Traumatic Injuries of the Upper Extremity

1. Traumatic Injuries of the Upper Extremity Kevin deWeber, MD MAJ, MC Primary Care Sports Medicine

2. 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

5. Normal axillary view

6. 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

7. Cross-Chest Adduction Test • AC joint • Adduct shoulder • Patient pushes elbow up against resistance • Pain in AC = + test • false + test in RC pathology

8. Types of AC joint sprains

9. 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

10. Normal AC joint

11. Grade II AC joint sprain

12. Grade III AC joint sprain

13. 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.

14. 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

15. 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

16. 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

17. 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%

19. Lateral third clavicle fracture, type II displaced)

20. 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

21. 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

22. 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

23. Anterior shoulder dislocation

24. Anterior shoulder dislocation

25. Posterior shoulder dislocation

26. Hill-Sachs deformity

27. Bankart lesion

28. 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

29. The Stimson technique for anterior shoulder dislocation reduction.

30. 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

31. 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

32. Elbow trauma • Fractures • Dislocations • Ligament sprains • Look for compartment syndrome • Rule out neurovascular injury

37. 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

39. Fat pad signs

40. Elbow fractures • Supracondylar, epicondylar • Radial head/neck • Olecranon • Coronoid process • **Consult current texts or your friendly local orthopedist for treatment of each.

41. Radial head/neck fractures • Common fracture in adults • FOOSH usually • Detection may require oblique view • Assure proper alignment of head on capitellum (radiocapitellar line)

42. Radial head fracture types • Type I: less than 2 mm displacement • Type II: angulated or >2 mm displaced • Type III: comminuted

43. Radiocapitellar line

44. Radial head fracture

45. Radial head fracture

46. 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

48. 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

49. Skier’s Thumb • Mechanism of injury • Forced abduction and hyperextension of thumb • FOOSH with thumb caught in extension • Diagnosis • History • Radiographs • Physical exam

50. Skier’s Thumb