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Project: Ghana Emergency Medicine Collaborative

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1 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: 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 with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit 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 1 1

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3 Upper Extremity Injuries: Shoulder, Elbow and Wrist
Quibik, Wikimedia Commons Patrick M. Carter, MD Instructor Department of Emergency Medicine University of Michigan School of Medicine April 4, 2012

4 Objectives 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

5 Shoulder Anatomy Shoulder is the most mobile joint in the human body
Due to the increased functional abilities of the shoulder, it is at high risk for injury Shoulder Anatomy Sternoclavicular Joint Clavicle Acromioclavicular Joint Scapula Humerus Glenohumeral joint Muscles/ligaments that attach the shoulder bones, including special rotator cuff muscles Gray’s Anatomy, Wikimedia Commons

6 Sternoclavicular Joint Injuries
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 Sternoclavicular Ligament Sternoclavicular Injuries SC joint is most frequently moved, non-axial joint in the body SC joint has the least amount of stability of any major joint because less than ½ of the medial end of the clavicle articulates with the sternum Thus, Joint stability depends on the integrity of surrounding ligaments Costoclavicular Ligament Gray’s Anatomy, Wikimedia Commons

7 Sternoclavicular Joint Injuries
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 SC = Sternoclavicular CC = Costoclavicular

8 Sternoclavicular Joint Injuries
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) SC Sprains Mechanism of Injury = forcing the shoulder forward suddenly or applying medial directed force to the shoulder  Sprain Symptoms = Pain and swelling localized to the joint Treatment = Ice, Sling, Analgesics ****Remember to think about possible septic arthritis in injection drug users**** SC Dislocations Uncommon injuries requiring significant force to the shoulder usually from motor vehicle crashes Anterior dislocations > Posterior Dislocations Mechanism of injury Anterior Dislocation = Usually the result of either direct or indirect force applied directly to the joint with the should rolled backward at the time of impact Posterior Dislocation = If the shoulder is rolled forward at the time of impact, a posterior dislocation can result from a direct impact or indirect force to the shoulder Symptoms = Severe pain that is exacerbated arm motion Exam Anterior Dislocations = Prominent medial clavicle that is palpable anterior to the sternum Posterior Dislocations = clavicle may not be palpable X-rays views may not be diagnostic and special views or comparison views may be necessary. CT is the diagnostic tool of choice. If concerns for underlying vascular structures, consider IV contrast Treatment Anterior SC Dislocations = Uncomplicated anterior dislocations do not require attempted reduction as injury has little or no impact on function Injury is often unstable, so attempts at reduction will usually be unsuccessful, but reduction can be attempted by placing the patient supine with a towel roll under the scapula traction is applied to the arm with pressure on the medial end of the clavicle Sling, Ice, analgesics and orthopedic referral are recommended Posterior SC Dislocations = May be associated with lifethreatening injuries = = Pneumothorax, compression or laceration of vessels, trachea or esophagus ORTHOPEDIC CONSULTATION Closed reduction should be attempted in the operating room with vascular surgery present If immediate reduction is needed, position the patient the same as for anterior DC dislocations, towel clip is applied to clavicle and pulled upward

9 Sternoclavicular Joint Injuries
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 Treatment Anterior SC Dislocations = Uncomplicated anterior dislocations do not require attempted reduction as injury has little or no impact on function Injury is often unstable, so attempts at reduction will usually be unsuccessful, but reduction can be attempted by placing the patient supine with a towel roll under the scapula traction is applied to the arm with pressure on the medial end of the clavicle Sling, Ice, analgesics and orthopedic referral are recommended Posterior SC Dislocations = May be associated with lifethreatening injuries = = Pneumothorax, compression or laceration of vessels, trachea or esophagus ORTHOPEDIC CONSULTATION Closed reduction should be attempted in the operating room with vascular surgery present If immediate reduction is needed, position the patient the same as for anterior DC dislocations, towel clip is applied to clavicle and pulled upward **** Figure of 8 clavicular strap is older method of immobilizing. Simple sling is good enough for support, tends to cause less discomfort and the results are equal in studies comparing two techniques. Figure of 8 might be used in places without commercially available slings (e.g. Ghana)

10 Acromioclavicular Joint Injuries
Ligament 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 Gray’s Anatomy, Wikimedia Commons Coracoclavicular Ligaments - Coracoacromial ligament - Trapezoid Coracoclavicular ligament - Conoid Coracoclavicular ligament

11 Acromioclavicular Joint Injuries
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 AC = Acromioclavicular CC = Corococlavicular

