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GEMC: Upper Extremity Injuries: Shoulder, Elbow and Wrist: Resident Training

The document reviews key orthopedic injuries of the upper extremities including the shoulder, elbow, and wrist, detailing mechanisms of injury, classifications, diagnosis, and treatment options. It is part of a collaborative effort by the Ghana Emergency Medicine team and is intended for educational purposes, not as a substitute for professional medical advice. Key complications related to these injuries, such as dislocations and fractures, are also discussed.

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Project: Ghana Emergency Medicine Collaborative Document Title: Upper Extremity Injuries: Shoulder, Elbow and Wrist Author(s): Patrick M. Carter (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
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Patrick M. Carter, MD! Instructor! Department of Emergency Medicine! University of Michigan School of Medicine! April 4, 2012! 3   Quibik,  Wikimedia  Commons  
¡  Review key orthopedic injuries of the shoulder, upper arm, elbow, forearm and wrist! §  Fractures! §  Dislocations! §  Ligamentous Injuries! ¡  Identify key x-ray findings ! ¡  Review treatment options for orthopedic disorders of upper extremity! ¡  Review key complications of upper extremity disorders! ¡  Not a complete review of all upper extremity injuries! 4  
5  Gray’s  Anatomy,  Wikimedia  Commons  
Sternoclavicular  Ligament   Costoclavicular  Ligament   ¡  Less than ½ of the medial end of the clavicle usually articulates with the sternum! ¡  Joint Stability is dependent on the integrity of the surrounding ligaments! 6  Gray’s  Anatomy,  Wikimedia  Commons  
¡  Classification! §  1st Degree = Sprain ! ▪  Partial tear of SC and CC ligaments with mild subluxation! §  2nd Degree = Subluxation! ▪  Complete tear of SC ligament with partial tear of CC ligament! ▪  Clavicle subluxates from the manubrium on x-ray! §  3rd Degree = Dislocation! ▪  Complete tear of SC and CC ligaments! ▪  Complete dislocation of clavicle from the manubrium! ▪  Anterior > Posterior! ▪  Posterior = True Emergency – 25% will have concurrent life- threatening injuries to adjacent mediastinal structures! 7  
¡  Mechanism of Injury! §  Direct force applied to the medial end of the clavicle! §  Indirect force to the shoulder with the shoulder rolled either forward or backward that tears medial ligaments! ¡  Symptoms/Signs! §  Pain and swelling over the SC joint! §  Pain with movement of shoulder! §  Anterior Dislocation = Prominent medial clavicle anterior to sternum! §  Posterior Dislocation = Clavicle may not be palpable, may be subtle! ¡  Diagnosis! §  X-ray! §  CT scan (Diagnostic Study of Choice if concern for underlying structures)! 8  
¡  Treatment! §  1st Degree = Sling, Analgesia, Ice! §  2nd Degree ! ▪  Sling or Figure of Eight Clavicular Strap, Orthopedic Follow-up! §  3rd Degree ! ▪  Anterior Dislocation! ▪  Uncomplicated anterior dislocations often don’t require reduction! ▪  Sling or Figure of Eight, Analgesia and outpatient follow-up! ▪  Posterior Dislocation! ▪  Reduction often necessary due to underlying injury! ▪  Closed reduction in OR! ▪  Reduction ! ­  Towel roll between scapula! ­  Traction applied to arm! ­  Towel clip on clavicle with traction to reduce! 9  
¡  AC Joint Anatomy! ¡  Mechanism of Injury! §  Fall on outstretched arm with transmission to AC joint! §  Fall on shoulder with arm adducted (most common)! §  Scapula and Shoulder girdle driven inferiorly with clavicle in normal position! ¡  Signs/Symptoms! §  Joint Tenderness! §  Swelling over the joint! §  Pain with movement of affected extremity! §  Displacement of clavicle! Coracoclavicular  Ligaments    -­‐  Coracoacromial  ligament    -­‐  Trapezoid  Coracoclavicular  ligament    -­‐  Conoid  Coracoclavicular  ligament   Acromioclavicular     Ligament   10   Gray’s  Anatomy,  Wikimedia  Commons  
¡  AC Joint Injury Classification! §  Tossy and Allman Classification (Types 1-3)! §  Rockwood Classification (Types 4-6)! ¡  Classification! §  Type 1 = Sprain = Partial tear of AC ligament, No CC ligament injury! §  Type 2 = Subluxation = Complete tear of AC ligament, CC ligament stretched or incompletely torn! §  Type 3 = Dislocation = Complete tears of AC and CC ligaments with displacement of clavicle! §  Direction of displacement defines types 4-6! ▪  Type IV = Posterior displacement in or through trapezius! ▪  Type V = Superior displacement (more serious type 3 injury)! ▪  Type VI = Inferior displacement of clavicle behind biceps tendon! 11  
12   Source:  Steve  Oh,  2004  
¡  X-rays! §  AP views of clavicle usually sufficient! §  Stress views not commonly used anymore and do not alter course of treatment! §  Axillary views necessary for posterior dislocation identification (Type 4)! §  Findings! ▪  Type 1 = Radiographically normal! ▪  Type 2 = Increased distance between clavicle and acromion (< 1 cm)! ▪  Type 3 = Increased distance between the clavicle and acromion (> 1 cm)! ▪  Type 4-6 = Defined by displacement! ¡  Treatment! §  Type 1-2 = Sling x 1-2 weeks, Rest, Ice, Analgesia, Early ROM 7-14 days! §  Type 3 = Immobilize in sling, Prompt orthopedic referral! ▪  Controversy regarding operative vs. conservative treatment options! ▪  Shift towards conservative treatment! §  Type 4-6 = Sling, Prompt orthopedic referral, Likely will require surgical management! 13  
14   Root4(one),  Wikimedia  Commons   Source  Undetermined  
¡  Clavicle! §  Provides support and mobility for upper extremity functions! §  Protects adjacent structures! ¡  Mechanism of Injury! §  Direct blow to clavicle! §  Fall on outstretched shoulder! ¡  Symptoms/Signs ! §  Pain, Swelling and Deformity! §  Arm is held inward and downward and supported by other extremity! §  Open fractures result from severe tenting and piercing of overlying skin! ¡  Imaging ! §  CXR or Clavicle films! §  Children may have a greenstick fracture without definite fracture on x-ray imaging! 15   Magnus  Manske,  Wikimedia  Commons   Source  Undetermined  
¡  Allman Classification! §  Middle 1/3 (80%)! ▪  Most common area to fracture! ▪  Especially in children! §  Distal 1/3 (15%)! ▪  Often associated with ruptured CC joint with medial elevation! ▪  May require operative intervention to avoid non-union! §  Medial 1/3 (5%)! ▪  Uncommon! ▪  Requires strong injury forces! ▪  Higher association with intrathoracic injury ! ▪  (e.g Subclavian Artery/Vein injury)! 16   Image  adapted  from  Anatomagraphy,   Wikimedia  Commons     Group  III   ~Medial  1/3   ~3%-­‐6%   Group  I   ~Middle  1/3   ~69%-­‐85%   Group  II   ~Distal  1/3   ~12%-­‐28%   Allman  Classification  
17   Source  Undetermined  
¡  Emergency Orthopedic Consultation! §  Open Fractures! §  Fractures with neurovascular injuries! §  Fractures with significant tenting at high risk for converting to open! ¡  Indications for Surgical Repair! §  Displaced distal third! §  Open! §  Bilateral! §  Neurovascular injury! ¡  Treatment = Sling, Orthopedic Follow-up! §  Non-operative management is successful in 90%! ¡  Middle 1/3 Clavicle Non-union risk factors! §  Shortening > 2 cm! §  Comminuted fracture! §  Elderly female! §  Displaced fracture! §  Significant associated trauma! 18  
