This is a proximal humeral fracture. 85% of these can be conservatively managed. The mainstay of treatment is analgesia. It is important to do a thorough neurological examination as nerve compromise may be present in as many as 25% of these patients. Beware of those that may need surgical intervention, and so don’t always reassure the patient in the emergency department that no surgical intervention is necessary.

One method of classifying proximal humeral fractures is through the Neer Classification System.

This divides the proximal humerus into the head of the humerus, the shaft of the humerus, the greater trochanter and the lesser trochanter. Each of these portions forms a part. The Neer classification categorises the fracture according to the displacement of each of these parts relative to each other, and it may be used to determine management options. 

• Fractures involving the surgical neck as a part are more  common
• Minimal risk of avascular necrosis
• Likely conservative management if no significant displacement between parts (Neer’s classification)
• Key structures of concern  are the axillary nerve and posterior circumflex artery
• Damage to the axillary nerve will result in paralysis to the deltoid and teres minor muscles; the patient will not being able to abduct their arm
• The axillary nerve also innervates the skin over the lower deltoid (regimental badge area). 

• Between the greater and lesser tubercle, at the site of the old epiphyseal plate
• Much much less common than surgical neck fractures
• At risk of avascular necrosis
• Likely to need operative management open reduction and internal fixation or arthroplasty 

• Generally both of these are initially treated in a collar and cuff with plenty of analgesia.
• Assess for neurovascular compromise
• As this takes a whole arm out of action you need to ensure patients will be able to manage at home and a physio/OT assessment is recommended.
• Follow up in fracture clinic 

There is a left sided sacral fracture identified as a step in the ring. This is an easily missed fracture on a plain radiograph, a diagnostic conundrum made worst by the observation that only 30% of plain radiographs will show up a sacral fracture. The Denis classification can be used to classify sacral fracture lines with relation to the neural foramina.

• Class 1 fractures involve the sacral ala lateral the neural foramina.
• Class 2 fractures involve the neural foramina.
• Class 3 fractures involve the spinal canal itself.

• Up to 25% of sacral fractures can have neurological compromise.
• Pelvic splanchnic nerves (S2,S3,S4) and branches of the pudendal nerve (S2,S3,S4) provide innervation for sexual function, defecation and urination.
• If there is no neurological complication and it is a stable fracture, it may be conservatively managed with analgesia and mobilisation as able.
• It is important to warn the patient of the risk of venous thromboembolism from reduced mobility.

In the context of clinical rib fracture, radiographs are only done if:

• There are symptoms or signs suggesting an associated injury such as a pneumothorax or haemothorax
• Multiple fractures are suspected. The number of ribs fractured can be predictive of complications and the patient may necessitate admission. A flail chest is when you break more than two ribs in more than two places and allows paradoxical movement of the chest wall.
• Suspected pathological fractures
• For documentation for medico-legal purposes, such as in cases of abuse (NB skeletal survey images should only be requested by a consultant paediatrician and agreed with a consultant radiologist. There are RCR guidelines around this.
• To help direct adequate pain relief (although this should be done on a clinical basis, in patients who are unable to communicate pain effectively it may help guide the use of stronger analgesia than that used for soft tissue injury alone)
• it is worth remembering that eat x-Rays are poor at identifying simplerib fractures, they are normally diagnosed and treated on a clinical basis

Rib fractures are conservatively managed but their complications should not be underestimated. Pulmonary contusions may be present in 17% of rib fractures, an associated pneumothorax in 14-35% and an associated haemopneumothorax in 20-25%. Other complications include injury to liver and spleen. The incidence of complications rises with increasing numbers of fractured ribs.

Physiologically pain from movement during breathing leads to shallow breathing, atelectasis formation, poor oxygenation and risk of infection in the lung. Therefore provision of good pain relief is imperative and the above needs to be explained to the patient.

Consider admission for elderly patients or those with significant respiratory co-morbidities such as chronic obstructive pulmonary disease. Consider admission for any patients with multiple rib fractures. PCA’s, thoracic epidurals and costal blocks may be used for analgesia and for patients with >5 broken ribs may potentially be referred to Cardiothoracics for consideration of ORIF.

Ensure that there is a history of trauma consistent with the resultant fracture? If not, consider the possibility of bone metastases and pathological fractures.

Most rib fractures heal in six weeks although the pain will improve over the first few weeks. Patients should be advised to:

• hold the injured area to brace it when coughing,
• Stop at least 3 times a day to perform some deep breathing exercises to oxygenate the injured area of lung.
• Take regular analgesia to ensure they are able to take a deep breath in.
• Seek early medical advice and antibiotics if they develop a temperature or chest infection.
• To avoid contact sports until the rib fractures have healed

This is a base of 5^th metatarsal fracture. The determination of conservative or surgical management depends on the anatomical location of the fracture line.

• Zone 1 (pseudo Jones fracture): proximal tubercle only
  • Avulsion fracture of peroneus brevis tendon
  • Conservatively managed
  • Explain to the patient that it may take 6-8 weeks to heal fully
  • Protected weight-bearing as able

• Zone 2 (Jones fracture):atthemetaphyseal-diaphyseal junction
  • Increased risk of non-union, at risk of avascularity due to blood being supplied from the proximal metacarpal end via metaphyseal arteries that branch out at this location
  • Manage in a non weightbearing short leg cast
  • Intramedullary screw fixation in athletic individuals or non-union fractures

• Zone 3: diaphyseal fracture
  • More commonly tend to be stress fractures
  • Increased risk of non-union
  • Manage in a non-weightbearing short leg cast
  • At times intramedullary screw fixation in athletic individuals or non-union fractures

• All of these fractures should be able to be managed through an out patient fracture clinic service
• Do not confuse the apophysis at the base of the 5^th metatarsal with a fracture line. Fracture lines in this area tend to be transverse as opposed to the apophyses which is longitudinal to the long axis of the metatarsal bone.