Exam 3 EM UE Flashcards
MOI/background: Clavicle Fx
5% of all fx, common in kids
Middle 3rd 80%: FOOSH often
Proximal 3rd: Rare, due to direct blow
Distal 3rd: direct blow to top of shoulder
MOI/background: Scapular Fx
Rare, 1% of fx, usually in YM MOI: extreme amt of force Assoc injuries present in ~80% 1st rib fx Hemopneumothorax, Pneumothorax
MOI/background: Proximal Humerus Fx
4-5% of all fx,
Freq elderly women w/ OP who falls
Generally 4 fx lines Anatomic neck Greater tuberosity Lesser Tuberosity Surgical Neck
MOI/background:Humeral shaft Fx
Often a/w radial nerve injury (ie mid sahft)
Onset immediately after injury
MOI/background: Shoulder dislocation
Very Common, M>F, 95% anterior, 5% posterior
Anterior MOI: usually abduction & external rotation of the arm
Posterior MOI: often caused by seizures
MOI/background:Supracondylar fx
Most elbow injuries secondary to fall; most <15yo
FOOSH w elbow locked in extension posterior displacement of distal fragment of the humerus
Potential for injury to brachial artery (common), median n, and triceps (CHECK IF NEUROVASCULARLY INTACT
MOI/background:Dislocation “Nursemaids elbow”
Pediatric, 2-6yo common, hx pulling arm or falling on arm
Child guards extremity and limits ROM
Arm slightly flexed & pronated
May complain of wrist or forearm pain
MOI/background:Radial/Ulnar fx
FOOSH or direct blow to forearm
Uncommon to have isolated ULNA fx, think direct blow/child abuse
MOI/background: Monteggia fx
Fx proximal third of ulna and dislocation of radial head, PAINFUL** (due to high impact)
Extremity shortened, radial head palpable in antecubital fossa
ways to remember monteggia vs galeazzi radial/ulnar injuries
Ways to remember
Monteggia M means More proximal (fx)
Fracture and opposite dislocation always go together
Rad Gal(eazzi)
MOI/background: Galeazzi fx
Radial fx with distal radioulnar joint disrupted @ wrist
what causes Volar deformity write fx? Tx?
Bartons or smiths fx Tx (Depends on displacement and angulation)
Non-displaced fx: sugar tong or volar splint
Refer to ortho
Displaced : closed/open reduction
Immobilization for 6-8wk (for peds), adults 10-12
MOI/background: Colles Wrist fx
Dorsal deformity of distal radius “dinner fork”
60% have assoc ulnar fx
MOI/background: Carpal fx ie Scaphoid (Navicular)
FOOSH
Point tenderness in Anatomic snuffbox esp with ulnar deviation (towards pinky
MOI/background: Metacarpal fx
4 areas: head (distal), neck, shaft and base (proximal, into CMC joint i.e. Bennett’s fx)
May be intra articular
Most common MOI: direct blows or something falling on hand; More common in males
Boxers Fx MOI/background:
Distal 5th metacarpal
Punched someone or something
Lots of soft tissue swelling, point tenderness
ROM usually preserved
ALWAYS asses for assoc human bite: look for abrasion/laceration over MCP
MOI/background: Bennets fx
Base of thumb metacarpal
Involves CMC joint, disrupts joint @ volar base
MOI/background: MCP ligament injury aka gamekeepers thumb
Gamekeepers thumb
Thumb MCP UCL tear
Transient lateral dislocation of the thumb that has spontaneously reduced
Ski pole injuries, MVA
IP dislocation
PIP or DIP dislocation occur w or w/o fx, but almost all involve rupture of ligamentous structures. MOI: most common hyperextension or lat force
*PIP most frequent
Subungal hematoma (distal phalange) background/tx
Subungal hematoma: blood collection with fx
Evacuate hematoma w 18gauge needle or electrocautery
Dressing and splinting
Volar amputation tx/background
If no bone exposure, nothing needs to be done, heal by secondary intention
Subtotal amputation: background, possible MOI, tx
ex MOI: finger going through table saw
Clean, irrigate and debride
May repair yourself or refer to hand specialist ASAP
Nail bed (germinal and sterile nail matrix) has to be repaired as well as laceration
Tetanus, Abx, analgesics
Refer to hand to f/u
If complete tip amp: update tetanus, oral abx, analgesic
Tuft Fx/crush injury Background and tx
Tuft fx: very distal fx
Splint, refere to ortho/hand
Compartments of the hand? (10 total)
4 Dorsal interossei 3 Volar interossei Adductor Pollicis Thenar Hypothenar
Compartments of the forearm?
