15 - Upper Extremity Injuries Flashcards
1
Q
The shoulder
A
- Clavicle, scapula and ball of humerus
- Supposed to be very flexible and very stable
2
Q
A/C separation
A
- Term confused clavical dislocation
- Injury to the ligaments that connect the clavicle to the scapula
- Very common injury
- Mechanism of injury (MOI)
o Fallen on outstretched hand (FOOSH)
o Direct blow
3
Q
Types of A/C separation
A
Types of A/C separation
- Do NOT need to know the types
- Type I: probably won’t see on x-ray
- Type II: more visible on x-ray
- Type III: more visible on x-ray
4
Q
Type I A/C separation
A
- Type I is a minor sprain
- Acromioclavicular joint
5
Q
Type II A/C separation
A
- Type II is a rip of acromicoclavicular ligament and partial coracoclavicular
6
Q
Type III A/C separation
A
- Type III is a tear of acromioclavicular and coracoclavicular ligament
7
Q
Treatment for A/C separation
A
- Sling for a few weeks
8
Q
Clavicular fractures
A
- MOA – usually direct blow or FOOSH
- Mainly mid shaft and distal
- Usually do not require surgery
- Proximal can have serious issues
- Very common in young males
9
Q
Shoulder dislocation
A
- Anterior direction 98% of time
- Posterior only if seizure/electrocution
- Most common dislocation seen in ER (1.7% US population)
10
Q
Mechanism of injury for shoulder dislocation
A
- FOOSH
- Mechanisms involving shoulder abd., extension and external rotation (volley ball spike)
11
Q
Age groups for shoulder dislocation
A
- Primarily in young males (9:1) and older women (3:1)
12
Q
Shoulder dislocation
A
- Proper sedation, pain meds, muscle relaxation (Etomidate is much better to use than versed because they will not be so groggy. With versed, patient acts like a head injury)
- Shoulder immobilizer (about 2 wks)
- Refer
- Xray before and after - Not as easy as you would think to know if you have gotten it back in place
- CHECK NERVE before and after reduction ***
13
Q
Long term consequences for shoulder dislocation
A
- Nerve damage (axillary esp.)
- Vessel injury – rare
- Re-dislocate
- Rotator cuff injury fairly common
14
Q
Recurrence of shoulder dislocation
A
- VERY LIKELY
- If first happened 40, 10% chance
15
Q
Humeral fractures MOI
A
- Direct blow
- Axial load at ELBOW
- Little old ladies, high energy, pathological fx
- Arm wrestling
16
Q
Treatment of humeral SHAFT fracture
A
Humeral shaft
o ***Hard brace and PT
o Risky surgery with no better healing (radial nerve is commonly injured)
17
Q
Treatment of PROXIMAL humeral fracture
A
- Proximal Fracture: +/- ORIF, joint replacement or sling with PT
18
Q
NOTE: big fractures in elderly
A
- It’s not just hip fractures that can have extreme consequences for elderly patients
- Patients can also rapidly decline following a humeral fracture
19
Q
Biceps rupture
A
- Looks like a big bump on the arm where the biceps is located
- Either do surgery or just leave it – typically if the patient is elderly, it will not be addressed surgically
- Can do PT to get some function back without surgery
20
Q
Elbow fracture MOI
A
- Fallen on outstretched hand (FOOSH)
- Twisting
- Direct blow
21
Q
Ped’s elbow fracture
A
- Most common is supracondylar fractures
- Radial head
- Olecrenon
22
Q
X-ray signs of elbow fracture KNOW THIS!!!
