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

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

  • And know referral criteria for complications

  • Normal axillary view

    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

    • AC joint

    • Adduct shoulder

    • Patient pushes elbow up against resistance

    • Pain in AC = + test

      • false + test in RC pathology

    Types of AC joint sprains

    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

    Normal AC joint

    Grade II AC joint sprain

    Grade III AC joint sprain

    • 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)

    • 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 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)

    • Ice, analgesia

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

    • Sling/swath

    • Early referral

    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%

    Lateral third clavicle fracture, type II displaced)

    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

    • 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

    • 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

    Anterior shoulder dislocation

    Anterior shoulder dislocation

    Posterior shoulder dislocation

    Hill-Sachs deformity

    Bankart lesion

    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

    The Stimson technique

    for anterior shoulder

    dislocation reduction.

    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

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

    • Glenoid rim fxs displaced >5mm

    • Irreducible dislocations (soft tissue interposition)

    • Young athletes

    Elbow trauma

    • Fractures

    • Dislocations

    • Ligament sprains

    • Look for compartment syndrome

    • Rule out neurovascular injury

    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

    Fat pad signs

    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

    • Common fracture in adults

    • FOOSH usually

    • Detection may require oblique view

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

    • Radial head fracture types

    • Type I: less than 2 mm displacement

    • Type II: angulated or >2 mm displaced

    • Type III: comminuted



    Radial head fracture

    Radial head fracture

    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

    • 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 Thumb

    • Mechanism of injury

      • Forced abduction and hyperextension of thumb

      • FOOSH with thumb caught in extension

    • Diagnosis

      • History

      • Radiographs

      • Physical exam

    Skier’s Thumb

    Skier’s thumb: exam

    • Anesthesia (block)

    • Valgus stress to MCPJ in extension

    • Over 20° opening is probably grade III tear

    Stener Lesion

    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

    • Grades I & II

      • Thumb spica splint 2-4 weeks, then

      • Splint or tape 3 months

  • Grade III

    • Controversial

    • Surgery

    • Refer to Ortho

  • Scaphoid Fracture

    • History

      • FOOSH

      • Dull, deep, ache in radial side of wrist

    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

    • Minimal swelling

    • Tenderness in snuff box

    • Pain with axial load

    Scaphoid tubercle


    Scaphoid fracture:Radiographs

    • AP

    • Lateral

    • Oblique

    • Scaphoid view

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

    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)

    • 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

    • Proximal fractures

    • Angulated; displaced >1mm

    • Scapholunate dissociation

    • Presentation > 2 wks

    • Early return to play necessary

    • Non-union or AVN

    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


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

    Articular disc





    TFCC tear:Examination (cont)

    • Tenderness just distal to ulnar styloid

    TFCC tear:Examination (cont)

    • Press test

      • Patient presses arms of chair to lift body off seat

    • 100% sensitive

    TFCC tear:Examination (cont)

    • TFCC load test

      • Pain is a + test

    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

    • 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

    TFCC Tear:Treatment

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

    • Referral criteria:

      • Associated injuries including DRUJ instability

      • Persistent pain after immobilization


    • 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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