Traumatic injuries of the upper extremity
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Traumatic Injuries of the Upper Extremity. John Hardin, ATC Sports Medicine. Objectives: You should be able to treat. AC joint sprains Anterior shoulder dislocations Clavicular fractures Radial head fractures Skier’s thumb Scaphoid fractures TFCC tears

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Traumatic Injuries of the Upper Extremity

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Traumatic injuries of the upper extremity

Traumatic Injuries of the Upper Extremity

John Hardin, ATC

Sports Medicine


Objectives you should be able to treat

Objectives:You should be able to treat...

  • AC joint sprains

  • Anterior shoulder dislocations

  • Clavicular fractures

  • Radial head fractures

  • Skier’s thumb

  • Scaphoid fractures

  • TFCC tears

  • And know referral criteria for complications


  • Traumatic injuries of the upper extremity

    Normal axillary view


    Ac joint sprains

    AC joint sprains

    • AKA “separated shoulder”

    • Mechanism:

      • Blow to top of shoulder

      • May result from fall onto outstretched arm or elbow

    • Focal tenderness and pain with shoulder motion

    • Cross-chest adduction test usually positive


    Cross chest adduction test

    Cross-Chest Adduction Test

    • AC joint

    • Adduct shoulder

    • Patient pushes elbow up against resistance

    • Pain in AC = + test

      • false + test in RC pathology


    Traumatic injuries of the upper extremity

    Types of AC joint sprains


    Ac joint sprains radiology eval

    AC joint sprains:Radiology eval

    • Standard AP shoulder views inadequate

      • usually over-penetrate the AC joint

    • Image both sides for comparison

    • Get specific AC joint view (Zanca)

      • AP with 10° cephalic incline

    • Axillary view can show posterior dislocation


    Traumatic injuries of the upper extremity

    Normal AC joint


    Traumatic injuries of the upper extremity

    Grade II AC joint sprain


    Traumatic injuries of the upper extremity

    Grade III AC joint sprain


    Traumatic injuries of the upper extremity

    • Weighted AC x-rays seldom unmask unstable injures

      • Bossart PJ et al. Lack of efficacy of “weighted” radiographs in diagnosing acute acromioclavicular separations. Ann Emerg Med 1988; 117:20-24.


    Management of mild ac joint sprains types i and ii

    Management of mild AC joint sprains (types I and II)

    • Ice, analgesia

    • Sling 1-3 weeks

    • Early ROM as pain permits

    • Strength exercises after full ROM achieved

    • Return to sports after pain-free function achieved


    Management of type iii ac joint sprints

    Management of type IIIAC joint sprints

    • Initially same as for I and II

    • Referral to ortho advisable within 72 hours

    • Most authors advocate conservative management

      • Outcome just as good as surgery, with quicker recovery time


    Acute management of severe ac joint sprains types iv v vi

    Acute management of severe AC joint sprains (types IV, V, VI)

    • Ice, analgesia

    • Management of any complications (type VI associated with clavicle fxs, rib fxs, and brachial plexus injuries)

    • Sling/swath

    • Early referral


    Clavicular fractures

    Clavicular Fractures

    • One of the most common fractures

    • Classification

      • Middle third - most common (thinnest section)

      • Distal third

      • Proximal third

    • Image with AP thorax and 45° AP cephalic tilt

    • Rule out neurological or vascular compromise; pneumothorax in 3%


    Traumatic injuries of the upper extremity

    Lateral third clavicle fracture, type II displaced)


    Er management of clavicular fractures

    ER Management ofClavicular Fractures

    • Ice, analgesics, arm support for all

    • Referral rule:

      • Any displaced, non-middle-third fractures

    • Non-displaced fxs: sling; ROM prn comfort

    • Displaced middle-third fractures: figure 8 splint

      • Re-image in 7 days to assure reduction. If not, refer for shoulder spica cast


    Shoulder dislocations

    Shoulder dislocations

    • Most commonly dislocated large joint

    • Anterior in 97%

    • Mechanism: force on abducted/externally rotated shoulder

    • Exam:

      • Shoulder externally rotated

      • Fullness anteriorly; acromion prominent post.