12 Acromioclavicular Joint Injuries
Source: Steve Oh, 2004

13 Acromioclavicular Joint Injuries
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

14 Acromioclavicular Separation – Type III
> 1 cm displacement defines type 3 Root4(one), Wikimedia Commons Source Undetermined

15 Clavicle Fractures Clavicle Mechanism of Injury Symptoms/Signs Imaging
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 Magnus Manske, Wikimedia Commons Source Undetermined

16 Allman Classification
Clavicle Fractures 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) Allman Classification Group III ~Medial 1/3 ~3%-6% Group I ~Middle 1/3 ~69%-85% Group II ~Distal 1/3 ~12%-28% Image adapted from Anatomagraphy, Wikimedia Commons

17 Clavicle Fractures Source Undetermined

18 Clavicle Fractures 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

19 Scapular Injuries Scapula Mechanism of Injury Clinical Presentation
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 Gray’s Anatomy, Wikimedia Commons

20 Scapular Injuries Classification Imaging 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 Gray’s Anatomy, Wikimedia Commons

21 Scapular Injuries 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 Body of scapula fracture Associated rib fractures Source Undetermined

22 Glenohumeral Joint Dislocation
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 Mechanism of Injury Anterior = Abduction, Extension and External Rotation Posterior = Seizure or Electric Shock Fall on forward-flexed, adducted and internally rotated arm

23 Anterior Shoulder Dislocations
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 Source Undetermined (1) age 40 and humeral ecchymosis, (2) age 40 and first dislocation, and (3) age <40 and injury mechanism other than nontrauma or a fall from standing height or lower. Source Undetermined

24 Posterior Shoulder Dislocations
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 Source Undetermined Source Undetermined

25 Luxatio Erecta 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 Source Undetermined

26 Glenohumeral Joint Dislocation
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 cc lidocaine alternative to procedural sedation After reduction, patient should be placed in shoulder immobilizer and orthopedic follow-up arranged Nevit Dilman, Wikimedia Commons

27 Shoulder Reduction Techniques
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 Source: University of Hawaii School of Medicine

28 Shoulder Reduction Techniques
Modified Hippocratic or Traction-Countertraction Technique Procedural sedation often necessary Source: University of Hawaii School of Medicine

29 Shoulder Reduction Techniques
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 Source: University of Hawaii School of Medicine If in seated position, have an assistant stand, facing the patient, and use one arm to firmly grasp the wrist of the dislocated arm. The assistant should then apply steady forward traction parallel to the floor while applying countertraction with the other arm, which is outstretched and resting on the patient's clavicle Use both hands to rotate the inferior tip of the scapula medially and the superior aspect laterally with slight dorsal displacement. The goal is to move the glenoid fossa back into anatomical position. Source: University of Hawaii School of Medicine

30 Shoulder Reduction Techniques
Stimpson or Hanging Weight Technique Source: University of Hawaii School of Medicine

31 Glenohumeral Joint Dislocations
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

32 Complications Hill Sachs Deformity Bankart’s Lesion/Fracture
Compression fracture of posterolateral aspect of humeral head Results from impact of humeral head on the anterior glenoid rim as it dislocates or reduces Bankart’s Fracture = Fracture of the anterior glenoid lip Hellerhoff, Wikimedia Commons RSatUSZ, Wikimedia Commons

33 Rotator Cuff Injuries 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

34 Humerus Fractures 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 Displacement of a fracture fragment by 1 cm, or angulation between fracture fragments of 45° or greater, is what defines a fragment as being a "separate" part. Hence, a proximal humerus fractures may be called 2-part, 3-part, or 4-part according to the Neer classification system, depending upon the amount of displacement and angulation seen on x-ray.

35 Proximal Humerus Fractures
3 1 2 Fragments of Humerus Head Articular surface of humeral head Greater tubercle Lesser tubercle Shaft of humerus James Heilman, MD, Wikimedia Commons Gray’s Anatomy, Wikimedia Commons

36 Mid-shaft Humerus Fractures
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 Radial Nerve injury = Wrist Drop = Inability of extend wrist, fingers, thumb, Loss of sensation over dorsal web space of 1st digit

37 Mid-shaft Humerus Fractures
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 Bill Rhodes, Wikimedia Commons

38 Biceps Rupture 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 Gray’s Anatomy, Wikimedia Commons Patenthalse, Wikimedia Commons

