INJURY OF  UPPER  EXTREMITIES

 

  1. All the following are the treatments offered in ER. For definitive treatment pts are referred to orthopedics.
     
  2. Review  chapter  of  Anesthesia for Conscious Sedation and  Regional Anesthesia before proceeding with the procedure. 

 

CLAVICULAR  FX

 

  1. Occur 2ry to direct trauma or fall on shoulder.
     
  2. Fx of middle 1/3  is the most common site.
     
  3. Swelling, pain and deformity are commonly found.  Look for skin tenting and, if evident try to reduce the fx ASAP
     
  4. AP Xray of clavicle confirms the dx.
     
  5. Vascular injury to subclavian vessel can  occur. Angio is needed for dx.
     
  6. Neurological deficit may involve brachial plexus (C5-T1) that affects the sensory and motor distribution  of  arm, forearm and hand.
     
  7. Treatment c/o immobilization with sling or figure-of-eight x 6 wks. Operative indication: failed closed reduction

 

AC  JOINT  SPRAIN / SEPARATION

 

  1. Occurs 2ry to fall and direct blow.
     
  2. Injury can involve only AC (acromioclavicular) ligament or, if severe, coracoclavicular ligament. In case of the latter  one can appreciate the upward displacement of clavicle AC injury thus can be classified into six stages:
     
    1. AC sprain. Pain without radiological evidence of AC disruption
       
    2. Disruption of acromioclavicular ligament and intact but sprained coracoclavicular ligament. On exam elevation of clavicle may be evident. X-ray is diagnostic when  weights are applied.
       
    3. Disruption of acromioclavicular ligament and of coracoclavicular ligament. On x-ray  more than 25% superior displacement of clavicle is evident.
       
    4. Disruption of acromioclavicular ligament and of coracoclavicular ligament and posterior displacement of clavicle.
       
    5.  Disruption of acromioclavicular ligament and of coracoclavicular ligament with disruption  of deltoid and trapezius muscle tendon attachment. Acromion and clavicle  have extreme degree of separation.
       
    6. VI - Like stage V  but clavicle has inferior  displacement
       
  3. On exam pain and clavicular  upward prominence may be evident.
     
  4. Xray  (of  both shoulders for comparison)  with  10 lb weight in suspected extremity confirms the dx.
     
  5. Treatment c/o applying shoulder immobilizer, ice and rest for stages I -III in the ER, and referral  to orthopedic clinic for f/u. Stages  IV - VI require STAT ortho consult and +/- trauma consult because they indicate severe trauma.

 

SHOULDER  FX

 

  1. Occurs 2ry to direct or indirect mechanism
     
  2. Classified into Surgical (below the humeral head) or Anatomical (fx of  humeral epiphysis) fx.
     
  3. They can be further classified into angulated (> or < 45), displaced and comminuted.
     
  4. Greater or Lesser tuberosities can be involved with consequent damage to rotator cuff.  Injury to rotator cuff  will give deficit on abduction. Deformity may be noticed.
     
  5. AP Xray and "Y" view confirms the dx.
     
  6. Associated  injury: r/o damage to brachial plexus (axillary, radial, median and ulnar nerve) clavicular fx, axillary artery, gleno-humeral dislocation.
     
  7. Treatment generally c/o sling with shoulder immobilizer  x 3-4 wks. and then "pendulum" exercise.  Operative  indications: comminution, articular displacement.

 

SHOULDER  DISLOCATION

 

  1. Occurs 2ry to indirect trauma during abduction and lateral rotation.
     
  2. Classified into Anterior = 95%  or Posterior = 5% (occurs during seizure, electrical shock).
     
  3. On exam a notch my be appreciated in shoulder area.
     
  4. AP  xray  film and the " Y " view  xray confirms the dx.
     
  5. Neurovascular and Associated injury assessment c/o testing brachial plexus (axillary, radial, median and ulnar nerve) clavicular fx, axillary artery thrombosis.
     
  6. Treatment of Anterior dislocation:
     
    1. For successful reduction good sedation must be achieved. This is accomplished with MSO4 and  Midazolam (Versed) - see Conscious Sedation. Do not forget to put pt on POx /  O2 and cardiac  monitor as per Conscious Sedation protocol.
       
