Traumatic Injuries of the Upper Extremity

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Traumatic Injuries of the Upper Extremity

• Kevin deWeber, MD
• MAJ, MC
• Primary Care Sports Medicine

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ObjectivesYou should be able to treat...

• AC joint sprains
• Anterior shoulder dislocations
• Clavicular fractures
• Radial head fractures
• Skiers thumb
• Scaphoid fractures
• TFCC tears
• And know referral criteria for complications

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Normal axillary view
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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

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Cross-Chest Adduction Test

• AC joint
• Adduct shoulder
• Patient pushes elbow up against resistance
• Pain in AC test
• false test in RC pathology

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Types of AC joint sprains
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AC joint sprainsRadiology 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

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Normal AC joint
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Grade II AC joint sprain
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Grade III AC joint sprain
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• 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 11720-24.

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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

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Management of type IIIAC 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

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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

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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

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Lateral third clavicle fracture, type II
displaced)
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ER Management ofClavicular Fractures

• Ice, analgesics, arm support for all
• Referral rule
• Any displaced, non-middle-third fractures
• 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

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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

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Radiology of shoulder dislocations

• AP and axillary views optional scapular lateral
  (Y)
• Location of humeral head w.r.t glenoid
• 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

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Anterior shoulder dislocation
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Anterior shoulder dislocation
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Posterior shoulder dislocation
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Hill-Sachs deformity
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Bankart lesion
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Shoulder dislocation reduction techniques

• Types of maneuvers
• Traction (Stimson, self-reduction, Hippocrates,
  Eskimo,Milch)
• Scapular manipulation
• Leverage (Kocher)
• Combined maneuvers (slump, Snowbird)
• No comparative research

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The Stimson technique for anterior
shoulder dislocation reduction.
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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 gt40 (to prevent stiffness) and in recurrent
  dislocators

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Indications for early orthopedic referral for pts
with shoulder dislocation

• Displaced greater tuberosity fxs (gt1 cm
  post-reduction)
• Glenoid rim fxs displaced gt5mm
• Irreducible dislocations (soft tissue
  interposition)
• Young athletes

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Elbow trauma

• Fractures
• Dislocations
• Ligament sprains
• Look for compartment syndrome
• Rule out neurovascular injury

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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 cant be extended, obtain AP/lat of both
  humerus and forearm

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Fat pad signs
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Elbow fractures

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

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Radial head/neck fractures

• Common fracture in adults
• FOOSH usually
• Detection may require oblique view
• Assure proper alignment of head on capitellum
  (radiocapitellar line)

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• Radial head fracture types
• Type I less than 2 mm displacement
• Type II angulated or gt2 mm displaced
• Type III comminuted

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Radiocapitellar line
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Radial head fracture
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Radial head fracture
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ER treatment ofRadial 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

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Skiers Thumb

• Pathoanatomy
• Sprain of ulnar collateral ligament of thumb MCP
• Grades I, II, and III
• I no laxity
• II laxity but intact
• III complete tear

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Skiers Thumb

• Mechanism of injury
• Forced abduction and hyperextension of thumb
• FOOSH with thumb caught in extension
• Diagnosis
• History
• Radiographs
• Physical exam

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Skiers Thumb
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Skiers thumb exam

• Anesthesia (block)
• Valgus stress to MCPJ in extension
• Over 20 opening is probably grade III tear

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Stener Lesion
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Skiers Thumb

• Stener lesion
• 64 of Grade III injuries
• Adductor aponeurosis interposed
• Prohibits reattachment of ligament
• MRI and arthrogram are sensitive

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Skiers ThumbTreatment

• Grades I II
• Thumb spica splint 2-4 weeks, then
• Splint or tape 3 months
• Grade III
• Controversial
• Surgery
• Refer to Ortho

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Scaphoid Fracture

• History
• FOOSH
• Dull, deep, ache in radial side of wrist

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Scaphoid FractureAnatomy

• Blood supplied from distal pole
• The more proximal the fracture, the greater the
  risk of avascular necrosis (AVN) or delayed union

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Scaphoid FractureExamination

• Minimal swelling
• Tenderness in snuff box
• Pain with axial load

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Scaphoid tubercle fracture
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Scaphoid fracture Radiographs

• AP
• Lateral
• Oblique
• Scaphoid view
• Normal plain films dont rule out a scaphoid
  fracture

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Scaphoid FractureTreatment

• 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

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Scaphoid FractureTreatment (cont)

• Clinically suspected fracture with normal plain
  films
• Treat as non-displaced fracture
• PRICE
• 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

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Scaphoid FractureReferral criteria

• Proximal fractures
• Angulated displaced gt1mm
• Scapholunate dissociation
• Presentation gt 2 wks
• Early return to play necessary
• Non-union or AVN

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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

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TFCC tear
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TFCC

• Thickened pad of connective tissue that functions
  as a cushion for ulnar axial loads

Articular disc
Meniscus
Ulnar collateral ligament
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TFCC tearExamination (cont)

• Tenderness just distal to ulnar styloid

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TFCC tearExamination (cont)

• Press test
• Patient presses arms of chair to lift body off
  seat
• 100 sensitive

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TFCC tearExamination (cont)

• TFCC load test
• Pain is a test

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TFCC tearExamination (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

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TFCC TearRadiography

• 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

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MRI TFCC tear
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TFCC TearTreatment

• Long arm cast with forearm neutral for 4-6 weeks
• Referral criteria
• Associated injuries including DRUJ instability
• Persistent pain after immobilization

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Review

• Refer all vertically displaced AC joint sprains
• Refer any displaced, non-middle-third
  claviclular fractures
• Pick and KNOW 1-2 shoulder reduction methods
• Conservatively treat non-displaced radial head
  fractures
• Refer all Skiers thumb that gap gt20
• Treat suspected scaphoid fxs even if xrays neg
• Treat TFCC tears with 6 wks long arm cast