¡  Scapula! §  Links the axial skeleton to the upper extremity! §  Stabilizing platform for the motion of the arm! §  1% cases of blunt trauma have scapular fracture! §  3-5% of shoulder injuries! ¡  Mechanism of Injury! §  Direct blow to the scapula! §  Trauma to the shoulder! §  Fall on an outstretched arm! ¡  Clinical Presentation! §  Localized pain over the scapula! §  Ipsilateral arm held in adduction! §  Any movement of arm exacerbates pain! ¡  High association with other intrathoracic injuries (>75%)! §  Due to high degree of energy required for fracture! §  Pulmonary contusion > 50% of cases! §  Pneumothorax, Rib fractures commonly associated! Glenoid   Body   Neck   19  Gray’s  Anatomy,  Wikimedia  Commons  
¡  Classification! §  Anatomic Location! §  Body = 50-60%! §  Neck = 25%! ¡  Imaging! §  Shoulder/Dedicated Scapular Series! ▪  AP/Lateral/Axillary! §  Axillary views help identify fractures:! ▪  Glenoid fossa! ▪  Acromion! ▪  Coracoid Process! §  Consider CXR/Chest CT to rule out associated injuries! 20   Gray’s  Anatomy,  Wikimedia  Commons  
¡  Treatment! §  Sling, Ice, Analgesia! §  Immobilization! §  Early ROM exercises! §  Orthopedic Referral for ORIF! ▪  Glenoid articular surface fractures with displacement! ▪  Scapular neck fractures with angulation! ▪  Acromial fractures associated with rotator cuff injuries! ! 21   Source  Undetermined  
¡  Shoulder dislocation = Most common dislocation in the ED! ¡  Classification! §  Anterior (95-97%)! ▪  Subcoricoid, Subglenoid, Subclavicular, Intrathroracic! §  Posterior (2-3%)! ▪  Most commonly missed dislocation in the ED! ▪  Association with Seizure, Electric Shock/lightening injuries! §  Inferior (Luxatio Erecta)! §  Superior (Very Rare)! ¡  Mechanism of Injury! §  Anterior = Abduction, Extension and External Rotation with force applied to shoulder! §  Posterior = Indirect force with forceful internal rotation and adduction! 22  
¡  Clinical Presentation! §  “Squared off” Shoulder! §  Patient resists abduction and internal rotation! §  Humeral head palpable anteriorly! §  Must test axillary nerve function/ sensation! ¡  Quebec Decision Rule! §  Radiographs needed for:! ▪  Age > 40 and humeral ecchymosis! ▪  Age > 40 and 1st dislocation! ▪  Age < 40 and mechanism other than fall from standing height or lower! §  Failed to be validated due to low sensitivity (CJEM 2011)! ¡  Recurrent Shoulder dislocations! ¡  Radiographs! §  AP/Lateral/Y-view! 23   Source  Undetermined     Source  Undetermined    
¡  Clinical Presentation! §  Prominence of posterior shoulder! §  Anterior flatness! §  Unable to externally rotate or abduct the affected arm! ¡  Radiography! §  AP Radiograph! ▪  “Light Bulb Sign”! ▪  Internal rotation of the humerus! §  Y view! ▪  Diagnostic for posterior dislocation! 24   Source  Undetermined     Source  Undetermined    
¡  Inferior Shoulder Dislocation! ¡  Hyperabduction force ! ¡  Levers humerus against the acromion tearing inferior capsule! ¡  Forces humeral head out inferiorly! ¡  Clinical Presentation! ¡  Humerus is fully abducted, elbow flexed, hand behind the head! ¡  Humeral head palpated on lateral chest wall! ¡  Frequently associated with:! ¡  Soft tissue injuries/rotator cuff tears! ¡  Fractures of humeral head! ¡  Neurovascular compression injury is common! 25   Source  Undetermined  
¡  Treatment! §  Reduction using a variety of techniques! ▪  Success rate = 70-96% regardless of technique! §  Shoulder dislocation with associated humeral head fracture typically require orthopedic consultation and may require operative repair! §  Neurovascular exam pre- and post reduction! §  Procedural Sedation if initial attempts unsuccessful! §  Intra-articular injection of 10-20 cc lidocaine alternative to procedural sedation! §  After reduction, patient should be placed in shoulder immobilizer and orthopedic follow-up arranged! 26   Nevit  Dilman,  Wikimedia  Commons  
¡  External Rotation! §  Hennepin Technique! §  Gentle external rotation ! §  Followed by slow abduction of arm! §  Reduction typically complete prior to reaching coronal plane! §  78% success rate! §  Procedural sedation rarely needed! 27   Source:  University  of  Hawaii  School  of  Medicine    
¡  Modified Hippocratic or Traction-Countertraction Technique! 28   Source:  University  of  Hawaii  School  of  Medicine    
¡  Scapular Manipulation! §  Technique! ▪  Seated Position! ▪  Steady forward traction on wrist parallel to floor! ▪  Rotate inferior tip of scapula medially and superior aspect laterally! §  96% Success rate! §  Requires two people! §  Borders of scapula can be difficult to identify in obese patients! §  Rarely requires sedation! 29   Source:  University  of  Hawaii  School  of  Medicine     Source:  University  of  Hawaii  School  of  Medicine    
¡  Stimpson or Hanging Weight Technique! 30   Source:  University  of  Hawaii  School  of  Medicine    
¡  Complications! §  Recurrent dislocation (Most Common)! ▪  < 20 years old: > 90% ! ▪  > 40 years old: 10-15% ! §  Bony Injuries! ▪  Hill-Sachs Deformity ! ▪  Compression fracture or groove of posterolateral aspect of humeral head! ▪  Results from impact of humeral head on the anterior glenoid rim as it dislocates or reduces! ▪  Avulsion of greater tuberosity (Higher incidence > 45 years old)! ▪  Bankart’s Fracture = Fracture of the anterior glenoid lip! §  Nerve Injuries (10-25% dislocations)! ▪  Most often are traction related neuropraxias and resolve spontaneously! ▪  Axillary nerve (most common) or Musculocutaneous nerve! §  Rotator Cuff Tears ! ▪  86% of patients > 40 years will have associated rotator cuff tear! §  Axillary Artery Injury (rare) ! ▪  Elderly patients with weak pulse ! ▪  Rapidly expanding hematoma! 31  
¡  Hill Sachs Deformity! ¡  Bankart’s Lesion/Fracture! http://www.mypacs.net/repos/mpv3_repo/viz/ full/18712/935613.jpg   32   Hellerhoff,  Wikimedia  Commons   RSatUSZ,  Wikimedia  Commons  
¡  Rotator cuff = 4 muscles that insert tendons into the greater and lesser tuberosity! §  SITS MUSCLES = Subscapularis, Supraspinatous, Infraspinatous, Teres minor! ¡  Mechanisms of Injury! §  Acute tear = Forceful abduction of the arm against resistance (e.g. fall on outstretched arm)! §  Chronic teat = 90% = Results from subacromial impingement and decreased blood supply to the tendons (worsens as patient ages)! ¡  Clinical Picture! §  Typically affects males at 40 y/o or later! §  Pain over anterior aspect of shoulder, tearing quality to pain, typically worse at night! §  PE with weak and painful abduction or inability to initiate abduction (if complete tear)! §  Tenderness on palpation of supraspinatous over greater tuberosity! ¡  Imaging! §  In ED, plain film x-rays indicated to exclude fracture and may show degenerative changes and superior displacement of humeral head! §  MRI is diagnostic (not typically done in ED setting)! ¡  Treatment! §  Sling Immobilization, Analgesia, Ortho Referral! §  Complete tears require early surgical repair (< 3 weeks)! §  Chronic tears are managed with immobilization, analgesia and orthopedic follow-up for rehabilitation exercises and possible steroid injection! 33  
¡  Proximal Humerus Fractures! §  Common in elderly patients with osteoporosis! §  Mechanism of Injury = Fall on outstretched hand with elbow extended! §  Clinical Presentation! ▪  Pain, swelling and tenderness around the shoulder! ▪  Brachial plexus and axillary arteries injuries! ▪  Higher incidence (>50%) in displaced fractures ! §  Neer Classification guides treatment! ▪  Fractures separate humerus into 4 fragments by epiphyseal lines! ▪  Displacement > 1 cm or angulation > 45 degrees defines a fragment as a “separate part” when fractures occur! ▪  If none of fragments are displaced > 1cm, fracture is termed 1 part ! §  Treatment! ▪  One part fractures (85%) = immobilization in sling/swathe, ice, analgesics, orthopedic referral! ▪  Two/Three/Four part fractures = Orthopedic Consultation! 34  
