1. Acute Upper Extremity Injuries
CPT William Cooper D.O.
Department of Orthopaedic Surgery
DeWitt Army Community Hospital

2. Topics Reviewed Pectoralis Rupture AC joint sprains
Shoulder dislocations
Clavicular fractures
Biceps Rupture
Radial head fractures
Elbow Dislocation
Skier’s thumb
Perilunate injuries
Scaphoid fractures
TFCC tears
Jersey Finger
Mallet Finger
Sagittal Band rupture

5. Pectoralis Major Rupture
Excessive tension on maximally eccentrically contracted muscle
Weightlifters
Localized swelling and ecchymosis
Palpable defect
Weakness with adduction and internal rotation
Most common in men 20-50
Complete rupture most common

7. Pectoralis Major Rupture
Treatment
Surgical repair to bone for complete tears
Nonoperative for partial tears
Outcome
Less than ideal
Weakness, decreased ROM, increased muscle fatigue
Cosmesis

8. 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

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

10. Types of AC joint sprains
Type 1: mild injury of the AC ligaments
Type II: AC lig's disrupted only
Type III: AC and coracoclavicular lig's disrupted
Type IV: Clavicle displaced posteriorly through trapezius; AC and CC lig's disrputed.
Type V: AC joint dislocation with extreme superior elevation of the clavicle.
Type VI: clavicle displaced inferior to acromion and coracoid process.

11. 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

12. Normal AC joint

13. Grade II AC joint sprain

14. Grade III AC joint sprain

15. 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.

16. 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

17. Management of type III AC 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

18. 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

19. 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%

21. Lateral third clavicle fracture

22. ER Management of Clavicular Fractures
Ice, analgesics, arm support for all
Referral rule:
Any displaced, non-middle-third fractures
Shortening/displacement >2cm
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

23. 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
Shoulder d/L: 7% incidence in young athletes
Axillary neurapraxia in 33%; brachial plexus

24. Radiology of shoulder dislocations
AP and axillary views; optional scapular lateral (Y)
Velpeau view
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

25. Anterior shoulder dislocation

26. Anterior shoulder dislocation

27. Posterior shoulder dislocation

28. Hill-Sachs deformity

29. Bankart lesion

30. Shoulder dislocation reduction techniques
Types of maneuvers
Traction (Stimson, self-reduction, Hippocrates, Eskimo,Milch)
Scapular manipulation
Leverage (Kocher)
Combined maneuvers (slump, Snowbird)

31. The Stimson technique
for anterior shoulder
dislocation reduction.

32. J. Bone Joint Surg. Am., Dec 2009; 91: 2775 – 2782
The FARES method
Significantly more effective, faster, and less painful method of reduction of an anterior shoulder dislocation in comparison with the Hippocratic and Kocher methods

34. 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

35. 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
Immediate arthroscopic repair of Bankart lesions in athletes at West Point; reduced recurrence from 80% to <20%.
Arciero et al. Arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994; 22:

36. Biceps Tendon Rupture Proximal rupture Most common in age > 60
Usually degenerative changes present initially
Usually hear/feel snap
Some may experience pain relief afterwards
Popeye deformity
Treatment nonoperative
Unless young patient with traumatic rupture

37. Biceps Tendon Rupture Distal Biceps Rupture
Much less common (5% of biceps ruptures)
Middle aged patients
Usually tendonopathy/degenerative changes present which predispose
Forceful, eccentric overload of the partially flexed elbow
Up to 50% loss of supination power has been documented after rupture
Treatment is surgical

38. Biceps Tendon Rupture
The Hook Test for Distal Biceps Tendon Avulsion Am J Sports Med November ; published online before print August 8, 2007

39. Does this happen in distal biceps rupture???

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

45. 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

47. Fat pad signs

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

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

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

51. Radiocapitellar
line
Radiocapitellar line should bisect radial head and intersect the center of the capitellum.

52. Radial head fracture

53. ER treatment of Radial 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

55. Elbow Dislocations Defined by the direction of the forearm bones
80% posterolateral

56. Elbow Dislocations Treatment
Simple dislocations – no associated fracture
1 week immobilization
Splint in 90 degrees flexion with forearm pronated
Begin therapy/ROM
Good long term results
Complex dislocations – fracture present
Surgery
Radial head and neck 50-60% of time
Instability within 30 degrees of full extension may be an indication for acute ligamentous repair.
Lateral ligamentous complex is always repaired
MCL if instability persists

