Injuries of the Upper Limb Flashcards
how are injuries of upper limb caused?
Injuries are causes by application of force
The severity of the injury depends on a number of factors:
- The magnitude and direction of forces
- Type of forces:
Direct force (physical contract) –> Blunt or Penetrating trauma
Indirect force (no physical contact) - Individual variation:
Age: The older the patient:
Osteoporosis –> weaker bone
Soft tissues generally weaker (ligaments, muscles and tendons)
Slower healing
Altered physiological responses - Associated medical problems: (Diabetes, CVD, warfarin etc)
Sex
Health
what is a common mechanisms of injuries to upper limb?
A common mechanism resulting in injury to the upper limb is FOOSH – fall on outstretched hand
This can occur:
Trips/falls
Sporting injuries
Work-related injuries
Assaults
what can get injured?
Bones – fractures
Joints- dislocation and subluxation (partial dislocation)
Ligaments - can get sprained
Blood vessels – axillary, brachial, radial and ulnar arteries/veins
Nerves – brachial plexus, radial, axillary, ulnar and median
Muscle
how do you assess upper limb injury?
History –> Examination –> Tests (X-rays)
- Take a History
Injury mechanism (what happened?)
Complaints of patient:
- Pain/swelling/loss of function
- Neurological symptoms (loss of sensation)
- Vascular symptoms (loss of pulse)
- Previous health/medications of patient
- Any Allergies? - Examination of patient
- Look: for deformity, scarring, swelling, changes in colour
Compare to other limb
- Feel: for
Tenderness
Crepitus: a grating sound or sensation produced by friction between bone and cartilage or between the fractured parts of a bone
Temperature
- Assess Movement
Active movement: get patient to perform a movement
Passive movement: you perform the movement on the patient (could be too painful for patient to move)
This allows you to:
Test the function and strength of muscle groups
Testing the functioning of ligaments
what are the similarities and differences in upper limb vs lower limbs?
Similar anatomy:
Both contain a ball and socket joint (shoulder and hip joint)
A long bone (humerus and femur)
A hinge joint (elbow and knee)
two distal bones
small compact bones
Differences:
Stability: The socket of the shoulder joint is much more shallower than the socket of the hip joint. That means shoulder joint is more unstable 🡪 shoulder joint dislocates more frequently
Mobility: The shoulder joint is much more mobile
Function:
what is a common injury of the upper limb?
management?
Soft Tissue Injuries:
Vast majority of injuries to the upper limb are soft tissue injuries e.g. bruises or sprains
Management:
Rest: slings, splints, plaster
Ice
Elevation (to ↓ swelling)
Analgesia (pain killers)
Early mobilisation (stops stiffness)
how does shoulder dislocation present as?
what are the initial management principles?
Presentation: Shoulder gives squared appearance as seen in image.
Initial management principles:
Pain relief:
Support the arm
Entonox (Nitrous Oxide)
Morphine by I.V
how do you assess a shoulder dislocation?
treatment?
Assessment:
Does shoulder move?
Examine BVs and nerves
X-ray to confirm
Treatment: reduction of dislocated shoulder
Complications of shoulder dislocation:
Recurrence (shoulder remains unstable)
Axillary nerve damage
You also get Associated fracture of the bone (e.g. humerus)
Associated ligamentous injury: when there is shoulder dislocation there is always some injury to ligaments.
Stiffness
Instability
Left image [normal]
Right image [Dislocated shoulder, A = socket & B = ball of humerus. (Ball not sitting in joint)
how does an elbow dislocation occur?
treatment?
Uncommon
Usually follows a fall
The deformity is obvious on an X ray.
Treatment: Reduced under sedation
Can also have associated fractures
Plaster support is usually provided
Doesn’t recur as frequently as shoulder dislocations
what is the treatment of fractured bones?
- Reduction: Bone is returned into acceptable position.
- Open Reduction: bone is realigned using a surgical operation.
- Closed Reduction: Bone realigned without cutting the skin (manipulation) - Fixation: Keep the bone in the improved position until fracture heals. Fixation can be done via:
- Non-surgical means: Use Plaster or a Brace
- Surgical means: Fixation using screws and plates
how would a fracture of the clavicle happen?
- Commonly due to FOOSH
- Fractures in middle 1/3 of clavicle are most common – weakest point as this is where it transitions form being convex to concave –> thinnest and lacks any muscular or ligamentous support
- The lateral fragment is depressed by the weight of the arm and is pulled medially and forward by the strong adductor muscles of the shoulder joint, especially the pectoralis major.
- The part of the clavicle near the centre of the body is tilted upwards by the sternocleidomastoid muscle.
diagnosis, treatment and complications of clavicle fracture?
Clinical diagnosis is easy as clavicle close to skin
Perform X-ray confirm diagnosis
Treatment: With or without surgery (depending on severity of the fracture)
Complications: few; clavicle sticks out in fracture and so lump often persists
how does a fracture of the humerus shaft occur?
Usually occurs following a fall
Potential Radial nerve damage:
Radial nerve can get trapped between bone fragments and may stop working.
Functioning of radial nerve can be assessed to by asking patient to extend their wrist and fingers. If nerve is damaged, they can’t do this. Radial nerve palsy – they can’t do this.
why can it be difficult to see an elbow fracture?
It can be difficult to see an elbow fracture:
Elbow effusion: fluid in the joint, will usually indicates a fracture
Fat pad signs: Show as a black shadow on an x-ray also indicate a fracture
what are the different fractures around the elbow?
fracture of the olecranon
displaced supracondylar fracture
how does a fracture of the olecranon (tip of elbow) occur?
Due to fall
Can result in Olecranon being pulled off
Surgery:
Realign olecranon the it is nailed/wired in place
what is a displaced supracondylar fracture?
Displaced Supracondylar fracture: occurs through the thin part of the distal humerus.
It can result in the bony fragment moving anteriorly which can press on blood vessels and disrupt circulation.
There is a risk especially to the brachial artery –> should check pulse
what are the different wrist and hand fractures?
greenstick fracture –> children
Colles fracture
what is a greenstick fracture?
Happens in children
A greenstick fracture is a fracture where the bone bends and break.
In children the bones are more elastic so in an injury they tend to bend more than snap
Treatment: Bones is children remodel well so rest in plaster is usually only required.
what is Colles fracture?
how can you manage it?
dinner fork deformity
Management:
Reduction: Bone is returned into acceptable position.
Open Reduction: bone realigned using a surgical operation. Screws and plates are usually used.
Closed Reduction: Bone realigned without cutting the skin (manipulation)
what is the fixation and complications of Colles fracture?
Fixation: Keep the hand in the improved position until fracture heals via:
Plaster immobilisation
Internal fixation with plates
Complications:
Malunion: Persistent angulation (fracture heals in an unacceptable anatomical position)
Pain
Weak grip
Limited movement
Carpal tunnel syndrome (if fragments press on medial nerve)
Reflex sympathetic dystrophy
Arthritis (if fracture involves articular surface)
name a metacarpal fracture
what is it treated with?
Boxer’s fracture:
Fracture of the neck of the 5th metacarpal (see image on right)
Can also happen due to FOOSH
Treated with strapping
what is neighbour or buddy strapping?
Splinting of injured finger to neighbouring finger to support it.
This allows injured finger to move (keeps it mobile) whilst also protecting it.
Used for many finger injuries
If alignment is maintained then the finger will usually do well with just strapping
When treating finger fractures it is important avoid rotation deformity due to an uncorrected axial rotation