Fragments  of  Humerus  Head   Articular  surface  of  humeral  head   Greater  tubercle   Lesser  tubercle   Shaft  of  humerus   35   3   1   2   James  Heilman,  MD,  Wikimedia  Commons   Gray’s  Anatomy,     Wikimedia  Commons  
¡  Typically involve middle 1/3 of the humeral shaft! ¡  Mechanism of Injury! §  Direct Blow (Most common)! §  Fall on outstretched arm or elbow! §  Pathologic Fracture (e.g. breast cancer)! ¡  Clinical Presentation ! §  Pain and deformity over affected region! §  Associated Injuries! ▪  Radial Nerve injury = Wrist Drop (10-20%)! ▪  Neuropraxia will often resolve spontaneously! ▪  Nerve palsy after manipulation or splinting is due to nerve entrapment and must be immediately explored by orthopedic surgery! ▪  Ulnar and Median nerve injury (less common)! ▪  Brachial Artery Injury! 36  
¡  Imaging = Standard x-ray imaging! ¡  Treatment! §  Non-operative Management (most common)! ▪  Simple Sling and Swath adequate for ED patients! ▪  Closed treatment options! ▪  Coaptation splint (sugar tong)! ▪  Hanging cast! ▪  External fixation! §  Operative management! ▪  Neurovascular compromise, pathologic fractures! ¡  Complications! §  Neurovascular injury! §  Delayed union! §  Adhesive capsulitis! 37   Bill  Rhodes,  Wikimedia  Commons  
¡  Proximal or distal biceps tendon rupture! ¡  Mechanism of Injury = Sudden or prolonged contraction against resistance in middle aged or elderly patients! ¡  Clinical Presentation! §  “Snap” or “Pop” typically described! §  Pain, swelling, tenderness over site of tendon rupture! §  Flexion of elbow = Mid-arm ball! §  Loss of strength sometimes minimal! §  X-rays to exclude avulsion fracture! ¡  ED Treatment! §  Sling, Ice, Analgesia, Orthopedic referral! §  Surgical repair for young, active patients! 38   Patenthalse,  Wikimedia  Commons   Gray’s  Anatomy,   Wikimedia  Commons  
39  Source  Undetermined  
Anterior  Fat  Pad          “Sail  Sign”   Posterior  Fat  Pad   (Never  normal)   Anterior  Humeral  Line   •   Normal  =  Middle  of  capitellum   •   Abnormal  =  Anterior  1/3  of   capitellum  or  completely  anterior   Radial-­‐Capitellar  Line   • Normal  =  Transects   middle  of  capitellum   40   Hellerhoff,  Wikimedia  Commons   Source  Undetermined   Source  Undetermined  
¡  Supracondylar Extension Fractures ! §  Most Common Type! §  Mechanism of injury ! ▪  Fall on outstretched arm with elbow in extension! §  Imaging ! ▪  Distal humerus fractures and humeral fragment displaced posteriorly! ▪  Sharp fracture fragments displaced anteriorly with potential for injury of brachial artery and median nerve! §  Treatment! ▪  Non-displaced fracture (Rare) = Immobilization in posterior splint! ▪  May be discharged home with close follow-up! ▪  Displaced fracture ! ▪  Orthopedic Consultation and reduction! ▪  Patients with displaced fractures or significant soft tissue swelling require admission for observation! 41  
¡  Supracondylar Flexion Fractures (rare)! §  Mechanism of Injury ! ▪  Direct blow to posterior aspect of flexed elbow! §  Fractures are frequently open! §  Imaging = Distal humerus fracture displaced anteriorly! §  Treatment! ▪  Non-displaced fractures! ▪  Splint immobilization and early orthopedic follow-up! ▪  Displaced fractures ! ▪  Orthopedic consultation for reduction ! ▪  Patients with displacement and soft tissue swelling require admission! 42  
Extension  Type  Fracture   Flexion  Type  Fracture   43   Source  Undetermined   Source  Undetermined   Source  Undetermined  
¡  Early Complications! §  Neurologic (7%)! ▪  Results from traction, direct trauma or nerve ischemia! ▪  Radial Nerve (Posterior-medial displacement)! ▪  Median Nerve (Posterior-lateral displacement)! ▪  Ulnar Nerve (Uncommon)! ▪  Anterior Interosseous Nerve Injuries ! ▪  High incidence with supracondylar fractures! ▪  No sensory component, Motor component must be tested (“OK sign”)! §  Vascular Entrapment (Brachial Artery)! ¡  Late Complications! §  Non-union/Mal-union! §  Loss of mobility! 44  
¡  Compartment syndrome of the forearm! ¡  Complication of elbow/forearm fractures! ¡  Increased compartment pressure results in ischemia of muscles of forearm, typically flexor compartment! ¡  Patient complains of pain out of proportion of injury, digit swelling and paresthesias! ¡  Also consider in any patient presenting with pain and numbness in hand after casting has been performed! ¡  Irreversible damage in 6 hours (see image)! ¡  Treatment ! §  Removal of cast! §  Surgical decompression with fasciotomy! 45   Source  Undetermined  
¡  Most common fractures of the elbow! ¡  Mechanism of Injury = Fall on outstretched hand! ¡  Clinical Finding = Tenderness and swelling over the radial head! ¡  Imaging! §  May not be seen on initial x-ray or may be subtle on x-ray! §  Evaluate for anterior or posterior fat pad which suggests diagnosis! ¡  Associated Injuries! §  Essex-Lopresti Lesion ! ▪  Disruption of fibrocartilage of the wrist and interosseus membrane! ▪  Distal radial-ulnar dissociation! §  Articular surface of capitellum frequently also injured! ¡  Treatment! §  Non-displaced = Sling, Ortho follow-up! §  Comminuted/Displaced Fractures require urgent orthopedic referral within 24 hours! 46   Source  Undetermined  
¡  Nursemaid’s elbow = Subluxation of radial head beneath the annular ligament! ¡  Mechanism of injury = Longitudinal traction on hand or forearm with arm in pronation! ¡  X-rays not necessary! ¡  Treatment = Reduction! §  Thumb over radial head with concurrent supination of forearm and flexion of elbow! §  Extension and pronation (another option for reduction)! 47   David  Tan,  Flickr  
48   Therese  Clutario,  Wikimedia  Commons   hyperpronation   supination   flexion  
¡  Third most common joint dislocation! ¡  Posterolateral (90%)! §  Mechanism of Injury = Fall on outstretched hand! §  Clinical Findings ! ▪  Marked swelling with loss of landmarks ! ▪  Posterior prominence of olecranon! §  Immediate consideration must be given to neurovascular status! ▪  Ulnar or Median Nerve injury common (8-21%) ! ▪  Brachial artery injury (5-13%)! §  Associated fractures (30-60%) of coronoid process and radial head! §  Terrible triad injury = elbow dislocation + radial head and coronoid fracture (unstable)! ¡  Anterior (Uncommon)! §  Mechanism of Injury = Blow to Olecranon with elbow in flexion! §  Associated Injuries = Much higher incidence of vascular impingement! 49  
http://tw.myblog.yahoo.com/doctor-­‐-­‐anjenli/article? mid=776&prev=778&next=774&l=f&fid=79   Anterior  Elbow  Dislocation   Posterior  Elbow  Dislocation   50   Source  Undetermined   Source  Undetermined  
¡  Elbow Reduction! §  Immobilize humerus! §  Apply traction at wrist! §  Slight flexion of the elbow! §  Posterior pressure on olecranon! ¡  Post-Reduction ! ¡  Long Term Complications! §  Post-traumatic arthritis! §  Joint instability! ! 51  
¡  Fracture of both ulnar and radius! §  Usually displaced fracture! ¡  Mechanism of Injury ! §  Direct blow to forearm! ¡  Associated Injury! §  Peripheral Nerve Deficits! ▪  Uncommon in most closed injuries! ▪  More common with open fractures! §  Development of compartment syndrome! ¡  Treatment! §  Displaced – ORIF! ¡  Complications! §  Compartment Syndrome! §  Malunion! 52   Source  Undetermined  
