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Wrist & Elbow Injuries

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Melbourne Arm Clinic GP education
Wrist and elbow injuries
Orthopaedic Upper Limb Surgeons

Published in: Health & Medicine
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Wrist & Elbow Injuries

  1. 1. Wrist and elbow injuries
  2. 2. Wrist Injuries and their sequlae • TYPICAL • “ Had a fall while playing footy” • “ Fell off my Mountain Bike” • “motor vehicle accident”
  3. 3. • ATYPICAL • “ I work as a carpenter and I got up this morning and it was really sore” • “ I thought I sprained it when I was arm wrestling with my brother” • “ got up this morning and its been really aching and you can see the swelling”
  4. 4. • On Further questioning, what you may hear is: • “ ah yes, I think I had an injury when I was a kid” • “now that you ask, I had landed on this same wrist 2 months ago, it was sore for a couple of days and I dismissed it as a sprain”
  5. 5. • On examination: • You may localize the pain as radial sided or ulnar sided • If its Radial sided: • SCAPHOID fracture! • Scapholunate instability • Radial Styloid fracture • Trapezium fracture • Base of Thumb OA • Colles fracture • Dequervains tenosynovitis
  6. 6. • If its Ulnar Sided/ or central dorsal: • Lunate injuries : a dislocation? • Keinbock s disease of the Lunate • Ulnar sided impaction on carpus due to old malunited shortened distal radius fractures • TFCC injuries • DRUJ injuries, acute or chronic • ECU injuries or snapping • Uncommonly cysts and tumours
  7. 7. THE SCAPHOID!
  8. 8. • I always prefer X rays , which are a baseline investigative tool for all scaphoid fractures. • Scaphoid views must be asked for specifically • Almost all X rays must be complimented with a CT • MRI • 1. for children • 2. Where AVN is suspected, for proximal pole fractures • 3. Where there may be a soft tissue component in addition to the scaphoid fracture, such as a perilunate injury.
  9. 9. • Even for “undisplaced” fractures, what interests me is the amount of a “Humpback deformity”
  10. 10. • Aim of treatment for Scaphoid fractures: • PRIMARY: • Achieve solid union • SECONDARY • Shortest time to healing with least disruption to the patient, in terms of use of the arm and wrist stiffness • Prevention of the natural progression of this condition left untreated which is known as a SNAC wrist which is essentially arthritis
  11. 11. TREATMENT • Cast for undisplaced scaphoids is acceptable! • I define Undisplaced scaphoids as one where its hard to pick up the fracture on a plain x ray , however its seen on a ct. • PROS of cast: • Easy • Non expensive • Non invasive • Works well for undisplaced fractures • CONS: • Stiffness • Inconvenient • May not unite
  12. 12. CAST DURATION • Distal pole: 6 weeks • Waist: 8 weeks • Proximal Pole :12 weeks
  13. 13. OPERATIVE
  14. 14. • TO SUMMARISE: THE FIVE QUESTIONS THAT MUST BE ASKED • Is there an associated distal radius / other carpal bone injury? • Is there a Proximal pole fracture? • Is there a Displaced waist fracture? • Is there a Humpback deformity on a Ct? • Is it chronic and is it really a non union now? • Answer of yes to any, will benefit from surgery! •
  15. 15. RESULTS
  16. 16. AVN • Seen in Proximal pole fractures and most likely, all patients with a proximal pole fracture need fixation which increases the chances of union and decreases the chance of AVN
  17. 17. When to refer? • Any chronic scaphoid fracture • A scaphoid fracture picked up late, even if undisplaced • A displaced scaphoid fracture: any scaphoid fracture that is clearly visible on an x ray is considered displaced • Combination injuries • A sequelae of a scaphoid fracture known as a SNAC wrist, this is a non union of a scaphoid with early arthritis . Xrays and Ct will suffice.
  18. 18. A SCAPHOLUNATE INJURY
  19. 19. • When the initial x rays are normal, the patient has a swollen wrist with tenderness on the dorsum and over the scaphoid, an MRI is a good adjunct , as it shows the scapholunate ligament disruption very clearly. • Depending on the amount of disruption, surgery is often required • These are severe injuries which can potentially impact the use of the arm, with respect to the patients occupation, so it is important to refer these patients early!
  20. 20. KEINBOCK S DISEASE • This is yet another condition that requires early detection and treatment. This is a disease generally seen in the young patient . • We don’t know the cause. • The disease is progressive • What Medical science can offer are “ salvage surgeries” not really a cure.
  21. 21. • Postulated that there is an increase in Intraosseus pressure, the cause of the increased pressure is unknown • Some blame is due to an aberration in the native blood supply to the lunate
  22. 22. • DIAGNOSIS: • Generally males aged 20-40 • Pain over the dorsocentral aspect of the wrist • Pain and weakness whilst gripping • Swelling at the back of the wrist with tenderness • X rays and MRI
  23. 23. Left untreated!
  24. 24. • If Picked up early: • Can offer a radial or ulnar shortening , with excellent results • If Picked up late: • Can offer limited or full fusions of the wrist, which are good from a pain perspective but at the expense of movement
  25. 25. New generation: pyrocarbon lunate replacements
  26. 26. ELBOW • ELBOW DISLOCATIONS AND THE ASSOCIATED CONDITIONS: • 1. PURELY SOFT TISSUE INJURIES • 2. TERRIBLE TRIADS • 3. RADIAL HEAD FRACTURES
  27. 27. Elbow Dislocations • I prefer to see every dislocation. • A lot of the Emergency departments don’t record if the Elbow is stable or not at the time of enlocation and they are sent off as “ simple “ elbow dislocations. • A lot of injuries are missed in the process
  28. 28. • Example:
  29. 29. • EARLY diagnosis and appropriate investigations by means of x rays and Ct , rarely MRI are important for treatment • Treatment involves ligament reconstruction or repair, and fixation of bony fragments with an aim to start early physical therapy, and minimize stiffness
  30. 30. Radial head fractures • Very common • Generally after a fall on an outstretched hand • X rays and sometimes CT are required.
  31. 31. • When to refer? • 1. Displaced fractures • 2. in conjunction with other injuries such as fractures around the elbow or soft tissue injuries • 3. communited fractures • A lot of the population have simple undisplaced fractures that can be treated in a sling for 10 days and mobilize as soon as the swelling and pain settle , which is generally around the 5 days mark. • These have predictable and good results
  32. 32. TERRIBLE TRIAD INJURY • Elbow dislocation • Coronoid Fracture • Radial head fracture
  33. 33. • This needs fixation always and a dedicated physiotherapy protocol that can be found on our Melbourne Arm Clinic website, in order to get the best outcome from a “ terrible” injury.

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