      • Neurovascular testing


    Radiology of shoulder dislocations

    Radiology of shoulder dislocations

    • AP and axillary views; optional scapular lateral (Y)

    • Location of humeral head w.r.t glenoid

    • Look for fractures (not a contra-indication to reduction)

    • Always pre-reduction x-rays in primary cases

    • Optional pre-reduction x-rays in recurrent cases

    • Always post-reduction x-rays


    Traumatic injuries of the upper extremity

    Anterior shoulder dislocation


    Traumatic injuries of the upper extremity

    Anterior shoulder dislocation


    Traumatic injuries of the upper extremity

    Posterior shoulder dislocation


    Traumatic injuries of the upper extremity

    Hill-Sachs deformity


    Traumatic injuries of the upper extremity

    Bankart lesion


    Shoulder dislocation reduction techniques

    Shoulder dislocation reduction techniques

    • Types of maneuvers

      • Traction (Stimson, self-reduction, Hippocrates, Eskimo,Milch)

      • Scapular manipulation

      • Leverage (Kocher)

      • Combined maneuvers (slump, Snowbird)

    • No comparative research


    Traumatic injuries of the upper extremity

    The Stimson technique

    for anterior shoulder

    dislocation reduction.


    Post reduction treatment for shoulder dislocation

    Post-reduction treatment for shoulder dislocation

    • Ice 72 hrs, NSAID 7-14 days

    • Immobilization 3-6 weeks

      • Capsule needs time to heal

    • Physical Therapy referral for rehab

    • Less immobilization (1 week) and quicker rehab in pts >40 (to prevent stiffness) and in recurrent dislocators


    Indications for early orthopedic referral for pts with shoulder dislocation

    Indications for early orthopedic referral for pts with shoulder dislocation

    • Displaced greater tuberosity fxs (>1 cm post-reduction)

    • Glenoid rim fxs displaced >5mm

    • Irreducible dislocations (soft tissue interposition)

    • Young athletes


    Elbow trauma

    Elbow trauma

    • Fractures

    • Dislocations

    • Ligament sprains

    • Look for compartment syndrome

    • Rule out neurovascular injury


    Axioms in elbow trauma radiograph evals

    Axioms in elbow trauma radiograph evals

    • Look for fat pads signs (capsular effusion)

      • Anterior fat pad (from coronoid fossa) may be normal; compare to other side

      • Posterior fat pad (from olecranon fossa) is always abnormal

    • Compare to x-rays of other side in children

    • If elbow can’t be extended, obtain AP/lat of both humerus and forearm


    Traumatic injuries of the upper extremity

    Fat pad signs


    Elbow fractures

    Elbow fractures

    • Supracondylar, epicondylar

    • Radial head/neck

    • Olecranon

    • Coronoid process

    • **Consult current texts or your friendly local orthopedist for treatment of each.


    Radial head neck fractures

    Radial head/neck fractures

    • Common fracture in adults

    • FOOSH usually

    • Detection may require oblique view

    • Assure proper alignment of head on capitellum (radiocapitellar line)


    Traumatic injuries of the upper extremity

    • Radial head fracture types

    • Type I: less than 2 mm displacement

    • Type II: angulated or >2 mm displaced

    • Type III: comminuted


    Traumatic injuries of the upper extremity

    Radiocapitellar

    line


    Traumatic injuries of the upper extremity

    Radial head fracture


    Traumatic injuries of the upper extremity

    Radial head fracture


    Er treatment of radial head neck fractures

    ER treatment ofRadial head/neck fractures

    • Consider aspiration of hemarthrosis to relieve pain

    • Type I

      • Posterior splint a few days

      • Sling; AROM when tolerated

      • Physical therapy in 3 weeks

    • Types II and III - splint and refer


    Skier s thumb

    Skier’s Thumb

    • Pathoanatomy

      • Sprain of ulnar collateral ligament of thumb MCP

      • Grades I, II, and III

        • I = no laxity

        • II = laxity but intact

        • III = complete tear


    Skier s thumb1

    Skier’s Thumb

    • Mechanism of injury

      • Forced abduction and hyperextension of thumb

      • FOOSH with thumb caught in extension

    • Diagnosis

      • History

      • Radiographs

      • Physical exam


    Skier s thumb2

    Skier’s Thumb


    Skier s thumb exam

    Skier’s thumb: exam

    • Anesthesia (block)