¡  Isolated fracture of ulnar shaft! ¡  Mechanism ! §  Direct blow to ulna! §  Patient raising forearm to protect face! ¡  Treatment! §  Non-displaced! ▪  Immobilization in splint! §  Displaced ! ▪  >10 degrees angulation! ▪  Displacement > 50% of ulna! ▪  Orthopedic consultation - ORIF! 53   Source  Undetermined  
¡  Distal Radius Fracture! §  Distal radio-ulnar dislocation! ¡  Reverse Monteggia’s fx! ¡  Mechanism of Injury! §  Direct blow to back of wrist! §  Fall on outstretched hand! ¡  Complication = Ulnar nerve injury! ¡  Treatment = ORIF ! http://www.learningradiology.com/caseofweek/ caseoftheweekpix2/cow157lg.jpg   54   Th.  Zimmermann,  Wikimedia  Commons  
¡  Proximal 1/3 Ulnar Fracture! §  Dislocation of radial head! ¡  Mechanism of Injury = Direct blow to posterior aspect of ulna! §  Fall on outstretched hand! ¡  Imaging ! §  Elbow/Forearm x-rays! §  Radial head dislocation missed in 25% of cases! §  Carefully examine the alignment of radial head! ¡  Associated Injury = Radial Nerve Injury! ¡  Treatment ! §  ORIF ! §  Closed Reduction/Splinting ! 55   Jane  Agnes,  Wikimedia  Commons  
Galeazzi   Radial  Fracture   Ulnar  Fracture   Monteggia   G   M   U  R   56   Patrick  Carter,  University  of  Michigan   Patrick  Carter,  University  of  Michigan  
¡  Transverse fracture of distal radius with dorsal displacement of distal fragment! ¡  Mechanism = Fall on outstretched hand! ¡  Most common fracture in adults > 50 years old! ¡  Exam = Classic Dinner Fork Deformity! ¡  Associated Injuries! §  Ulnar styloid fracture! §  Median Nerve Injury! ¡  Unstable Fractures! §  >20 degrees angulation, intra-articular involvement, comminuted fractures or > 1 cm of shortening! ¡  Treatment! §  Non-displaced Fracture ! ▪  Sugar Tong Splint, Referral to Orthopedic Surgery! §  Displaced Fracture! ▪  Reduction – Finger traps and manipulation under procedural sedation or with hematoma block! ▪  Immobilization in Sugar tong splint! ▪  Referral to Orthopedic Surgery! 57  
¡  Transverse fracture of distal radius with volar displacement! ¡  Mechanism = Fall on outstretched arm with forearm in supination! ¡  Associated Injury = Median Nerve Injury! ¡  Treatment! §  Reduction with finger traps and manipulation! §  Immobilization in sugar tong or long arm splint! §  Orthopedic referral! 58  
¡  Colles Fracture !! ¡  Smith Fracture! Goals  of  Reduction:   *    Restore  volar  tilt   *    Radial  Inclination   *    Proper  radial  length   59   Lucien  Monfils,  Wikimedia  Commons     Source  Undetermined  
60   Source  Undetermined  
¡  Scaphoid Fracture! §  Most common carpal bone fracture! §  Mechanism = fall on outstretched hand or axial load to thumb! §  2/3 of fracture in waist of scaphoid! §  Imaging – Initial x-rays may fail to demonstrate fracture ! ▪  > 10% of cases! ▪  Repeat Imaging in 2 weeks will often show fracture! §  Clinical findings = tenderness in anatomical snuff box! §  Treatment! ▪  Non-displaced or clinically suspected fracture ! ▪  Thumb spica Splint! ▪  Displaced fractures will require ORIF! ▪  Complications ! ▪  Avascular necrosis of proximal fragment -> arthritis! ▪  Delayed union or malunion! 61  
62   Gilo1969,  Wikimedia  Commons    
¡  Triquetrum Fracture (2nd most common)! §  Mechanism = Fall on outstretched hand! §  Body fracture or avulsion chip fractures! §  Exam = Tenderness on palpation distal to ulnar styloid on dorsal aspect of wrist, painful flexion! §  Avulsion fracture best visualized on lateral or oblique view of wrist! §  Treatment = Volar splint, Orthopedic referral! ¡  Lunate Fracture! §  Mechanism = Fall on outstretched hand! §  Exam = Pain over mid-dorsum of wrist increased with axial loading of 3rd digit! §  Vascular supply is through distal end of bone -> high risk for avascular necrosis of the proximal portion! §  Plain x-rays are often normal! §  Treatment = Immobilization in thumb spica splint, orthopedic referral! §  Complications ! ▪  Kienbock’s disease = Avascular necrosis of proximal segment! ▪  Chronic pain, decreased grip strength, osteoarthritis! ! 63  
¡  Triquetrum Fracture! ¡  Lunate Fracture! 64   Hellerhoff,  Wikimedia  Commons   Source  Undetermined  
¡  Lunate is at the center of the carpal bones ! §  Majority of ligamentous injuries are centered on the lunate! §  Injuries are from forceful dorsiflexion of wrist! §  Degree of force determines severity of injury! ▪  Spectrum from isolated tear to dislocations! ¡  Spectrum of ligamentous injuries! §  Scapholunate ligament instability! §  Triquetrolunate ligament instability! §  Perilunate and Lunate dislocations! 65  
¡  Scapholunate ligament binds the scaphoid and lunate together! ¡  Most common ligamentous injury of hand! ¡  Commonly missed! ¡  Pain with wrist hyperextension, snapping or clicking sensation with radial/ulnar deviation! ¡  Radiographic signs! §  Scaphoid is foreshortened and has a dense ring shaped image around its distal edge (signet or cortical ring sign)! §  Widening of space between the lunate/scaphoid ! ▪  > 3 mm, Terry Thomas sign! ¡  Treatment ! §  Thumb spica or radial gutter splint! §  Orthopedic Referral! 66  
¡  Terry Thomas and Signet Ring Sign! 67   Source  Undetermined  
¡  Perilunate and lunate dislocations are the result of the most severe carpal ligamentous injury! ¡  Mechanism of Injury = Violent Hyperextension usually combined with a fall from height or motor vehicle crash! ¡  Clinical examination ! §  Generalized swelling, pain and tenderness over wrist! §  May be deceiving with no evidence of gross deformity! ¡  Radiographic evaluation is key to diagnosis! ¡  Treatment = Orthopedic Consultation! §  Treatment is dependent on severity of injury! §  Closed reduction and long-arm immobilization if possible! §  Open, unstable and irreducible dislocations require OR! §  Some orthopedists take all dislocations to OR! ¡  Complications! §  Degenerative Arthritis! §  Delayed union/Malunion/Non-union! §  Avascular necrosis! 68  
¡  4 C’s Need to line up on normal x-ray! Lunate   69   Source  Undetermined  
¡  Lunate Dislocation! §  Capitate is centered over the radius and the lunate is tilted out! §  Spilled Tea cup deformity! ¡  Peri-lunate Dislocation! §  Lunate is centered over the radius and capitate is tilted out! §  Associated with scaphoid fx! 70   Source:   Radiology  Assistant  Source:   Radiology  Assistant  
¡  Carpal Tunnel Syndrome! §  Entrapment of Median nerve! §  Tinel’s sign = Tapping over volar wrist produces paresthesias! §  Phalen’s sign = Hyperflexion of wrist = Paresthesias! §  Risk Factors = Pregnancy, Hypothyroid, DM, RA! §  Treatment = Splinting, Rest, Surgical Decompression! ¡  DeQuervain’s Tenosynovitis! §  Overuse syndrome with inflammation of extensor tendons of thumb! §  Characterized by pain along radial aspect of wrist that is exacerbated with use of thumb! §  Finkelstein’s test = Ulnar deviation of fisted hand produces pain! §  Treatment = NSAIDS, Splint, Rest! ¡  Guyon’s Canal Syndrome! §  Ulnar nerve entrapment syndrome! §  Numbness and tingling in ring and small finger! §  Causes = repetitive trauma (handle bar neuropathy), cyst! §  Treatment = Splint, Surgical Decompression! 71  
72   ?  

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GEMC: Upper Extremity Injuries: Shoulder, Elbow and Wrist: Resident Training

  • 1.
    Project: Ghana EmergencyMedicine Collaborative Document Title: Upper Extremity Injuries: Shoulder, Elbow and Wrist Author(s): Patrick M. Carter (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
  • 2.
    Attribution Key for moreinformation see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2  
  • 3.
