Transcript Injuries to the shoulder and upper extremities

Ski injuries to the upper
extremities
Eugene Bailey, MD
Department of Family Medicine
SUNY Upstate Medical University
Toggenberg MA Presentation
January 03, 2010
Objectives
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General Comments
Shoulder Injurties
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Humerus fractures
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ShoulderDislocation
Clavicular fracture
Scapular fracture
Acromioclavicular joint (ACJ)
injury
Head
Shaft
Suprachondylar
Elbow
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Anterior/Posterior
dislocation
Olecrenon fracture
Radial head fracture
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Wrist
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Scaphoid fracture
Colles fracture
Hand/Fingers
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Skier’s thumb
(Gamekeeper’s thumb)
Not going to cover
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Bicipital tendonitis
Medial and Lateral epichondylitis
Nursemaid’s elbow
Carpel tunnel syndrome
Bursitis
Finger fractures
General Comments
Zone of Injury
General Comments
In the field
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ABCs
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Airway
Breathing
Circulation
Always assess neurovascular status
(CMS = circulation, motor and sensory)
Control any bleeding
Do not move victim until stabilized
General Comments
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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)
Remember
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"Ability and experience are probably the
most important factors in determining
an individual's likelihood of injury when
pursuing an outdoor sport."
“ARMS”
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Appearance and alignment
Radial pulse
Motor function and mechanism of injury
Sensation
Self-splinting
Prevention
Case Scenario
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A call comes to you
over your radio that
a skier is down and
appears to have an
injury.
You grab a
toboggan and
respond to the
scene quickly
Upper extremity injuries
Snowboarding
www.ski-injury.com
Upper extremity injuries
Snowboarding – Val, Colorado (10 year survey)
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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
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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
Idzikowski, et al. AJSM 2000;28:825-832.
Upper extremity injury
Skiing
www.ski-injury.com
Upper extremity injury
Skiboard
www.ski-injury.com
Shoulder Injuries
Shoulder dislocation
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MOI:
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Fall onto an outstretched
hand c the momentum of
the fall twisting the body
around wretching the
shoulder out of joint
Posterior blow to
shoulder
Majority are anterior
dislocation (97%)
Shoulder dislocation
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The diagnosis of a
dislocated shoulder is
usually clinical
Walk slowly holding
affected arm, careful not
to move it. Usually arm is
away from body.
Loss of smooth contour of
the shoulder anatomy
Radiograph of Anterior shoulder dislocation
Shoulder dislocation
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X-rays do not have
to be obtained
before treatment
There are numerous
techniques for
reduction
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Kocher’s technique
Traction
Leverage
Shoulder dislocation
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Immobilize the
injured joint
Blanket roll
Sling
Sling and swath
Ice
Clavicular fracture
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Most commonly
fractured bone in
the entire body!
MOI:
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Transmission of force
up the arm
Fall onto shoulder
Direct blow to the
clavicle
Clavicular fracture
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presents with:
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pain to direct palpation
over the clavicle or with
movement of the arm or
neck
may be deformity of the
bone with swelling and
ecchymosis. (“tenting”
over fracture site)
Arm held to the side
Palpate for crepitus
Clavicular Fracture
Distal third classification
•Middle third - 80%
•Proximal third - 5%
•Distal third
- 15%
Clavicular Fracture
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Simple sling
Figure-of-eight
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Do not apply if
causes patient
discomfort
Do not apply for
distal fractures
Ice
Anderson, et.al., Acta Orthop Scand 1987;58:71-74
Stanley, et. al., Injury 1988;19:162-164
Scapular Fracture
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MOI: Forceful, direct
blow to the back
Very rare because
well protected by
muscles
Always assess for
spinal injury or
breathing difficulty
Sling and swathe
Acromio-clavicular joint (ACJ) injury
ACJ Injury
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MOI:
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Falling directly onto
the adducted
shoulder
Injury to the
ligament causes
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Tear (subluxation)
Dislocation
ACJ Injury
Grade 1
Grade 2
Grade 3………
ACJ Injury
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Presentation:
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Type 1/Grade 1 –
local tenderness
without deformity
Type 2,3,4,5,6/
Grade 2,3 – local
tenderness with
deformity
ACJ Injury
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Simple sling!