    2. Hennipen's method - pt's elbow flexed to 90 is externally rotated and than  the arm is elevated.
       
    3. Countertraction - take sheet and wrap it around pt's axilla and other end around the waist of your assistant. At the same time apply countertraction to the arm until shoulder is reduced.
       
    4. Passive method - after proper sedation, pt lies face down. 15 lb. weight is hung on the arm and pt holds on to a IV pole. Generally relocation  occurs in 15-20 min without ER personnel intervention.
       
    5. Scapular manipulation - sedate as above. Sit the pt up and while an assistant applies constant traction, one must rotate the inferior tip of scapula medially and upper aspect of scapula laterally
       
  7. Posterior reduction can be achieved by the same method, plus a gentle push  from behind on the humeral  head.
     
  8. After the reduction is accomplished  pt is given sling x 1-3 wks. and referral to ortho.

 

HUMERAL  SHAFT  FX

 

  1. Occurs most commonly 2ry to direct injury.
     
  2. Can be displaced, spiral or comminuted.
     
  3. Tenderness and swelling are present.
     
  4. AP and lateral Xray confirm the dx.
     
  5. Neurovascular assessment c/o testing radial nerve and brachial artery.
     
  6. Treatment c/o hanging cast. Closed manipulation can be attempted. Operative injury: spiral fx with nerve injury, associated forearm fx, very angulated fx.

 

ELBOW  INJURY

 

  1. When suspected,  obtain AP and  Lateral view x-rays. Look for Anterior (occasionally present in normal xrays) and Posterior (always sign of  fx) fat  pad  sign as a clue to a fx.
     
  2. ROM in supination / pronation is limited.
     
  3. NV injuries to assess are: ulnar, median and radial nerve, brachial artery.  Look for compartment syndrome.
     
  4. When  NV compromise exist, attempt the reduction without delay.
     
  5. Possible fx of elbow are:
     
    1. Distal Humerus - generally  is treated with manipulative reduction and splinting in 90 flexion
       
    2. Oleocranon  Fx - generally  is treated with manipulative reduction and splinting in 45-90 flexion
       
    3. Radial Head Fx - generally  is treated with  manipulative reduction and sling with early motion  exercise. If  hematoma is conspicuous it can be aspirated for early mobilization.
       
    4. Elbow Dislocation - treated with  manipulative reduction under conscious sedation and sling with early motion  exercise.
       
  6. All  the above fractures may need Orthopedic consult for  operative reduction.

 

FOREARM  FX

 

  1. R/O NV injuries as above
     
  2. R/O associated injuries to wrist and elbow.
     
  3. Radial Shaft fx - treated with long splint and elbow flexed at 90. Wrist films must be obtained in order not to miss Galeazzi fx = radial shaft fx with distal Radio-Ulnar joint dislocation.
     
  4. Ulnar Shaft fx - also called  "nightstick fx"  for  the mechanism of injury. Treated with long arm splint and elbow in 90 flexion. Ulnar shaft fx may be associated with proximal radial head  sublux or dislocation. = Monteggias fx.  Treated initially  by posterior splint and ortho consult for surgical repair.

 

WRIST  and  HAND  FX

 

For any wrist and hand injury evaluate for nerve, vascular (pulses, capillary refill) and tendon injury as described in "Fracture Management General Principles"

  1. Colles fx = distal radial fx with or without ulnar  involvement. Can be further classified into dislocated, comminuted, angulated. Median and ulnar nerve function must be assessed. Treatment is reduction  and  splinting with wrist in 15 flexion and 15 ulnar deviation.
     
  2. Scaphoid fx - pain is present in " tobacco snuff box". Treated on clinical basis even if Xray is (-)ve. The waist of the scaphoid is the most frequently involved. Median nerve must be assessed. Thumb spica is applied. Repeat x-rays in 7-10 days to see if healing is present.
     
  3. Lunate fx also treated on clinical basis if pain is present in Lister's tubercle located in the wrist straight line from middle finger. Median nerve must be assessed. Thumb spica  is applied.
     