    • Valgus stress to MCPJ in extension

    • Over 20° opening is probably grade III tear


    Stener lesion

    Stener Lesion


    Skier s thumb3

    Skier’s Thumb

    • Stener lesion

      • 64% of Grade III injuries

      • Adductor aponeurosis interposed

      • Prohibits reattachment of ligament

      • MRI and arthrogram are sensitive


    Skier s thumb treatment

    Skier’s Thumb:Treatment

    • Grades I & II

      • Thumb spica splint 2-4 weeks, then

      • Splint or tape 3 months

  • Grade III

    • Controversial

    • Surgery

    • Refer to Ortho


  • Scaphoid fracture

    Scaphoid Fracture

    • History

      • FOOSH

      • Dull, deep, ache in radial side of wrist


    Scaphoid fracture anatomy

    Scaphoid Fracture:Anatomy

    • Blood supplied from distal pole

    • The more proximal the fracture, the greater the risk of avascular necrosis (AVN) or delayed union


    Scaphoid fracture examination

    Scaphoid Fracture:Examination

    • Minimal swelling

    • Tenderness in snuff box

    • Pain with axial load


    Traumatic injuries of the upper extremity

    Scaphoid tubercle

    fracture


    Scaphoid fracture radiographs

    Scaphoid fracture:Radiographs

    • AP

    • Lateral

    • Oblique

    • Scaphoid view

    • **Normal plain films don’t rule out a scaphoid fracture


    Scaphoid fracture treatment

    Scaphoid Fracture:Treatment

    • Non-displaced fracture of waist or distal pole

      • Long arm thumb spica cast 6 weeks

      • Then, short arm thumb spica cast for 2-6 weeks

        • Replace cast/get x-rays Q2 wks to assess healing


    Scaphoid fracture treatment cont

    Scaphoid Fracture:Treatment (cont)

    • Clinically suspected fracture with normal plain films

      • Treat as non-displaced fracture

      • “PRICE”

      • Short-arm thumb spica cast

      • F/U in 10 days for repeat x-rays

      • Consider bone scan/MRI if x-rays neg but fx suspected


    Scaphoid fracture referral criteria

    Scaphoid Fracture:Referral criteria

    • Proximal fractures

    • Angulated; displaced >1mm

    • Scapholunate dissociation

    • Presentation > 2 wks

    • Early return to play necessary

    • Non-union or AVN


    Triangular fibrocartilage complex tfcc tear

    Triangular Fibrocartilage Complex (TFCC) Tear

    • Mechanism of injury

      • Fall on dorsiflexed and ulnar deviated wrist

      • Axial load with forearm in hyperpronation

    • Patient c/o ulnar sided wrist pain, swelling, loss of grip strength


    Tfcc tear

    TFCC tear


    Traumatic injuries of the upper extremity

    TFCC

    • Thickened pad of connective tissue that functions as a cushion for ulnar axial loads

    Articular disc

    Meniscus

    Ulnar

    collateral

    ligament


    Tfcc tear examination cont

    TFCC tear:Examination (cont)

    • Tenderness just distal to ulnar styloid


    Tfcc tear examination cont1

    TFCC tear:Examination (cont)

    • Press test

      • Patient presses arms of chair to lift body off seat

    • 100% sensitive


    Tfcc tear examination cont2

    TFCC tear:Examination (cont)

    • TFCC load test

      • Pain is a + test


    Tfcc tear examination cont3

    TFCC tear:Examination (cont)

    • Rule out injury to distal radio-ulnar joint (DRUJ)

    • Squeeze radius/ulna together and passively rotate forearm

      • Painful in DRUJ injury

      • No pain in isolated TFCC tear


    Tfcc tear radiography

    TFCC Tear:Radiography

    • Plain films

      • Positive ulnar variance (ulna 1-5 mm longer than radial articular surface) a/w TFCC tear

      • Assess for fracture or ulnar subluxation

    • MRI or Arthrography optional to confirm


    Mri tfcc tear

    MRI: TFCC tear


    Tfcc tear treatment

    TFCC Tear:Treatment

    • Long arm cast with forearm neutral for 4-6 weeks

    • Referral criteria:

      • Associated injuries including DRUJ instability

      • Persistent pain after immobilization


    Review

    Review

    • Refer all vertically displaced AC joint sprains

    • Refer any displaced, non-middle-third claviclular fractures

    • Pick and KNOW 1-2 shoulder reduction methods

    • Conservatively treat non-displaced radial head fractures

    • Refer all Skier’s thumb that gap >20°

    • Treat suspected scaphoid fxs even if xrays neg

    • Treat TFCC tears with 6 wks long arm cast


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