    Patrick M. Carter,MD! Instructor! Department of Emergency Medicine! University of Michigan School of Medicine! April 4, 2012! 3   Quibik,  Wikimedia  Commons  
  • 4.
    ¡  Review keyorthopedic injuries of the shoulder, upper arm, elbow, forearm and wrist! §  Fractures! §  Dislocations! §  Ligamentous Injuries! ¡  Identify key x-ray findings ! ¡  Review treatment options for orthopedic disorders of upper extremity! ¡  Review key complications of upper extremity disorders! ¡  Not a complete review of all upper extremity injuries! 4  
  • 5.
    5  Gray’s  Anatomy,  Wikimedia  Commons  
  • 6.
    Sternoclavicular  Ligament   Costoclavicular  Ligament   ¡  Less than ½ of the medial end of the clavicle usually articulates with the sternum! ¡  Joint Stability is dependent on the integrity of the surrounding ligaments! 6  Gray’s  Anatomy,  Wikimedia  Commons  
  • 7.
    ¡  Classification! §  1stDegree = Sprain ! ▪  Partial tear of SC and CC ligaments with mild subluxation! §  2nd Degree = Subluxation! ▪  Complete tear of SC ligament with partial tear of CC ligament! ▪  Clavicle subluxates from the manubrium on x-ray! §  3rd Degree = Dislocation! ▪  Complete tear of SC and CC ligaments! ▪  Complete dislocation of clavicle from the manubrium! ▪  Anterior > Posterior! ▪  Posterior = True Emergency – 25% will have concurrent life- threatening injuries to adjacent mediastinal structures! 7  
  • 8.
    ¡  Mechanism ofInjury! §  Direct force applied to the medial end of the clavicle! §  Indirect force to the shoulder with the shoulder rolled either forward or backward that tears medial ligaments! ¡  Symptoms/Signs! §  Pain and swelling over the SC joint! §  Pain with movement of shoulder! §  Anterior Dislocation = Prominent medial clavicle anterior to sternum! §  Posterior Dislocation = Clavicle may not be palpable, may be subtle! ¡  Diagnosis! §  X-ray! §  CT scan (Diagnostic Study of Choice if concern for underlying structures)! 8  
  • 9.
    ¡  Treatment! §  1stDegree = Sling, Analgesia, Ice! §  2nd Degree ! ▪  Sling or Figure of Eight Clavicular Strap, Orthopedic Follow-up! §  3rd Degree ! ▪  Anterior Dislocation! ▪  Uncomplicated anterior dislocations often don’t require reduction! ▪  Sling or Figure of Eight, Analgesia and outpatient follow-up! ▪  Posterior Dislocation! ▪  Reduction often necessary due to underlying injury! ▪  Closed reduction in OR! ▪  Reduction ! ­  Towel roll between scapula! ­  Traction applied to arm! ­  Towel clip on clavicle with traction to reduce! 9  
  • 10.
    ¡  AC JointAnatomy! ¡  Mechanism of Injury! §  Fall on outstretched arm with transmission to AC joint! §  Fall on shoulder with arm adducted (most common)! §  Scapula and Shoulder girdle driven inferiorly with clavicle in normal position! ¡  Signs/Symptoms! §  Joint Tenderness! §  Swelling over the joint! §  Pain with movement of affected extremity! §  Displacement of clavicle! Coracoclavicular  Ligaments    -­‐  Coracoacromial  ligament    -­‐  Trapezoid  Coracoclavicular  ligament    -­‐  Conoid  Coracoclavicular  ligament   Acromioclavicular     Ligament   10   Gray’s  Anatomy,  Wikimedia  Commons  
  • 11.
    ¡  AC JointInjury Classification! §  Tossy and Allman Classification (Types 1-3)! §  Rockwood Classification (Types 4-6)! ¡  Classification! §  Type 1 = Sprain = Partial tear of AC ligament, No CC ligament injury! §  Type 2 = Subluxation = Complete tear of AC ligament, CC ligament stretched or incompletely torn! §  Type 3 = Dislocation = Complete tears of AC and CC ligaments with displacement of clavicle! §  Direction of displacement defines types 4-6! ▪  Type IV = Posterior displacement in or through trapezius! ▪  Type V = Superior displacement (more serious type 3 injury)! ▪  Type VI = Inferior displacement of clavicle behind biceps tendon! 11  
  • 12.
    12   Source:  Steve  Oh,  2004  
  • 13.
    ¡  X-rays! §  APviews of clavicle usually sufficient! §  Stress views not commonly used anymore and do not alter course of treatment! §  Axillary views necessary for posterior dislocation identification (Type 4)! §  Findings! ▪  Type 1 = Radiographically normal! ▪  Type 2 = Increased distance between clavicle and acromion (< 1 cm)! ▪  Type 3 = Increased distance between the clavicle and acromion (> 1 cm)! ▪  Type 4-6 = Defined by displacement! ¡  Treatment! §  Type 1-2 = Sling x 1-2 weeks, Rest, Ice, Analgesia, Early ROM 7-14 days! §  Type 3 = Immobilize in sling, Prompt orthopedic referral! ▪  Controversy regarding operative vs. conservative treatment options! ▪  Shift towards conservative treatment! §  Type 4-6 = Sling, Prompt orthopedic referral, Likely will require surgical management! 13  
  • 14.
    14   Root4(one),  Wikimedia  Commons   Source  Undetermined  
  • 15.
    ¡  Clavicle! §  Providessupport and mobility for upper extremity functions! §  Protects adjacent structures! ¡  Mechanism of Injury! §  Direct blow to clavicle! §  Fall on outstretched shoulder! ¡  Symptoms/Signs ! §  Pain, Swelling and Deformity! §  Arm is held inward and downward and supported by other extremity! §  Open fractures result from severe tenting and piercing of overlying skin! ¡  Imaging ! §  CXR or Clavicle films! §  Children may have a greenstick fracture without definite fracture on x-ray imaging! 15   Magnus  Manske,  Wikimedia  Commons   Source  Undetermined  
  • 16.
    ¡  Allman Classification! § Middle 1/3 (80%)! ▪  Most common area to fracture! ▪  Especially in children! §  Distal 1/3 (15%)! ▪  Often associated with ruptured CC joint with medial elevation! ▪  May require operative intervention to avoid non-union! §  Medial 1/3 (5%)! ▪  Uncommon! ▪  Requires strong injury forces! ▪  Higher association with intrathoracic injury ! ▪  (e.g Subclavian Artery/Vein injury)! 16   Image  adapted  from  Anatomagraphy,   Wikimedia  Commons     Group  III   ~Medial  1/3   ~3%-­‐6%   Group  I   ~Middle  1/3   ~69%-­‐85%   Group  II   ~Distal  1/3   ~12%-­‐28%   Allman  Classification  
  • 17.
  • 18.
    ¡  Emergency OrthopedicConsultation! §  Open Fractures! §  Fractures with neurovascular injuries! §  Fractures with significant tenting at high risk for converting to open! ¡  Indications for Surgical Repair! §  Displaced distal third! §  Open! §  Bilateral! §  Neurovascular injury! ¡  Treatment = Sling, Orthopedic Follow-up! §  Non-operative management is successful in 90%! ¡  Middle 1/3 Clavicle Non-union risk factors! §  Shortening > 2 cm! §  Comminuted fracture! §  Elderly female! §  Displaced fracture! §  Significant associated trauma! 18  
  • 19.
    ¡  Scapula! §  Linksthe axial skeleton to the upper extremity! §  Stabilizing platform for the motion of the arm! §  1% cases of blunt trauma have scapular fracture! §  3-5% of shoulder injuries! ¡  Mechanism of Injury! §  Direct blow to the scapula! §  Trauma to the shoulder! §  Fall on an outstretched arm! ¡  Clinical Presentation! §  Localized pain over the scapula! §  Ipsilateral arm held in adduction! §  Any movement of arm exacerbates pain! ¡  High association with other intrathoracic injuries (>75%)! §  Due to high degree of energy required for fracture! §  Pulmonary contusion > 50% of cases! §  Pneumothorax, Rib fractures commonly associated! Glenoid   Body   Neck   19  Gray’s  Anatomy,  Wikimedia  Commons  
  • 20.