Superficial volar (flexor)
Deep volar (FDL, FPL, Pronator Quadratus)
Dorsal (extensor)
Mobile wad of Henry (Brachioradialis, ECRB, ECRL)
Compartment Syndrome: what is it and what can it cause
Increased pressure within an osteofascial compartment leads to decreased tissue perfusion
Leads to muscle and tissue necrosis
Possible infection, gangrene, loss of limb, myoglobinuria and renal failure
Compartment Syndrome: Features
DIsporportionate pain Pain with passive stretch Pulselessness Swelling, hard shiny skin Sensory loss Muscle weakness (paralysis)
Compartment Syndrome: Causes
Fx Crush injury (commonly missed) Infection Injection injury Drug use
High Pressure Injection: etiology, background
Use of high pressure compression equipment
Left index finger most common site
Amt of material injected influences the mechanical distention and thus tissue pressure
Pressure reduces arterial inflow & venous outflow
Type of material is important
Paints and pain solvents produce intense inflammatory rxn and are extremely damaging to tissue
High Pressure Injection injury: PE findings, s/sx
Initial findings may be few
Pt may not complain of much pain
But sig injury and freq POOR outcome
High Pressure Injection: Tx
Refer pt URGENTLY to experienced hand or ortho surgeon
Prompt surg debridement for tissue salvage
Hospitalize
Hand specialist consult ASAP
Surg: decompression, debridement, irrigation
Long drawn out course of recovery
PE/dx Clavicle fx
Children, usually not intentional/abuse
Palpable on PE; XRAY is dx
Look for angle of deformity &placement of fx along the clavicle
PE/dx scapular fx
Want to get detailed hx MOI
Young pt think possible child abuse
3 diff types of fx dep on part of scapula
XRAY is dx
Dx/tx proximal humerus fx
Dx
Usually a hx of falling
PE: mod/severe soft tissue swelling, a lot of ecchymosis
Tender to palpation at proximal humerus
Tx: Minimally displaced FX
Ice, Immobilization (clam shell)
Sling
Ortho consult for EARLY ROM (key bc shoulder gets stiff)
tx scapular fx
Depending on type of fx, usually hospitalize (observation for pneumothorax, hemopneumothorax)
Consult ortho
Ice, immobilization, analgesia (iia)
tx clavicle fx
Arm sling, immobilizer, fig 8 brace
Refer to Ortho
Repeat XRAY in 1-2 wk
*Usually left with some permanent deformity but normal function
humeral shaft fx dx/tx
Delayed union common Extension of wrist, thumb and fingers should be documented BEFORE arm is manipulated!!! ortho consult *If displaced, will need ORIF Hanging cast, Long arm sugar tong, Clamshell brace sling
dx Shoulder dislocation
Uncover both shoulders, inspect bilaterally
Pain, tenderness to palpation
Loss of normal shoulder ROM
Arm on affected side held by opposite hand in slight abduction
Prominent acromion, shoulder looks “squared off”
XRAY
AP, Lateral & Y so won’t miss dislocation
Always look for assoc fx of the humeral tuberosities and glenoid
Tx/reduction of shoulder dislocation
Tx: Immediate closed reduction
May need analgesia and/or m relaxant before, esp if shoulder has been out of place for several hours
Need counter traction, of some method, post reduction xrays
Sling or shoulder immobilizer
DC with consultation/referral
Pt supine w elbow in 90 deg flex
Arm is adducted to side of chest, shoulder place in 20 deg forward flexion
Shoulder is externally rotated until forearm in coronal plane