A
- Posterior Fat Pad (fat pad is visible in the back – blood)
- Anterior Sail Sign (beak in the front)
- Anterior humeral capitulum line
- Radial capitulum line
- Figure 8 (in the bone, you can see a figure 8)
23
Q
Sugartong
A
- A splint that doesn’t allow elbow or wrist movement
- Used for elbow or wrist fracture
24
Q
Pediatric elbow – Nursemaids
A
Nursemaids elbow aka Radial Head Subluxation
o MOI - Sudden pull upwards, usually of hand/wrist
o Symptoms – child won’t move the elbow
o Treatment – fast flexion with supination or pronation (works best if done right away)
25
***Colles fractures***
- Distal Radial fracture with dorsal displacement
- Can involve ulna as well
- Treatment depends in severity, patient age
- MOI: FOOSH – usually falling forward
- ***VERY common injury***
- Elderly females are common victims
26
Smith’s fracture
- Distal radial fracture with volar displacement
- From falling on flexed hand (just goes the opposite way as a Colles fracture)
- More likely falling backwards
27
***Scaphoid fractures***
- Most common carpel fracture (71%)
- High incidence AVN, non-union, delayed union, decreased strength, OA, decreased ROM (why you don’t want to miss)
- Treat all possible scaphoid fractures as fractures
28
Anatomy for scaphoid fracture
- Why fracture is so bad…
- ***Because blood supply is distal to proximal, proximal fractures worse. If proximal 5th of bone, probably isn’t going to heal***
29
***Scaphoid injury***
- MOI: FOOSH with hyper-extended/radial deviation
30
***Symptoms of scaphoid fracture***
- Snuff Box tenderness
- Scaphoid tenderness
- Pain with thumb compression
- If they have ANY OF THESE, they need to follow up
31
Diagnosing scaphoid fracture
- X-ray 86% sensitive (you will miss 14% of these)
- This is bad because it is a “million-dollar fracture” – if you miss it, you will be sued for 1 million
- Follow up: MRI or bone scan if suspicious
- Can wait a week and re-x-ray
32
Treatment for scaphoid fracture
- If nondisplaced – cast (usually), but can take 10-12 weeks to heal, may need bone stimulation
- If displaced, ORIF
33
***4th or 5th metacarpal fracture***
- AKA Boxer’s Fracture
- Usually from untrained punch thrower
- Rarely need surgery or reduction
34
***Mallet finger***
- Inability to extend DIP joint
- Unlike mallet toes, usually caused by acute trauma (unlike mallet toes, which are usually formed chronically)
- Usually can splint for 6 weeks, UNDISTURBED
- Often involves fracture but not always
35
Dislocation reduction
- Anesthesia?? She does not do this for digital dislocation, but she does offer a digital block
- Make it (dislocation) worse and pull, then splint
- X-rays before and after
- Neurovascular before and after
36
***Closed fist injuries***
- Aka clenched fist injury
- Aka fight bite
- Closed fist hits another person’s teeth
37
***Fight bite***
- Usually don’t see until infected
- Cultures, I & D (usually in OR) – do not close
- ABX that cover mouth flora
- Often look benign initially – still treat with fast follow up
- X-rays
- Neurovascular checks
- Referral
- Splint
38
Animal bites
- Antibiotics for hands, feet and face
- Don’t close puncture wounds
- Augmentin is the drug of choice
- Cat scratches
39
***High pressure injury***
- High pressure device injects material into (usually) hand
- Look benign but are SURGICAL emergencies
- Cause severe inflammatory response
- Paint solvents – 60-80% amputation
- Grease – 22%
- Even water needs surveillance
- Usually Male, non-dominant hand
40
***High pressure injury – ER treatment***
- Abx
- Td
- X-rays
- Neurovascular check
- Consultation – EXTREMELY IMPORTANT (needs surgical consult)
- Splint
41
CASE STUDY - “Boxer’s fractures”
o 4th or 5th metacarpal fracture (but usually the 5th)
o 50-40-30-20
o If you have less than 50 degrees of angulation, you don’t need to do anything else
42
CASE STUDY - "Fighter’s bite"
o Culture first
o Check the tetanus status
o Drain the wound initially in the ER, but needs a pulse lavage in the OR
o Antibiotics: Augmentin (oral) or Zosyn (IV) ***
o She uses Rocefen (cefazolin) as well
o If they are pen-allergic, you cannot use Augmentin, but clindamycin would work
o Treatment is to splint it (even if there is no fracture, because it will feel better)
43
CASE STUDY - Other concerns
o Possible tendinitis (infection)
o Osteomyelitis
o 18% amputation from a fight bite – very serious, needs to be addressed immediately
o As soon as she sees a bite (human, dog, cat), she gives antibiotic prophylaxis
44
Drug of choice for ALL bites
***Drug of choice for ALL bites = AUGMENTIN***
45
What to know for fighter’s bite
o Need to treat aggressively, always need a surgical consult
o Give prophylactic antibiotics (augmentin) for fight bite
o I & D is needed when there are signs of infection – abx are not enough!