    ¡  Classification! §  AnatomicLocation! §  Body = 50-60%! §  Neck = 25%! ¡  Imaging! §  Shoulder/Dedicated Scapular Series! ▪  AP/Lateral/Axillary! §  Axillary views help identify fractures:! ▪  Glenoid fossa! ▪  Acromion! ▪  Coracoid Process! §  Consider CXR/Chest CT to rule out associated injuries! 20   Gray’s  Anatomy,  Wikimedia  Commons  
  • 21.
    ¡  Treatment! §  Sling,Ice, Analgesia! §  Immobilization! §  Early ROM exercises! §  Orthopedic Referral for ORIF! ▪  Glenoid articular surface fractures with displacement! ▪  Scapular neck fractures with angulation! ▪  Acromial fractures associated with rotator cuff injuries! ! 21   Source  Undetermined  
  • 22.
    ¡  Shoulder dislocation= Most common dislocation in the ED! ¡  Classification! §  Anterior (95-97%)! ▪  Subcoricoid, Subglenoid, Subclavicular, Intrathroracic! §  Posterior (2-3%)! ▪  Most commonly missed dislocation in the ED! ▪  Association with Seizure, Electric Shock/lightening injuries! §  Inferior (Luxatio Erecta)! §  Superior (Very Rare)! ¡  Mechanism of Injury! §  Anterior = Abduction, Extension and External Rotation with force applied to shoulder! §  Posterior = Indirect force with forceful internal rotation and adduction! 22  
  • 23.
    ¡  Clinical Presentation! § “Squared off” Shoulder! §  Patient resists abduction and internal rotation! §  Humeral head palpable anteriorly! §  Must test axillary nerve function/ sensation! ¡  Quebec Decision Rule! §  Radiographs needed for:! ▪  Age > 40 and humeral ecchymosis! ▪  Age > 40 and 1st dislocation! ▪  Age < 40 and mechanism other than fall from standing height or lower! §  Failed to be validated due to low sensitivity (CJEM 2011)! ¡  Recurrent Shoulder dislocations! ¡  Radiographs! §  AP/Lateral/Y-view! 23   Source  Undetermined     Source  Undetermined    
  • 24.
    ¡  Clinical Presentation! § Prominence of posterior shoulder! §  Anterior flatness! §  Unable to externally rotate or abduct the affected arm! ¡  Radiography! §  AP Radiograph! ▪  “Light Bulb Sign”! ▪  Internal rotation of the humerus! §  Y view! ▪  Diagnostic for posterior dislocation! 24   Source  Undetermined     Source  Undetermined    
  • 25.
    ¡  Inferior ShoulderDislocation! ¡  Hyperabduction force ! ¡  Levers humerus against the acromion tearing inferior capsule! ¡  Forces humeral head out inferiorly! ¡  Clinical Presentation! ¡  Humerus is fully abducted, elbow flexed, hand behind the head! ¡  Humeral head palpated on lateral chest wall! ¡  Frequently associated with:! ¡  Soft tissue injuries/rotator cuff tears! ¡  Fractures of humeral head! ¡  Neurovascular compression injury is common! 25   Source  Undetermined  
  • 26.
    ¡  Treatment! §  Reductionusing a variety of techniques! ▪  Success rate = 70-96% regardless of technique! §  Shoulder dislocation with associated humeral head fracture typically require orthopedic consultation and may require operative repair! §  Neurovascular exam pre- and post reduction! §  Procedural Sedation if initial attempts unsuccessful! §  Intra-articular injection of 10-20 cc lidocaine alternative to procedural sedation! §  After reduction, patient should be placed in shoulder immobilizer and orthopedic follow-up arranged! 26   Nevit  Dilman,  Wikimedia  Commons  
  • 27.
    ¡  External Rotation! § Hennepin Technique! §  Gentle external rotation ! §  Followed by slow abduction of arm! §  Reduction typically complete prior to reaching coronal plane! §  78% success rate! §  Procedural sedation rarely needed! 27   Source:  University  of  Hawaii  School  of  Medicine    
  • 28.
    ¡  Modified Hippocraticor Traction-Countertraction Technique! 28   Source:  University  of  Hawaii  School  of  Medicine    
  • 29.
    ¡  Scapular Manipulation! § Technique! ▪  Seated Position! ▪  Steady forward traction on wrist parallel to floor! ▪  Rotate inferior tip of scapula medially and superior aspect laterally! §  96% Success rate! §  Requires two people! §  Borders of scapula can be difficult to identify in obese patients! §  Rarely requires sedation! 29   Source:  University  of  Hawaii  School  of  Medicine     Source:  University  of  Hawaii  School  of  Medicine    
  • 30.
    ¡  Stimpson orHanging Weight Technique! 30   Source:  University  of  Hawaii  School  of  Medicine    
  • 31.
    ¡  Complications! §  Recurrentdislocation (Most Common)! ▪  < 20 years old: > 90% ! ▪  > 40 years old: 10-15% ! §  Bony Injuries! ▪  Hill-Sachs Deformity ! ▪  Compression fracture or groove of posterolateral aspect of humeral head! ▪  Results from impact of humeral head on the anterior glenoid rim as it dislocates or reduces! ▪  Avulsion of greater tuberosity (Higher incidence > 45 years old)! ▪  Bankart’s Fracture = Fracture of the anterior glenoid lip! §  Nerve Injuries (10-25% dislocations)! ▪  Most often are traction related neuropraxias and resolve spontaneously! ▪  Axillary nerve (most common) or Musculocutaneous nerve! §  Rotator Cuff Tears ! ▪  86% of patients > 40 years will have associated rotator cuff tear! §  Axillary Artery Injury (rare) ! ▪  Elderly patients with weak pulse ! ▪  Rapidly expanding hematoma! 31  
  • 32.
    ¡  Hill SachsDeformity! ¡  Bankart’s Lesion/Fracture! http://www.mypacs.net/repos/mpv3_repo/viz/ full/18712/935613.jpg   32   Hellerhoff,  Wikimedia  Commons   RSatUSZ,  Wikimedia  Commons  
  • 33.
    ¡  Rotator cuff= 4 muscles that insert tendons into the greater and lesser tuberosity! §  SITS MUSCLES = Subscapularis, Supraspinatous, Infraspinatous, Teres minor! ¡  Mechanisms of Injury! §  Acute tear = Forceful abduction of the arm against resistance (e.g. fall on outstretched arm)! §  Chronic teat = 90% = Results from subacromial impingement and decreased blood supply to the tendons (worsens as patient ages)! ¡  Clinical Picture! §  Typically affects males at 40 y/o or later! §  Pain over anterior aspect of shoulder, tearing quality to pain, typically worse at night! §  PE with weak and painful abduction or inability to initiate abduction (if complete tear)! §  Tenderness on palpation of supraspinatous over greater tuberosity! ¡  Imaging! §  In ED, plain film x-rays indicated to exclude fracture and may show degenerative changes and superior displacement of humeral head! §  MRI is diagnostic (not typically done in ED setting)! ¡  Treatment! §  Sling Immobilization, Analgesia, Ortho Referral! §  Complete tears require early surgical repair (< 3 weeks)! §  Chronic tears are managed with immobilization, analgesia and orthopedic follow-up for rehabilitation exercises and possible steroid injection! 33  
  • 34.
    ¡  Proximal HumerusFractures! §  Common in elderly patients with osteoporosis! §  Mechanism of Injury = Fall on outstretched hand with elbow extended! §  Clinical Presentation! ▪  Pain, swelling and tenderness around the shoulder! ▪  Brachial plexus and axillary arteries injuries! ▪  Higher incidence (>50%) in displaced fractures ! §  Neer Classification guides treatment! ▪  Fractures separate humerus into 4 fragments by epiphyseal lines! ▪  Displacement > 1 cm or angulation > 45 degrees defines a fragment as a “separate part” when fractures occur! ▪  If none of fragments are displaced > 1cm, fracture is termed 1 part ! §  Treatment! ▪  One part fractures (85%) = immobilization in sling/swathe, ice, analgesics, orthopedic referral! ▪  Two/Three/Four part fractures = Orthopedic Consultation! 34  
  • 35.
    Fragments  of  Humerus  Head   Articular  surface  of  humeral  head   Greater  tubercle   Lesser  tubercle   Shaft  of  humerus   35   3   1   2   James  Heilman,  MD,  Wikimedia  Commons   Gray’s  Anatomy,     Wikimedia  Commons  
  • 36.