  4. Other Carpal fxs are visualized on x-ray. Median and ulnar (if Hamate and Triquetrum) nerves must be assessed. Treatment generally is achieved with volar splint, except Capitate which is treated with  thumb spica.
     
  5. 1st Metacarpal fx :
     
    1. Shaft - treated with thumb spica.
       
    2. Intraarticular- Bannet's fx (simple fx with sublaxation) and Rolando's fx (comminuted fx),  both located at the base. Treated in the ER with thumb spica and  Orthopedic consultation.
       
    3. Gamekeeper's / Skier's injury - injury  to the ligament anchoring  metacarpal bone to proximal phalanx.  In ER treated with thumb spica.
       
  6. 2d - 5th Metacarpal  fx :
     
    1. Head, neck (Boxer's fx when 5th finger is involved) , shaft or base can be broken. When the base is broken, carpal bones may be injured as well. The latter can injured nerve structures thus ulnar nerve function must be tested.  If angulation is of more than  10 - 40 from 2d  to 5th metacarpal respectively, or shortening of more than  4mm, ortho must be consulted. Otherwise, non displaced  fx can be treated in ER  with gutter  or  volar splint extending  but not including PIP, with MCP flexion at 90,  wrist at 20  extension.
       
  7. PIP and MIP fx:
     
    1. malrotation, tested by bringing all fingers to palmar crease and comparing  to normal hand, is not acceptable and  reduction must be attempted. A non displaced fx is treated  in the ER with buddy  tapping  (tape  fractured digit to the adjacent). If  fx is displaced, apply volar splint or gutter from elbow to PIP or MCP at 90 and wrist at 20 extention.
       
  8. DIP fx:
     
    1. look for nail-bed injury
       
    2. flexor or extensor tendon injury  are frequent (see d )
       
    3. fx of DIP generally  treated with  splint.
       
    4. occasionally, extensor ligament can avulse the dorsum of DIP that results in inability to extend the DIP = Mallet fx . These pts are treated with splint in hyperextended position x 6 wk or internal fixation.

 

 

ROTATOR CUFF INJURY, CALCIFIC  TENDINITIS, IMPINGEMENT and ADHESIVE  CAPSULITIS (FROZEN SHOULDER)

 

  1. Rotator Cuff consists of  subscapularis, supraspinatus, infraspinatus, teres minor.
     
  2. It can undergo degeneration or acute tear 2ry to injury.
     
  3. Dx in ER made on clinical grounds. Pt c/o pain and is unable to perform abduction. If significant tear is present, when pt's arm is passively abducted to 90 and mild weight is applied to wrist, pt's arm will drop suddenly. X-ray is done if indicated.  In ER treatment c/o sling immobilization.
     
  4. If one suspects Calcific Tendonitis (pain and tenderness along the insertion of supraspinatus, i.e. coracoacromial arch), the X-ray  reveals calcifications. Treatment c/o ice, brief period of sling immobilization and NSAIDs.
     
  5. Impingement Syndrome - biomechanical  trauma sustained to rotator cuff tendons as they are trapped between humeral head inferiorly and coracoacromial ligament and acromion superiorly. The causes of impingement could be subacromial bursitis, tendonitis and tear  of  rotator cuff - all with a common dominator of  overuse and pathologically  are associated with inflammation and fibrosis in the bursa. Pt c/o dull ache with activity. Impingement is dx clinically by Hawkin's test: 90 flexion  of  humerus  with internal rotation  of shoulder produces pain. Subacromial Bursitis - both the impingement test and  shoulder abduction  between 70-100 degrees  will reproduce the pain. Treatment c/o ice, brief period of sling immobilization and NSAIDs. If this was not successful local injection of  5ml 1% bipuvocaine  and corticisteroid into the borsa can be attempted in conjunction with experienced orthopedic, rheumatologist or physical therapist.
     
  6. Adhesive Capsulitis - aka Frozen Shoulder is chronic inflammation  and fibrosis of glenohumeral joint capsule. Can occur after prolonged immobilization. Pt c/o of pain and decrease in ROM. Treatment c/o NSAIDs, steroid injection (in conjunction with  orthopedic, rheumatology  or physical therapy consult) and exercise to increase ROM.

 

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