39 Radiographic Evaluation of the Elbow
Elbow radiographic evaluation can be difficult True Lateral X-ray = Hourglass or Figure of 8 at distal Humerus Fat Pad Signs Posterior Fat Pad Sign = Never seen on normal x-ray imaging Indicates distension of joint capsule by effusion with likely occult fracture Often associated with occult radial head fracture Anterior Fat Pad Sign = Small one may be present on normal x-rays Increased anterior fat pad (sail sign) is abnormal and may indicate fracture Anterior Humeral Line Line drawn along anterior surface of humerus and extending through the elbow Normally, transects the middle of the capitellum but with Supracondylar fractures, transects the anterior 1/3 of the capitellum or passes completely anterior to the capitellum Radial-Capitellar Line Line drawn through the middle of the radius Normally, transects the middle of the capitellum Abnormal line may indicate radial head dislocation or subtle fracture Radial Head Evaluation Carefully inspect the radial head. Fracture may be subtle and only clue may be slight cortical irregularity Distal Humerus Evaluation Careful inspection and evaluation of anterior humeral head line Source Undetermined

40 Radiographic Evaluation of the Elbow
Anterior Humeral Line Normal = Middle of capitellum Abnormal = Anterior 1/3 of capitellum or completely anterior Anterior Fat Pad “Sail Sign” Source Undetermined Radial-Capitellar Line Normal = Transects middle of capitellum Posterior Fat Pad Sign = Never seen on normal x-ray imaging Anterior Fat Pad Sign = Small one may be present on normal x-rays Anterior Humeral Line = Line drawn along anterior surface of humerus and extending through the elbow Normally, transects the middle of the capitellum but with Supracondylar fractures, transects the anterior 1/3 of the capitellum or passes completely anterior to the capitellum Radial-Capitellar Line Line drawn through the middle of the radius Normally, transects the middle of the capitellum Abnormal line may indicate radial head dislocation or subtle fracture Posterior Fat Pad (Never normal) Source Undetermined Hellerhoff, Wikimedia Commons

41 Supracondylar Fractures
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

42 Supracondylar Fractures
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

43 Supracondylar Fractures
Extension Type Fracture Flexion Type Fracture Source Undetermined Source Undetermined Source Undetermined

44 Supracondylar fractures
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

45 Volkmann’s Ischemic Contracture
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 Source Undetermined

46 Radial Head Fracture 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 Source Undetermined

47 Radial Head Subluxation
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) David Tan, Flickr

48 Radial Head Subluxation
flexion hyperpronation supination Therese Clutario, Wikimedia Commons

49 Elbow Dislocations 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

50 Elbow Dislocation Anterior Elbow Dislocation
Posterior Elbow Dislocation Source Undetermined Source Undetermined

51 Elbow Dislocation Elbow Reduction Post-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 Traction distally at wrist with assistant immobilizing the humerus While maintaining traction, flex the elbow and apply posterior pressure to the humerus Post red= Reassess ROM of elbow and neurovascular status Immobilize in long-arm posterior splint in 120 degrees of flexion (i.e. full flexion) Observe for delayed vascular compromise

52 Both Bone Forearm Fracture
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 Source Undetermined

53 Nightstick Fracture 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 Source Undetermined

54 Galeazzi Fracture Distal Radius Fracture Reverse Monteggia’s fx
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 Th. Zimmermann, Wikimedia Commons

55 Monteggia’s Fracture 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 ORIF = majority, closed red/splinting = may be possible, more commonly in kids Jane Agnes, Wikimedia Commons

56 Galeazzi vs. Monteggia Fractures
Radial Fracture Ulnar Fracture Monteggia R U Patrick Carter, University of Michigan Patrick Carter, University of Michigan

57 Colles Fracture 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

58 Smith Fracture 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

59 Colles vs. Smith Fracture
Colles Fracture Smith Fracture Source Undetermined Lucien Monfils, Wikimedia Commons Goals of Reduction: * Restore volar tilt * Radial Inclination * Proper radial length

60 Carpal Fractures Source Undetermined

61 Scaphoid Fracture 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

62 Scaphoid Fracture Gilo1969, Wikimedia Commons

63 Carpal Fractures Triquetrum Fracture (2nd most common) Lunate Fracture
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 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

64 Carpal Fractures Triquetrum Fracture Lunate Fracture
Hellerhoff, Wikimedia Commons Source Undetermined

65 Carpal Ligamentous Injuries
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

66 Scapholunate Ligament Instability
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

67 Scapholunate Dislocation
Terry Thomas and Signet Ring Sign Source Undetermined

68 Perilunate and Lunate Dislocations
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

69 Lunate vs. Peri-lunate Dislocation
Source Undetermined 4 C’s Need to line up on normal x-ray

70 Lunate vs. Peri-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 Source: Radiology Assistant Source: Radiology Assistant

71 Carpal Overuse Syndromes
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

72 Questions? ?

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