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Ski injuries to the upper extremities Eugene Bailey, MD Department of Family Medicine SUNY Upstate Medical University Toggenburg Ski Patrol 2008.

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Presentation on theme: "Ski injuries to the upper extremities Eugene Bailey, MD Department of Family Medicine SUNY Upstate Medical University Toggenburg Ski Patrol 2008."— Presentation transcript:

1 Ski injuries to the upper extremities Eugene Bailey, MD Department of Family Medicine SUNY Upstate Medical University Toggenburg Ski Patrol 2008

2 Objectives General Comments Humerus fractures Head Shaft Suprachondylar Elbow Anterior/Posterio dislocation Olecrenon fracture Radial head fracture Chorocoid fracture Wrist Scaphoid fracture Colles fracture Hand/Fingers Skier’s thumb (Gamekeeper’s thumb)

3 Not going to cover Bicipital tendonitis Medial and Lateral epichondylitis Nursemaid’s elbow Carpel tunnel syndrome Bursitis Finger fractures

4 General Comments Zone of Injury

5 General Comments In the field ABCs Airway Breathing Circulation Always assess neurovascular status (CMS = circulation, motor and sensory) Control any bleeding Do not move victim until stabilized

6 General Comments If possible, always ask the patient to “point with one finger to the area that hurts the most.” Remove jewelry, etc before splinting Patient will self-splint the upper extremity (internal rotation, elbow flexed and adducted to body)

7 Self-splinting

8 “ARMS” Appearance and alignment Radial pulse Motor function and mechanism of injury Sensation

9 Prevention

10 Ski Injuries - Statistics

11 Upper extremity injuries Snowboarding

12 Upper extremity injuries Snowboarding – Val, Colorado (10 year survey) 7430 injuries Most 30 yrs or younger 74% men, 26% women 39% beginners, 61% intermediate or experts Men rode more advanced levels than women Results Injured were more likely to be beginners than non-injured 49.06% upper extremities (56.43% fractures, 26.78% sprains and 9.66% dislocations) Wrist fx (x scaphoid) more common in beginners, women and younger age groups Intermediate and expert were more likely to sustain hand, elbow and shoulder injuries as well as more severe injuries Snowboarders who wear protective wrist guards are ½ as likely to sustain wrist injury Snowboarders who wear protective wrist guards are ½ as likely to sustain wrist injury Idzikowski, et al. AJSM 2000;28:

13 Upper extremity injury Skiing

14 Upper extremity injury Skiboard

15 Humerus Injuries

16 Bony Anatomy: Humerus Distally – 2 condyles forming articular surfaces of trochlea and capitellum Proximally – neck and head articulate with glenoid fossa of scapula

17 Humeral Fractures MOI Head - Direct trauma to the humerus from collision with an object or fall directly onto the bone Shaft – bent forces like breaking a stick (shear or torsion) Supraconylar – upper transmission of force on outstretched hand

18 Humeral Head fracture Diagnosis Upper humeral fractures usually involve the surgical neck of the bone extracapsular low incidence of avascular necrosis (AVN) Anatomical Neck intracapsular higher incidence of AVN

19 Humeral Head Fractures NEER Classification *Velpeau view if cannot abduct arm *

20 Humeral Head Fractures Treatment One part fractures (no fracture fragments displaced < 1cm or 45 deg) Non-operative immobilization in sling1-2 weeks Early motion started immediately 75% good to excellent results; 10% poor Any other fracture Closed reduction with percutaneous pinning ORIF 2-6 weeks to allow pain free movement

21 Humeral Fractures Complications Avascular Necrosis of Humeral Head Especially at risk with 4 part fractures Non-union 3-6 mos after injury Shoulder stiffness with prolonged immobilization

22 Humeral Shaft Fracture Diagnosis Fractures of the shaft of the humerus 1-3% of all fractures Up to 18% have radial nn palsey

23 Humeral Shaft Fracture

24 Humeral Fractures Treatment Non-operative Acceptable alignment AP anglulation - 20 deg Varus – 30 deg <30mm shortening 70-80% with % union rates Time-consuming and requires cooperative patient Collar and cuff; coaptation splint; hanging cast; functional bracing Weight of forearm provides traction

25 Humeral Fractures Treatment Operative Absolute Indications Failure of closed treatment Associated articular involvement Vascular injuries Ipsilateral forearm fractures Pathological fractures Open fractures Polytrauma Relative Indications Short oblique or transverse fracture in an active individual Body habitus Patient compliance Staff considerations

26 Humeral Fractures Complications Radial nerve palsy Most at risk – distal 1/3 fractures Occurs up to 18% of fractures 90% neurapraxias and heal in 3-4 mos Exploration indicated No recovery in 3-4 mos (clinical or EMG) Loss of function with closed reduction Open fractures Holstein-Lewis distal 1/3 spiral fractures

27 Supracondylar fracture Diagnosis Supracondylar fractures Most common pediatric elbow fracture (65% of fractures and dislocations of the elbow) Commonly associated with neurovascular injury

28 Supracondylar fractures Diagnosis Classification Type I - non-displaced Type II - angulated but not translated in the sagittal plane with hinging of the posterior cortex of the humerus Type III - posteriorly displaced with IIIA being posteromedial and type IIIB being posterolateral

29 Supracondylar Fractures Diagnosis Radiology AP view Baumann’s angle Medial epichondylar epiphyseal angle (MEE) Lateral view Humero- trochlear angle Oblique

30 Supracondylar Fracture Treatment Non-displaced fxs – cast immobilization Displaced fxs – close reduction with percutaneous pinning