    ¡  Typically involvemiddle 1/3 of the humeral shaft! ¡  Mechanism of Injury! §  Direct Blow (Most common)! §  Fall on outstretched arm or elbow! §  Pathologic Fracture (e.g. breast cancer)! ¡  Clinical Presentation ! §  Pain and deformity over affected region! §  Associated Injuries! ▪  Radial Nerve injury = Wrist Drop (10-20%)! ▪  Neuropraxia will often resolve spontaneously! ▪  Nerve palsy after manipulation or splinting is due to nerve entrapment and must be immediately explored by orthopedic surgery! ▪  Ulnar and Median nerve injury (less common)! ▪  Brachial Artery Injury! 36  
  • 37.
    ¡  Imaging =Standard x-ray imaging! ¡  Treatment! §  Non-operative Management (most common)! ▪  Simple Sling and Swath adequate for ED patients! ▪  Closed treatment options! ▪  Coaptation splint (sugar tong)! ▪  Hanging cast! ▪  External fixation! §  Operative management! ▪  Neurovascular compromise, pathologic fractures! ¡  Complications! §  Neurovascular injury! §  Delayed union! §  Adhesive capsulitis! 37   Bill  Rhodes,  Wikimedia  Commons  
  • 38.
    ¡  Proximal ordistal biceps tendon rupture! ¡  Mechanism of Injury = Sudden or prolonged contraction against resistance in middle aged or elderly patients! ¡  Clinical Presentation! §  “Snap” or “Pop” typically described! §  Pain, swelling, tenderness over site of tendon rupture! §  Flexion of elbow = Mid-arm ball! §  Loss of strength sometimes minimal! §  X-rays to exclude avulsion fracture! ¡  ED Treatment! §  Sling, Ice, Analgesia, Orthopedic referral! §  Surgical repair for young, active patients! 38   Patenthalse,  Wikimedia  Commons   Gray’s  Anatomy,   Wikimedia  Commons  
  • 39.
  • 40.
    Anterior  Fat  Pad          “Sail  Sign”   Posterior  Fat  Pad   (Never  normal)   Anterior  Humeral  Line   •   Normal  =  Middle  of  capitellum   •   Abnormal  =  Anterior  1/3  of   capitellum  or  completely  anterior   Radial-­‐Capitellar  Line   • Normal  =  Transects   middle  of  capitellum   40   Hellerhoff,  Wikimedia  Commons   Source  Undetermined   Source  Undetermined  
  • 41.
    ¡  Supracondylar ExtensionFractures ! §  Most Common Type! §  Mechanism of injury ! ▪  Fall on outstretched arm with elbow in extension! §  Imaging ! ▪  Distal humerus fractures and humeral fragment displaced posteriorly! ▪  Sharp fracture fragments displaced anteriorly with potential for injury of brachial artery and median nerve! §  Treatment! ▪  Non-displaced fracture (Rare) = Immobilization in posterior splint! ▪  May be discharged home with close follow-up! ▪  Displaced fracture ! ▪  Orthopedic Consultation and reduction! ▪  Patients with displaced fractures or significant soft tissue swelling require admission for observation! 41  
  • 42.
    ¡  Supracondylar FlexionFractures (rare)! §  Mechanism of Injury ! ▪  Direct blow to posterior aspect of flexed elbow! §  Fractures are frequently open! §  Imaging = Distal humerus fracture displaced anteriorly! §  Treatment! ▪  Non-displaced fractures! ▪  Splint immobilization and early orthopedic follow-up! ▪  Displaced fractures ! ▪  Orthopedic consultation for reduction ! ▪  Patients with displacement and soft tissue swelling require admission! 42  
  • 43.
    Extension  Type  Fracture   Flexion  Type  Fracture   43   Source  Undetermined   Source  Undetermined   Source  Undetermined  
  • 44.
    ¡  Early Complications! § Neurologic (7%)! ▪  Results from traction, direct trauma or nerve ischemia! ▪  Radial Nerve (Posterior-medial displacement)! ▪  Median Nerve (Posterior-lateral displacement)! ▪  Ulnar Nerve (Uncommon)! ▪  Anterior Interosseous Nerve Injuries ! ▪  High incidence with supracondylar fractures! ▪  No sensory component, Motor component must be tested (“OK sign”)! §  Vascular Entrapment (Brachial Artery)! ¡  Late Complications! §  Non-union/Mal-union! §  Loss of mobility! 44  
  • 45.
    ¡  Compartment syndromeof the forearm! ¡  Complication of elbow/forearm fractures! ¡  Increased compartment pressure results in ischemia of muscles of forearm, typically flexor compartment! ¡  Patient complains of pain out of proportion of injury, digit swelling and paresthesias! ¡  Also consider in any patient presenting with pain and numbness in hand after casting has been performed! ¡  Irreversible damage in 6 hours (see image)! ¡  Treatment ! §  Removal of cast! §  Surgical decompression with fasciotomy! 45   Source  Undetermined  
  • 46.
    ¡  Most commonfractures of the elbow! ¡  Mechanism of Injury = Fall on outstretched hand! ¡  Clinical Finding = Tenderness and swelling over the radial head! ¡  Imaging! §  May not be seen on initial x-ray or may be subtle on x-ray! §  Evaluate for anterior or posterior fat pad which suggests diagnosis! ¡  Associated Injuries! §  Essex-Lopresti Lesion ! ▪  Disruption of fibrocartilage of the wrist and interosseus membrane! ▪  Distal radial-ulnar dissociation! §  Articular surface of capitellum frequently also injured! ¡  Treatment! §  Non-displaced = Sling, Ortho follow-up! §  Comminuted/Displaced Fractures require urgent orthopedic referral within 24 hours! 46   Source  Undetermined  
  • 47.
    ¡  Nursemaid’s elbow= Subluxation of radial head beneath the annular ligament! ¡  Mechanism of injury = Longitudinal traction on hand or forearm with arm in pronation! ¡  X-rays not necessary! ¡  Treatment = Reduction! §  Thumb over radial head with concurrent supination of forearm and flexion of elbow! §  Extension and pronation (another option for reduction)! 47   David  Tan,  Flickr  
  • 48.
    48   Therese  Clutario,  Wikimedia  Commons   hyperpronation   supination   flexion  
  • 49.
    ¡  Third mostcommon joint dislocation! ¡  Posterolateral (90%)! §  Mechanism of Injury = Fall on outstretched hand! §  Clinical Findings ! ▪  Marked swelling with loss of landmarks ! ▪  Posterior prominence of olecranon! §  Immediate consideration must be given to neurovascular status! ▪  Ulnar or Median Nerve injury common (8-21%) ! ▪  Brachial artery injury (5-13%)! §  Associated fractures (30-60%) of coronoid process and radial head! §  Terrible triad injury = elbow dislocation + radial head and coronoid fracture (unstable)! ¡  Anterior (Uncommon)! §  Mechanism of Injury = Blow to Olecranon with elbow in flexion! §  Associated Injuries = Much higher incidence of vascular impingement! 49  
  • 50.
    http://tw.myblog.yahoo.com/doctor-­‐-­‐anjenli/article? mid=776&prev=778&next=774&l=f&fid=79   Anterior  Elbow  Dislocation   Posterior  Elbow  Dislocation   50   Source  Undetermined   Source  Undetermined  
  • 51.
    ¡  Elbow Reduction! § Immobilize humerus! §  Apply traction at wrist! §  Slight flexion of the elbow! §  Posterior pressure on olecranon! ¡  Post-Reduction ! ¡  Long Term Complications! §  Post-traumatic arthritis! §  Joint instability! ! 51  
  • 52.
    ¡  Fracture ofboth ulnar and radius! §  Usually displaced fracture! ¡  Mechanism of Injury ! §  Direct blow to forearm! ¡  Associated Injury! §  Peripheral Nerve Deficits! ▪  Uncommon in most closed injuries! ▪  More common with open fractures! §  Development of compartment syndrome! ¡  Treatment! §  Displaced – ORIF! ¡  Complications! §  Compartment Syndrome! §  Malunion! 52   Source  Undetermined  
  • 53.