Collar and cuff
Ice
Humerus Injuries
Bony Anatomy: Humerus
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Distally – 2 condyles
forming articular
surfaces of trochlea
and capitellum
Proximally – neck
and head articulate
with glenoid fossa of
scapula
Humeral Fractures
MOI
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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
Humeral Head fracture
Diagnosis
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Upper humeral fractures
usually involve the
surgical neck of the
bone
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extracapsular
low incidence of
avascular necrosis (AVN)
Anatomical Neck
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intracapsular
higher incidence of AVN
Humeral Head Fractures
NEER Classification
*
*Velpeau view if cannot abduct arm
Humeral Head Fractures
Treatment
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One part fractures (no
fracture fragments
displaced < 1cm or 45
deg)
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Non-operative
immobilization in sling1-2
weeks
Early motion started
immediately
75% good to excellent
results; 10% poor
Any other fracture
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Closed reduction with
percutaneous pinning
ORIF
2-6 weeks to allow pain free
movement
Humeral Fractures
Complications
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Avascular Necrosis of Humeral Head
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Non-union
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Especially at risk with 4 part fractures
3-6 mos after injury
Shoulder stiffness with prolonged
immobilization
Humeral Shaft Fracture
Diagnosis
Fractures of the
shaft of the humerus
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1-3% of all fractures
Up to 18% have
radial nn palsey
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Humeral Shaft Fracture
Humeral Fractures
Treatment
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Non-operative
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Acceptable alignment
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AP anglulation - 20 deg
Varus – 30 deg
<30mm shortening
70-80% with 90-100%
union rates
Time-consuming and
requires cooperative patient
Collar and cuff; coaptation
splint; hanging cast;
functional bracing
Weight of forearm provides
traction
Humeral Fractures
Treatment
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Operative
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Absolute Indications
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Failure of closed treatment
Associated articular involvement
Vascular injuries
Ipsilateral forearm fractures
Pathological fractures
Open fractures
Polytrauma
Relative Indications
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Short oblique or transverse fracture in an active individual
Body habitus
Patient compliance
Staff considerations
Humeral Fractures
Complications
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Radial nerve palsy
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Most at risk – distal 1/3
fractures
Occurs up to 18% of
fractures
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90% neurapraxias and
heal in 3-4 mos
Exploration indicated
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No recovery in 3-4 mos
(clinical or EMG)
Loss of function with
closed reduction
Open fractures
Holstein-Lewis distal 1/3
spiral fractures
Supracondylar fracture
Diagnosis
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Supracondylar
fractures
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Most common
pediatric elbow
fracture (65% of
fractures and
dislocations of the
elbow)
Commonly
associated with
neurovascular injury
Supracondylar fractures
Diagnosis
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Classification
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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
Supracondylar Fractures
Diagnosis
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Radiology
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AP view
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Baumann’s angle
Medial epichondylar
epiphyseal angle
(MEE)
Lateral view
Humerotrochlear angle
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Oblique
Supracondylar Fracture
Treatment
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Non-displaced fxs –
cast immobilization
Displaced fxs – close
reduction with
percutaneous
pinning
Suprachondylar fracture
Complications
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Vascular injury –
brachial aa
Neurologic deficits –
median nerve;
possible radial nerve
Volkmann’s
contracture
Cubitus varus
Humerus Injuries
Emergency Care
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Sling
Ladder splint
Elbow Injuries
Radial Anatomy
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Radial head
articulates with
capitellum
Radial neck tapers
to radial tuberosity
which is insertion for
biceps brachii
tendon
Ulnar Anatomy
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Sigmoid/semilunar/
trochlear notch
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Anteriorly composed
of coronoid process
Posteriorly composed
of olecranon process
Articulates with
trochlea of humerus
Elbow Joint Articulation
- Elbow consists of
articulations:
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Ulnohumeral (elbow
flexion/extension)
Radiohumeral (forearm
pronation/supination)
Radioulnar (forearm
pronation/supination)
Elbow Injuries
MOI
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Fall onto
outstretched hand
(FOOSH) with elbow
extended or direct
trauma
Elbow dislocation
Diagnosis
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Second to shoulder
dislocations
Posterior dislocation
account for 80-90%
Most occur without
fracture
Elbow dislocation
Treatment
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Immediate reduction vs
splint and refer
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Children should be
splinted; increase
incidence of fractures
Need for radiographs
After relocation
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Assess neurovascular
status
Assess joint stability
Rehab early
Elbow fracture
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Radial head – 30%
Olecrenon – 20%
Coronoid fractures –
10 to 15% of elbow
dislocations
Elbow fat pads
Elbow Fat Pads
Elbow Fractures
Treatment
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Radial Head
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Non-displaced (type I)
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Displaced (type II)
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sling and or splint until no pain
Longer immobilization (1-2
weeks)
removal of bone fragments if
necessary
Comminuted (Type III)
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Surgery to remove bone
fragments
Repair ligament damage
Elbow Fractures
Treatment
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Olecrenon Fracture
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Non-displaced (type I)
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Displaced (type II)
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Sling, splint and or cast for
3-4 weeks
Follow by x-ray for
dislocation of fracture
ORIF
Comminuted (Type III)
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ORIF
Elbow Fractures
Treatment
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Coronoid Fracture
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Type 1
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Type 2
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Immobilization for 2 weeks
Immobilization for 2 weeks
Displaced or humeroulnar
joint instability may
consider ORIF
Type 3
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ORIF
Elbow dislocation or fracture
Emergency Care
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Immobilize
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Sling
Posterior elbow splint
using ladder splint or
SAM splint
ice
Wrist Injuries
Anatomy of the wrist
Wrist fracture
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Incidence of fracture
is 2x for
snowboarding vs.