31 Suprachondylar fracture Complications Vascular injury – brachial aa Neurologic deficits – median nerve; possible radial nerve Volkmann’s contracture Cubitus varus

32 Humerus Injuries Emergency Care Sling Ladder splint

33 Elbow Injuries

34 Radial Anatomy Radial head articulates with capitellum Radial neck tapers to radial tuberosity which is insertion for biceps brachii tendon

35 Ulnar Anatomy Sigmoid/semilunar/ trochlear notch Anteriorly composed of coronoid process Posteriorly composed of olecranon process Articulates with trochlea of humerus

36 Elbow Joint Articulation - Elbow consists of articulations: Ulnohumeral (elbow flexion/extension) Radiohumeral (forearm pronation/supination) Radioulnar (forearm pronation/supination)

37 Elbow Injuries MOI Fall onto outstretched hand with elbow extended or direct trauma

38 Elbow dislocation Diagnosis Second to shoulder dislocations Posterior dislocation account for 80-90% Most occur without fracture

39 Elbow dislocation Treatment Immediate reduction vs splint and refer Children should be splinted; increase incidence of fractures Need for radiographs After relocation Assess neurovascular status Assess joint stability Rehab early

40 Elbow fracture Radial head – 30% Olecrenon – 20% Coronoid fractures – 10 to 15% of elbow dislocations

41 Elbow fat pads

42 Elbow Fat Pads

43 Elbow Fractures Treatment Radial Head Non-displaced (type I) sling and or splint until no pain Displaced (type II) Longer immobilization (1-2 weeks) removal of bone fragments if necessary Comminuted (Type III) Surgery to remove bone fragments Repair ligament damage

44 Elbow Fractures Treatment Olecrenon Fracture Non-displaced (type I) Sling, splint and or cast for 3-4 weeks Follow by x-ray for dislocation of fracture Displaced (type II) ORIF Comminuted (Type III) ORIF

45 Elbow Fractures Treatment Coronoid Fracture Type 1 Immobilization for 2 weeks Type 2 Immobilization for 2 weeks Displaced or humeroulnar joint instability may consider ORIF Type 3 ORIF

46 Elbow dislocation or fracture Emergency Care Immobilize Sling Posterior elbow splint using ladder splint or SAM splint ice

47 Wrist Injuries

48 Anatomy of the wrist

49 Wrist fracture Incidence of fracture is 2x for snowboarding vs. skiing With loss of balance, the natural tendency is to break fall with outstretched hand (FOOSH)

50 Wrist fracture (distal radial) Most common - Distal radius or Colles fracture Silver fork deformity

51 Wrist Fracture (distal radial) Median nerve assessment (ant interosseous) normal abnormal

52 Wrist fracture

53 Colles Fracture Treatment



56 Closed reduction and immobilization in cast Stable fractures Examine for carpal tunnel syndrome before and after application Avoid palmar flexion and ulnar deviation (Cotton- Loder position) Percutaneous pinning External Fixators ORIF

57 Scaphoid fracture Diagnosis

58 Scaphoid fracture

59 Scaphoid Fracture Acute non-displaced, distal and horizontal Thumb spica cast Displaced or prox, vertical fractures ORIF Increased incidence of avascular necrosis

60 Prevention of Wrist Injury

61 Wrist fracture Emergency Care Padded splint Including the elbow is not essential in distal injuries Splint in the “position of function”, ie., fingers cupped around a gauze roll held in the palm Sling can be used to steady extremity to aid in patient comfort

62 Hand/Finger Injuries

63 Gamekeeper’s or skier’s thumb thumb forced away like from a ski pole Disruption or sprain to the ulnar collateral ligament (MCP joint) Splint including thumb (thumb spica)


65 Gamekeeper’s thumb with fracture

66 Gamekeeper’s thumb Treatment Short arm immobilizer with thumb splica Main complication is inability to heal Surgery (<2-3 weeks old) Gross radiologic instability Palpable torn ligament ends (Stener lesion) Reassessment reveal unstable joint

67 Conclusion Falls, collisions and direct blows cause injury to the upper extremities Humerus Elbow Wrist Hand/fingers Remember general comments “Zone of injury” Life-threatening injuries first (ABCs)

68 Conclusion Patients will self-splint the extremity Internal rotation, elbow flexed, adducted to body Injuries close to joints can involve neurovascular bundle Assess CMS ARMS Appearance and alignment, radial pulse, motor and MOI, sensation

69 Conclusion Accurate assessment and rapid transport critical (60” rule) Immobilize in the position found Sling and swathe is good immobilizer for upper extremity injuries Every patient should be advised to seek the care of a physician regardless of injury, especially if symptoms persist > 24 hrs.

70 Thank -You

71 Distal Humerus Anatomy Medial epicondyle proximal to trochlea – attachment site for UCL and flexor/pronator ms. Lateral epicondyle proximal to capitellum – attachment site for RCL, extensor/supinator ms. Radial fossa – accommodates margin of radial head during flexion Coronoid fossa – accepts coronoid process of ulna during flexion

72 Distal Humerus – Posterior Olecranon fossa accepts olecranon process of ulna during extension

73 Bony Alignment With elbow extended, straight line between medial/lateral epicondyles and tip of olecranon process’ With elbow flexed, isosceles triangle connects these points

74 Carrying Angle/Cubitus Valgus Formed by long axis of humerus and midline of forearm Male norms – degrees Female norms – degrees Larger angles are considered abnormal

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