1. Upper Limb Injuries

2. 13 yo boy falls off his bike and lands on his arm as he goes to break his fall. He comes into A+E and pain restricts movement in his L. arm. Hes complains the pain is over his L. upper shoulder
Middle
+++
Medial +
Lateral ++
What do you think has happened?
Clavicular fracture
Shoulder dislocation
- Remember to clarify what pt means by the words the use
Where is the most common location of a clavicle fracture to occur?
Between the proximal end of the lateral 3rd and distal end of middle 3rd / junction between lateral and middle 3rds of clavicle
On inspection you see an obvious deformity of the clavicle - what would it look like and why?
Lateral fragment pulled downward – due to weight of shoulder
Proximal fragment pulled upward – due to contraction of Sternocleidomastoid

4. Clavicle # Presentation: Complications: Management:
FOOSH – horizontal blow
Most commonly between middle-lateral 3rd
Sternal end of clavicle will stick out of chest, limb pulled down
Complications:
Brachial plexus damage
Subclavian vein
Management:
Not a lot…
‘figure of 8’ brace
Sling

5. Pt comes into A+E after being rammed in the shoulder during a rugby game. You suspect she has a shoulder dislocation.
What specific test do you want to do on examination?
Test sensation over REGIMENTAL BADGE (RB) region
Loss of sensation over RB region would indicate damage to which structure? What other clinical features may occur??
AXILLAY NERVE
Paralysis of deltoid & teres minor
Limb to hang limp by side
Loss of shoulder contour
Sensory loss over lateral shoulder (regimental badge region)
Why is an ANTERIOR shoulder dislocation most common?
Lower part of the joint capsule is lax & folded to permit free movement. This makes it the weakest point in the capsule.
Downward force applied to an abducted arm can dislocate the shoulder

6. Shoulder Dislocation Presentation: X-ray appearance: Complications:
FOOSH
Externally rotated
Looks ‘square’
X-ray appearance:
Head of humerus fallen down into space below glenoid fossa
Usually ANTERIOR (95%)
Complications:
Axillary artery and nerve damage

7. Elbow Injuries Nursemaids elbow: Tennis elbow: Golfers elbow:
Smooth head of radius and stretchy ligaments in children
Pulling their arm can easily pull the radius out!
Tennis elbow:
Sideways blow to MEDIAL side
Damaged medial (ulnar) collateral ligament
Golfers elbow:
Sideways blow to LATERAL side
Damaged lateral (radial) collateral ligament
Need to do valgus and varus stress test
Hold humerus and pull forearm to either side
Elbow is most likely to dislocate POSTERIORLY

8. Wrist #
Colles:
Classically osteoporotic elderly women following a fall
‘fork shaped’
Carpel tunnel can be stretched and damaged as well
Fix  traction and pull down, put in plaster
Should follow up by investigating for osteoporosis
Smith:
Fall on back of hand

9. 35 yo gymnast falls from parallel bars onto R. outstretched arm
35 yo gymnast falls from parallel bars onto R. outstretched arm. He complains of persistent pain on exercise involving anatomical snuffbox in R. wrist.
What are the borders of the anatomical snuff-box?
Extensor Pollicis Longus
Extensor Pollicis Brevis
Abductor Pollicis Longus
What do you think has happened to this gymnast?
Scaphoid fracture
On examination palpation of the snuffbox elicits pain – what is this clinical sign called?
The FY1 X-rays this guy in A+E. Plain radiograph comes back normal, so the FY1 treats as sprain – Why is this management incorrect
Snuffbox tenderness
Why is it important to identify and treat scaphoid fracture?
Scaphoid fracture doesn’t usually show up on radiograph, therefore normal radiograph doesn’t rule out scaphoid fracture
Risk of avascular necrosis if blood supply compromised – due to distal to proximal blood supply

10. Scaphoid # Bennets # Caused by FOOSH Painful snuffbox
Check for avascular necrosis!! (poor blood supply)
Bennets # 
# of 1st proximal metacarpal (thumb)
Caused by punching or thumb caught in steering wheel