57. Terrible Triad Elbow Injury
Elbow dislocation
Fractures
Radial head
Coronoid process
Treatment
Ligamentous repair, ORIF of the coronoid, and either ORIF or prosthetic replacement of the radial head
Persistent instability - hinged external fixator.
The primary goal in all elbow dislocations is early motion

58. Perilunate Dislocations
Result from forced dorsiflexion, ulnar deviation, and supination of the wrist
Approximately 25% missed in E.R.
Emergent reduction and stabilization of these injuries are recommended

59. Perilunate Dislocations
Treatment
Repair of ligamentous structures
Percutaneous pinning
Acute carpal tunnel syndrome may be present
Necessitates release
Late diagnosis associated with poor outcomes

60. Skier’s Thumb Sprain of ulnar collateral ligament of thumb MCP
Pathoanatomy
Sprain of ulnar collateral ligament of thumb MCP
Grades I, II, and III
I = no laxity
II = laxity but intact
III = complete tear

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

62. Skier’s Thumb

63. Skier’s thumb: exam Anesthesia (block)
Valgus stress to MCPJ in extension
Over 20° opening is probably grade III tear

64. Skier’s Thumb Stener lesion 64% of Grade III injuries
Adductor aponeurosis interposed
Prohibits reattachment of ligament
MRI and arthrogram are sensitive

65. Stener Lesion

66. 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

67. Scaphoid Fracture FOOSH Dull, deep, ache in radial side of wrist
History
FOOSH
Dull, deep, ache in radial side of wrist

68. Scaphoid Fracture: Anatomy
Blood supplied from distal pole
The more proximal the fracture, the greater the risk of avascular necrosis (AVN) or delayed union

70. Scaphoid Fracture: Examination
Minimal swelling
Tenderness in snuff box
Pain with axial load

71. Scaphoid tubercle
fracture

72. Scaphoid fracture: Radiographs
Lateral
Oblique
Scaphoid view
**Normal plain films don’t rule out a scaphoid fracture

75. 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

76. Scaphoid Fracture: Treatment (cont)
Clinically suspected fracture with normal plain films
Treat as non-displaced fracture
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 CT

77. Scaphoid Fracture: Referral criteria
Proximal fractures
Angulated; displaced >1mm
Scapholunate dissociation
Presentation > 2 wks
Early return to play necessary
Non-union or AVN

78. 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

79. TFCC
Thickened pad of connective tissue that functions as a cushion for ulnar axial loads
Articular disc
Meniscus
Ulnar
collateral
ligament

80. TFCC tear: Examination (cont)
Tenderness just distal to ulnar styloid

81. TFCC tear: Examination (cont)
Press test
Patient presses arms of chair to lift body off seat
100% sensitive

82. TFCC tear: Examination (cont)
TFCC load test
Pain = positive test

83. 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

84. 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

85. MRI: TFCC tear

86. Long arm cast with forearm neutral for 4-6 weeks
TFCC Tear: Treatment
Long arm cast with forearm neutral for 4-6 weeks
Referral criteria:
Associated injuries including DRUJ instability
Persistent pain after immobilization

87. Jersey Finger Avulsion of the FDP tendon from its insertion
Ring finger most commonly affected
Occurs with sudden hyperextension during finger flexion
May be seen on plain x-ray
Type I - retraction of tendon into palm
Type II - retraction to PIP
Type III - associated with a large, bony articular

88. Exam --Finger held in forced extension
--Tender along volar aspect of DIP
--Unable to flex DIP

89. Jersey Finger
Type I injuries must be repaired early (within 1 week) because of loss of blood supply to the tendon
Splint in position
Arthrodesis is generally favored over late (>3 months) repair due to finger stiffness after tendon grafting

90. Mallet Finger Avulsion of the terminal extensor tendon
X-ray used to rule out fracture.
Treated with prolonged (>6 weeks) extension splinting
Results are almost uniformly good.
Chronic injuries
Swan-neck deformities due to chronic overpull of the extensor tendon at the PIP with flexion of the distal interphalangeal joint (DIP

91. Mallet Finger

92. Sagittal Band Rupture “Boxer's knuckle”
Typically occurs in pugilists due to forceful subluxation of the extensor tendon
Index and long fingers in professionals
Ring and small fingers in amateurs
Acute injuries are treated with extension splinting for 4 weeks
Chronic injury will lead to persistent extensor tendon subluxation
Repaired or reconstructed

94. QUESTIONS