Arm is internally rotated to bring forearm into abduction position
*note: once dislocated, more easily dislocated in the future
PE findings/dx/labs of Supracondylar fx
Swelling, hemarthrosis, deformity, limited ROM
Assess motor and sensory function of Radial, Ulnar, median nn (RUM!); assess distal pulses
Skin abrasion/laceration, do any surg EARLY
Lab: comparative xray helpful (esp in kids) fluid accumulation POSTERIOR to distal humerus may lift periarticular fat away from bone producing +fat pad aka SAIL sign
Look for assoc dislocation
Look at olecranon process
Tx supracondylar fx
Early ortho consult Goal: preserve ROM Neurovascular compromise = immediate surg intervention Non-displaced? Then may splint Immediate reduction of any dislocation Ice, Immobilization, analgesia (iiA)
PE findings and tx of Nursemaids elbow
No swelling, bruising, focal tenderness
Subluxation of radial head Fully extend arm in supination
Apply light traction to wrist area
Bring arm to flexion, Feel pop as radial head reduces
5-10min, re-eval by checking for lollipop sign
PE and tx Radial/ulnar fx (includes monteggia and galeazzi)
Localized tenderness, but not usu swelling or ecchymosis
Reduce, cast, surgery may not be needed. Be cautious casting bc compartment syndrome if cast/splint to tightly
Tx of colles (dorsal deformity), smitha and barton (Volar deformity) wrist fx
Tx (Depends on displacement and angulation)
Non-displaced fx: sugar tong or volar splint
Refer to ortho
Displaced : closed/open reduction
Immobilization for 6-8wk (for peds), adults 10-12
PE findings carpal (scaphoid/navicular) fx
Usually minimal or no swelling or discoloring
+/- painful ROM of thumb
Freq does not show on xray
Beware avascular necrosis if untx (bc of retrograde/poor blood flow)
Tx of carpal (scaphoid/navicular) fx
If hx consistent with probably fx + tenderness in anatomic snuffbox Long arm thumb spicca splint even if fx not visible on xray
Ortho f/u in 2-3d
High rate non-union, possible avascular necrosis
PE findings of Boxers metacarpal fx
Distal 5th metacarpal
Punched someone or something
Lots of soft tissue swelling, point tenderness
ROM usually preserved
ALWAYS asses for assoc human bite: look for abrasion/laceration over MCP
Tx Boxers 5th metacarpal fx
Usually don’t recommend surgery, ROM pretty well preserved; might have extensor lag
Tx:
On lateral xray, assess for angulation
If min/no angulation ulnar guttar splint & refer ortho
If angulation >35 deg, need reduction
If assoc bite injury, vigorous wound care, abx (open fx)
Dx/PE findings and tx of Bennett’s 1st metacarpal fx
Base of thumb metacarpal
Involves CMC joint, disrupts joint @ volar base
Requires reduction and internal fixation thus ortho consult; may do outpt
PE/dx finding MCP UCL tear (Gamekeepers thumb)
Point tenderness at BASE of thumb
Stress test of UCL” >40 deg angulation
tx of MCP UCL tear (Gamekeepers thumb)
Thumb Spica Splint and refer to hand
Partial tear
Thumb spica cast for 6wk
Complete rupture
Renders thumb unstable, pt will have trouble pinching with thumb and index finger
Surgery
Tx of PIP/DIP dislocation
Splint and f/u with ortho/hand
Tx: 2nd through 5th fingers (MCP, PIP, DIPJ)
Apply gentle longitudinal traction with hyperextension (if dorsal dislocation) or hyperflexion (if volar dislocation) followed by pressure to the base of the affected phalanx in the direction that realigns the phalanges
