Exam 3 EM UE

Question 1

MOI/background: Clavicle Fx

Answer 1

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

Question 2

MOI/background: Scapular Fx

Answer 2

Rare, 1% of fx, usually in YM
MOI: extreme amt of force
Assoc injuries present in ~80%
1st rib fx
Hemopneumothorax, Pneumothorax

Question 3

MOI/background: Proximal Humerus Fx

Answer 3

4-5% of all fx,
Freq elderly women w/ OP who falls

Generally 4 fx lines
Anatomic neck
Greater tuberosity
Lesser Tuberosity
Surgical Neck

Question 4

MOI/background:Humeral shaft Fx

Answer 4

Often a/w radial nerve injury (ie mid sahft)

Onset immediately after injury

Question 5

MOI/background: Shoulder dislocation

Answer 5

Very Common, M>F, 95% anterior, 5% posterior
Anterior MOI: usually abduction & external rotation of the arm
Posterior MOI: often caused by seizures

Question 6

MOI/background:Supracondylar fx

Answer 6

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

Question 7

MOI/background:Dislocation “Nursemaids elbow”

Answer 7

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

Question 8

MOI/background:Radial/Ulnar fx

Answer 8

FOOSH or direct blow to forearm

Uncommon to have isolated ULNA fx, think direct blow/child abuse

Question 9

MOI/background: Monteggia fx

Answer 9

Fx proximal third of ulna and dislocation of radial head, PAINFUL** (due to high impact)
Extremity shortened, radial head palpable in antecubital fossa

Question 10

ways to remember monteggia vs galeazzi radial/ulnar injuries

Answer 10

Ways to remember
Monteggia M means More proximal (fx)
Fracture and opposite dislocation always go together
Rad Gal(eazzi)

Question 11

MOI/background: Galeazzi fx

Answer 11

Radial fx with distal radioulnar joint disrupted @ wrist

Question 12

what causes Volar deformity write fx? Tx?

Answer 12

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

Question 13

MOI/background: Colles Wrist fx

Answer 13

Dorsal deformity of distal radius “dinner fork”

60% have assoc ulnar fx

Question 14

MOI/background: Carpal fx ie Scaphoid (Navicular)

Answer 14

FOOSH

Point tenderness in Anatomic snuffbox esp with ulnar deviation (towards pinky

Question 15

MOI/background: Metacarpal fx

Answer 15

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

Question 16

Boxers Fx MOI/background:

Answer 16

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

Question 17

MOI/background: Bennets fx

Answer 17

Base of thumb metacarpal

Involves CMC joint, disrupts joint @ volar base

Question 18

MOI/background: MCP ligament injury aka gamekeepers thumb

Answer 18

Gamekeepers thumb
Thumb MCP UCL tear
Transient lateral dislocation of the thumb that has spontaneously reduced
Ski pole injuries, MVA

Question 19

IP dislocation

Answer 19

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

Question 20

Subungal hematoma (distal phalange) background/tx

Answer 20

Subungal hematoma: blood collection with fx
Evacuate hematoma w 18gauge needle or electrocautery
Dressing and splinting

Question 21

Volar amputation tx/background

Answer 21

If no bone exposure, nothing needs to be done, heal by secondary intention

Question 22

Subtotal amputation: background, possible MOI, tx

Answer 22

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

Question 23

Tuft Fx/crush injury Background and tx

Answer 23

Tuft fx: very distal fx

Splint, refere to ortho/hand

Question 24

Compartments of the hand? (10 total)

Answer 24

4 Dorsal interossei
3 Volar interossei
Adductor Pollicis
Thenar
Hypothenar

Question 25

Compartments of the forearm?

Answer 25

Superficial volar (flexor) Deep volar (FDL, FPL, Pronator Quadratus) Dorsal (extensor) Mobile wad of Henry (Brachioradialis, ECRB, ECRL)

Question 26

Compartment Syndrome: what is it and what can it cause

Answer 26

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

Question 27

Compartment Syndrome: Features

Answer 27

``` DIsporportionate pain Pain with passive stretch Pulselessness Swelling, hard shiny skin Sensory loss Muscle weakness (paralysis) ```

Question 28

Compartment Syndrome: Causes

Answer 28

``` Fx Crush injury (commonly missed) Infection Injection injury Drug use ```

Question 29

High Pressure Injection: etiology, background

Answer 29

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

Question 30

High Pressure Injection injury: PE findings, s/sx

Answer 30

Initial findings may be few Pt may not complain of much pain But sig injury and freq POOR outcome

Question 31

High Pressure Injection: Tx

Answer 31

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

Question 32

PE/dx Clavicle fx

Answer 32

Children, usually not intentional/abuse Palpable on PE; XRAY is dx Look for angle of deformity &placement of fx along the clavicle

Question 33

PE/dx scapular fx

Answer 33

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

Question 34

Dx/tx proximal humerus fx

Answer 34

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)

Question 35

tx scapular fx

Answer 35

Depending on type of fx, usually hospitalize (observation for pneumothorax, hemopneumothorax) Consult ortho Ice, immobilization, analgesia (iia)

Question 36

tx clavicle fx

Answer 36

Arm sling, immobilizer, fig 8 brace Refer to Ortho Repeat XRAY in 1-2 wk *Usually left with some permanent deformity but normal function

Question 37

humeral shaft fx dx/tx

Answer 37

``` 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 ```

Question 38

dx Shoulder dislocation

Answer 38

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

Question 39

Tx/reduction of shoulder dislocation

Answer 39

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

Question 40

PE findings/dx/labs of Supracondylar fx

Answer 40

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

Question 41

Tx supracondylar fx

Answer 41

``` 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) ```

Question 42

PE findings and tx of Nursemaids elbow

Answer 42

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

Question 43

PE and tx Radial/ulnar fx (includes monteggia and galeazzi)

Answer 43

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

Question 44

Tx of colles (dorsal deformity), smitha and barton (Volar deformity) wrist fx

Answer 44

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

Question 45

PE findings carpal (scaphoid/navicular) fx

Answer 45

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)

Question 46

Tx of carpal (scaphoid/navicular) fx

Answer 46

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

Question 47

PE findings of Boxers metacarpal fx

Answer 47

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

Question 48

Tx Boxers 5th metacarpal fx

Answer 48

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)

Question 49

Dx/PE findings and tx of Bennett's 1st metacarpal fx

Answer 49

Base of thumb metacarpal Involves CMC joint, disrupts joint @ volar base Requires reduction and internal fixation thus ortho consult; may do outpt

Question 50

PE/dx finding MCP UCL tear (Gamekeepers thumb)

Answer 50

Point tenderness at BASE of thumb | Stress test of UCL” >40 deg angulation

Question 51

tx of MCP UCL tear (Gamekeepers thumb)

Answer 51

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

Question 52

Tx of PIP/DIP dislocation

Answer 52

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