    ¡  Isolated fractureof ulnar shaft! ¡  Mechanism ! §  Direct blow to ulna! §  Patient raising forearm to protect face! ¡  Treatment! §  Non-displaced! ▪  Immobilization in splint! §  Displaced ! ▪  >10 degrees angulation! ▪  Displacement > 50% of ulna! ▪  Orthopedic consultation - ORIF! 53   Source  Undetermined  
  • 54.
    ¡  Distal RadiusFracture! §  Distal radio-ulnar dislocation! ¡  Reverse Monteggia’s fx! ¡  Mechanism of Injury! §  Direct blow to back of wrist! §  Fall on outstretched hand! ¡  Complication = Ulnar nerve injury! ¡  Treatment = ORIF ! http://www.learningradiology.com/caseofweek/ caseoftheweekpix2/cow157lg.jpg   54   Th.  Zimmermann,  Wikimedia  Commons  
  • 55.
    ¡  Proximal 1/3Ulnar Fracture! §  Dislocation of radial head! ¡  Mechanism of Injury = Direct blow to posterior aspect of ulna! §  Fall on outstretched hand! ¡  Imaging ! §  Elbow/Forearm x-rays! §  Radial head dislocation missed in 25% of cases! §  Carefully examine the alignment of radial head! ¡  Associated Injury = Radial Nerve Injury! ¡  Treatment ! §  ORIF ! §  Closed Reduction/Splinting ! 55   Jane  Agnes,  Wikimedia  Commons  
  • 56.
    Galeazzi   Radial  Fracture   Ulnar  Fracture   Monteggia   G   M   U  R   56   Patrick  Carter,  University  of  Michigan   Patrick  Carter,  University  of  Michigan  
  • 57.
    ¡  Transverse fractureof distal radius with dorsal displacement of distal fragment! ¡  Mechanism = Fall on outstretched hand! ¡  Most common fracture in adults > 50 years old! ¡  Exam = Classic Dinner Fork Deformity! ¡  Associated Injuries! §  Ulnar styloid fracture! §  Median Nerve Injury! ¡  Unstable Fractures! §  >20 degrees angulation, intra-articular involvement, comminuted fractures or > 1 cm of shortening! ¡  Treatment! §  Non-displaced Fracture ! ▪  Sugar Tong Splint, Referral to Orthopedic Surgery! §  Displaced Fracture! ▪  Reduction – Finger traps and manipulation under procedural sedation or with hematoma block! ▪  Immobilization in Sugar tong splint! ▪  Referral to Orthopedic Surgery! 57  
  • 58.
    ¡  Transverse fractureof distal radius with volar displacement! ¡  Mechanism = Fall on outstretched arm with forearm in supination! ¡  Associated Injury = Median Nerve Injury! ¡  Treatment! §  Reduction with finger traps and manipulation! §  Immobilization in sugar tong or long arm splint! §  Orthopedic referral! 58  
  • 59.
    ¡  Colles Fracture!! ¡  Smith Fracture! Goals  of  Reduction:   *    Restore  volar  tilt   *    Radial  Inclination   *    Proper  radial  length   59   Lucien  Monfils,  Wikimedia  Commons     Source  Undetermined  
  • 60.
  • 61.
    ¡  Scaphoid Fracture! § Most common carpal bone fracture! §  Mechanism = fall on outstretched hand or axial load to thumb! §  2/3 of fracture in waist of scaphoid! §  Imaging – Initial x-rays may fail to demonstrate fracture ! ▪  > 10% of cases! ▪  Repeat Imaging in 2 weeks will often show fracture! §  Clinical findings = tenderness in anatomical snuff box! §  Treatment! ▪  Non-displaced or clinically suspected fracture ! ▪  Thumb spica Splint! ▪  Displaced fractures will require ORIF! ▪  Complications ! ▪  Avascular necrosis of proximal fragment -> arthritis! ▪  Delayed union or malunion! 61  
  • 62.
  • 63.
    ¡  Triquetrum Fracture(2nd most common)! §  Mechanism = Fall on outstretched hand! §  Body fracture or avulsion chip fractures! §  Exam = Tenderness on palpation distal to ulnar styloid on dorsal aspect of wrist, painful flexion! §  Avulsion fracture best visualized on lateral or oblique view of wrist! §  Treatment = Volar splint, Orthopedic referral! ¡  Lunate Fracture! §  Mechanism = Fall on outstretched hand! §  Exam = Pain over mid-dorsum of wrist increased with axial loading of 3rd digit! §  Vascular supply is through distal end of bone -> high risk for avascular necrosis of the proximal portion! §  Plain x-rays are often normal! §  Treatment = Immobilization in thumb spica splint, orthopedic referral! §  Complications ! ▪  Kienbock’s disease = Avascular necrosis of proximal segment! ▪  Chronic pain, decreased grip strength, osteoarthritis! ! 63  
  • 64.
    ¡  Triquetrum Fracture!¡  Lunate Fracture! 64   Hellerhoff,  Wikimedia  Commons   Source  Undetermined  
  • 65.
    ¡  Lunate isat the center of the carpal bones ! §  Majority of ligamentous injuries are centered on the lunate! §  Injuries are from forceful dorsiflexion of wrist! §  Degree of force determines severity of injury! ▪  Spectrum from isolated tear to dislocations! ¡  Spectrum of ligamentous injuries! §  Scapholunate ligament instability! §  Triquetrolunate ligament instability! §  Perilunate and Lunate dislocations! 65  
  • 66.
    ¡  Scapholunate ligamentbinds the scaphoid and lunate together! ¡  Most common ligamentous injury of hand! ¡  Commonly missed! ¡  Pain with wrist hyperextension, snapping or clicking sensation with radial/ulnar deviation! ¡  Radiographic signs! §  Scaphoid is foreshortened and has a dense ring shaped image around its distal edge (signet or cortical ring sign)! §  Widening of space between the lunate/scaphoid ! ▪  > 3 mm, Terry Thomas sign! ¡  Treatment ! §  Thumb spica or radial gutter splint! §  Orthopedic Referral! 66  
  • 67.
    ¡  Terry Thomasand Signet Ring Sign! 67   Source  Undetermined  
  • 68.
    ¡  Perilunate andlunate dislocations are the result of the most severe carpal ligamentous injury! ¡  Mechanism of Injury = Violent Hyperextension usually combined with a fall from height or motor vehicle crash! ¡  Clinical examination ! §  Generalized swelling, pain and tenderness over wrist! §  May be deceiving with no evidence of gross deformity! ¡  Radiographic evaluation is key to diagnosis! ¡  Treatment = Orthopedic Consultation! §  Treatment is dependent on severity of injury! §  Closed reduction and long-arm immobilization if possible! §  Open, unstable and irreducible dislocations require OR! §  Some orthopedists take all dislocations to OR! ¡  Complications! §  Degenerative Arthritis! §  Delayed union/Malunion/Non-union! §  Avascular necrosis! 68  
  • 69.
    ¡  4 C’sNeed to line up on normal x-ray! Lunate   69   Source  Undetermined  
  • 70.
    ¡  Lunate Dislocation! § Capitate is centered over the radius and the lunate is tilted out! §  Spilled Tea cup deformity! ¡  Peri-lunate Dislocation! §  Lunate is centered over the radius and capitate is tilted out! §  Associated with scaphoid fx! 70   Source:   Radiology  Assistant  Source:   Radiology  Assistant  
  • 71.
    ¡  Carpal TunnelSyndrome! §  Entrapment of Median nerve! §  Tinel’s sign = Tapping over volar wrist produces paresthesias! §  Phalen’s sign = Hyperflexion of wrist = Paresthesias! §  Risk Factors = Pregnancy, Hypothyroid, DM, RA! §  Treatment = Splinting, Rest, Surgical Decompression! ¡  DeQuervain’s Tenosynovitis! §  Overuse syndrome with inflammation of extensor tendons of thumb! §  Characterized by pain along radial aspect of wrist that is exacerbated with use of thumb! §  Finkelstein’s test = Ulnar deviation of fisted hand produces pain! §  Treatment = NSAIDS, Splint, Rest! ¡  Guyon’s Canal Syndrome! §  Ulnar nerve entrapment syndrome! §  Numbness and tingling in ring and small finger! §  Causes = repetitive trauma (handle bar neuropathy), cyst! §  Treatment = Splint, Surgical Decompression! 71  
  • 72.