wrist

Positive scaphoid compression test (telescoping of thumb)

Neurovascular Status: Assess distal neurovascular status. No specific risks.

Reduction: Not indicated for isolated scaphoid fracture

Immobilisation: Wrist splint OR SAM splint immobilisation of the wrist

Advanced Assessment and Management

As per initial management

Imaging: X-Ray Scaphoid Series

Acute fractures may not be visible on initial plain X-Rays. If there is clinical suspicion of a fracture, splint and review within 7 days - if repeat imaging is normal and symptoms have fully resolved then no further action is required, but if there is still pain or tenderness (including ASB tenderness or pain on telescoping of thumb) then the patient will require specialist assessment and/or CT/MRI imaging.

In-Theatre Specialist Assessment: As above, or if any associated carpal instability or dislocation

Immobilisation: Wrist splint OR below-elbow backslab  

Last reviewed: 18/03/2026

Next review date: 18/03/2027

References

Davidson AW. Rock-Paper-Scissors. Injury. International Journal of Care of Injured. 2003: 34:61-63

Marsh A, Robertson J, Godman A, Boyle J, Huntley J. ‘Rock, Paper, Scissors, OK’: Introduction of a Simple Guideline to Improve Neurological Assessment in Paediatric Patients Presenting with Upper Limb Fractures. Orthopaedics Processes. 2013; 95-B(Supp_31):3-3 

White TO, Mackenzie SP, Gray AJ. McRae’s Orthopaedics Trauma and Emergency Fracture Management. Third Edition, 2016.