skiing
With loss of balance,
the natural tendency
is to break fall with
outstretched hand
(FOOSH)
Wrist fracture (distal radial)
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Most common Distal radius or
Colles fracture
Silver fork deformity
Wrist Fracture (distal radial)
Median nerve assessment (ant interosseous)
normal
abnormal
Wrist fracture
Colles Fracture
Treatment
Colles Fracture
Treatment
Colles Fracture
Treatment
Colles Fracture
Treatment
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Closed reduction and immobilization in cast
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Stable fractures
Examine for carpal tunnel syndrome before and
after application
Avoid palmar flexion and ulnar deviation (CottonLoder position)
Percutaneous pinning
External Fixators
ORIF
Scaphoid fracture
Diagnosis
Scaphoid fracture
Scaphoid Fracture
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Acute non-displaced,
distal and horizontal
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Thumb spica cast
Displaced or prox,
vertical fractures
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ORIF
Increased incidence
of avascular necrosis
Prevention of Wrist Injury
www.ski-injury.com
Wrist fracture
Emergency Care
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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
Hand/Finger Injuries
Gamekeeper’s or skier’s thumb
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thumb forced away
like from a ski pole
Disruption or sprain
to the ulnar
collateral ligament
(MCP joint)
Splint including
thumb (thumb
spica)
Gamekeeper’s thumb
with fracture
Gamekeeper’s thumb
Treatment
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Short arm immobilizer
with thumb splica
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Main complication is
inability to heal
Surgery (<2-3 weeks
old)
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Gross radiologic
instability
Palpable torn ligament
ends (Stener lesion)
Reassessment reveal
unstable joint
Conclusion
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Falls, collisions and direct blows cause injury
to the upper extremities
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Humerus
Elbow
Wrist
Hand/fingers
Remember general comments
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“Zone of injury”
Life-threatening injuries first (ABCs)
Conclusion
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Patients will self-splint the extremity
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Injuries close to joints can involve
neurovascular bundle
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Internal rotation, elbow flexed, adducted to body
Assess CMS
ARMS
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Appearance and alignment, radial pulse, motor
and MOI, sensation
Conclusion
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Accurate assessment and rapid transport
critical (60” rule)
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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.
Thank -You
Distal Humerus Anatomy
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Medial epicondyle
proximal to trochlea –
attachment site for UCL and
flexor/pronator ms.
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Lateral epicondyle
proximal to capitellum –
attachment site for RCL,
extensor/supinator ms.
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Radial fossa –
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Coronoid fossa – accepts
accommodates margin of
radial head during flexion
coronoid process of ulna
during flexion
Distal Humerus – Posterior
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Olecranon fossa
accepts olecranon
process of ulna
during extension
Bony Alignment
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With elbow
extended, straight
line between
medial/lateral
epicondyles and tip
of olecranon
process’
With elbow flexed,
isosceles triangle
connects these
points
Carrying Angle/Cubitus Valgus
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Formed by long axis
of humerus and
midline of forearm
Male norms – 11-14
degrees
Female norms – 1316 degrees
Larger angles are
considered abnormal