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Emergency Medicine

Emergency Medicine. Tynsia Harvey-Blount PGY-1. QUESTION 1.

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Emergency Medicine

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  1. Emergency Medicine Tynsia Harvey-Blount PGY-1

  2. QUESTION 1 A 3 year old female presents to the emergency department due to decreased use of her right arm. Her mother admits to pulling on her arm in an attempt to avoid a puddle she noticed on the floor. Her vital signs are within normal limits. Physical exam demonstrates guarding of the right arm held in pronated position. There is mild swelling of the elbow, and focal tenderness to palpation. What is the most appropriate first step in management? • X-ray of the arm, elbow, and forearm • MRI • Closed reduction via supination and flexion • Reassure parent and discharge from the ED

  3. QUESTION 1 A 3 year old female presents to the emergency department due to decreased use of her right arm. Her mother admits to pulling on her arm in an attempt to avoid a puddle she noticed on the floor. Her vital signs are within normal limits. Physical exam demonstrates guarding of the right arm held in pronated position. There is mild swelling of the elbow, and focal tenderness to palpation. What is the most appropriate first step in management? • Xray of the arm, elbow, and forearm • MRI • Closed reduction via supination and flexion • Reassure parent and discharge from the ED

  4. NURSEMAID ELBOWDIAGNOSIS • Also known as subluxation of radial head • Symptoms • a child with radial head subluxation tends to hold the elbow in slight flexion and the forearm pronated. • Physical Exam • pain and tenderness localized to the lateral aspect of the elbow.

  5. NURSEMAID ELBOW • Radiographs • recommended views • not routinely indicated in presence of classic history and physical examination • findings • radiographs are normal

  6. NURSEMAID ELBOWManagement Hyperpronation vs. Supination/Flexion method

  7. Follow-up • immobilization is not necessary and the child may immediately resume use of the arm. • follow up is only needed if the child does not resume normal use of his arm in the following weeks.

  8. QUESTION 2 A 17 year football player comes to the emergency department after falling during a game and landing on his left shoulder. He complains of pain. His vital signs are temp 37.4C; BP 111/79; RR 16; HR 120. Physical exam demonstrates loss of normal contour of the left shoulder, limited ROM and a prominent clavicle. He has tenderness on palpation of the AC joint. X-ray of shoulder and scapula confirms AC joint separation. What is the next appropriate step in management? • Narcotics followed by NSAID’s, sling for 2 weeks, and rehabilitation program • Surgical repair of the AC joint • Coracoclavicular ligament repair • MRI to stage injury, and then refer for surgery

  9. X-Ray

  10. QUESTION 2 A 17 year football player comes to the emergency department after falling during a game and landing on his left shoulder. He complains of pain. His vital signs are temp 37.4C; BP 111/79; RR 16; HR 120. Physical exam demonstrates loss of normal contour of the left shoulder, limited ROM and a prominent clavicle. He has tenderness on palpation of the AC joint. X-ray of shoulder and scapula confirms AC joint separation. What is the next appropriate step in management? • Narcotics followed by NSAID’s, sling for 2 weeks, and rehabilitation program • Immediate surgical repair of the AC joint • Coracoclavicular ligament repair • MRI to stage injury, and then refer for surgery

  11. AC separation • Symptoms • pain • Physical exam • palpate for lateral clavicle or AC joint tenderness • observe for abnormal contour of the shoulder compared to contralateral side • check for stability • AP stability assesses AC ligaments • vertical stability assesses Coracoclavicular (CC) ligaments

  12. AC separation • Radiographs • bilateral AP • compare displacement to contralateral side • measured as distance from top of coracoid to bottom of clavicle • 1/3 penetration on AP to visualize AC joint • axillary lateral  • required to diagnose Type IV (posterior) • zanca view  •  performed by tilting the x-ray beam 10° to 15° toward the cephalic direction and using only 50% of the standard shoulder anteroposterior penetration strength.  • stress views  • no longer used

  13. AC separationTreatment • Non-operative • ice, rest and sling for 3 weeks indications • Type I and II  • Type III in most individuals • rehab • early ROM • regain functional motion by 6 weeks • return to normal activity at 12 weeks • complications • AC joint arthritis • chronic subluxation and instability

  14. AC separationTreatment • Operative • ORIF or ligament reconstruction • indications • Type III in laborers and elite athletes • Type IV • Type V • Type VI • contraindications • patient unlikely to comply with postoperative rehabilitation • skin problems over fixation approach site • rehabilitation • sling immobilization without abduction for 6 weeks • no shoulder ROM for 6 weeks • generally return to full activity after 6 months 

  15. REFERENCES • Uptodate.com • Orthobullets.com • Medscape; AC separation and nursemaid elbow

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