Ski injuries to the upper extremities

1. Ski injuries to the upper extremities Eugene Bailey, MD Department of Family Medicine SUNY Upstate Medical University Toggenberg MA Presentation January 03, 2010

2. General Comments Shoulder Injurties ShoulderDislocation Clavicular fracture Scapular fracture Acromioclavicular joint (ACJ) injury Humerus fractures Head Shaft Suprachondylar Elbow Anterior/Posterior dislocation Olecrenon fracture Radial head fracture Wrist Scaphoid fracture Colles fracture Hand/Fingers Skier’s thumb (Gamekeeper’s thumb) Objectives

3. Not going to cover • Bicipital tendonitis • Medial and Lateral epichondylitis • Nursemaid’s elbow • Carpel tunnel syndrome • Bursitis • Finger fractures

4. General CommentsZone of Injury

5. General CommentsIn the field • ABCs • Airway • Breathing • Circulation • Always assess neurovascular status (CMS = circulation, motor and sensory) • Control any bleeding • Do not move victim until stabilized

6. General Comments • 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)

7. Remember • "Ability and experience are probably the most important factors in determining an individual's likelihood of injury when pursuing an outdoor sport."

8. “ARMS” • Appearance and alignment • Radial pulse • Motor function and mechanism of injury • Sensation

9. Self-splinting

10. Prevention

11. Case Scenario • 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

12. Upper extremity injuriesSnowboarding www.ski-injury.com

13. Upper extremity injuriesSnowboarding – Val, Colorado (10 year survey) • 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 • 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.

14. Upper extremity injurySkiing www.ski-injury.com

15. Upper extremity injurySkiboard www.ski-injury.com

16. Shoulder Injuries

17. Shoulder dislocation • MOI: • 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%)

18. Shoulder dislocation • 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

19. Radiograph of Anterior shoulder dislocation

20. Shoulder dislocation • X-rays do not have to be obtained before treatment • There are numerous techniques for reduction • Traction • Leverage Kocher’s technique

21. Shoulder dislocation • Immobilize the injured joint • Blanket roll • Sling • Sling and swath • Ice

24. Clavicular fracture • Most commonly fractured bone in the entire body! • MOI: • Transmission of force up the arm • Fall onto shoulder • Direct blow to the clavicle

25. Clavicular fracture • presents with: • 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

26. Clavicular Fracture Distal third classification • Middle third - 80% • Proximal third - 5% • Distal third - 15%

27. Clavicular Fracture • Simple sling • Figure-of-eight • 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

28. Scapular Fracture • 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

29. Acromio-clavicular joint (ACJ) injury

30. ACJ Injury • MOI: • Falling directly onto the adducted shoulder • Injury to the ligament causes • Tear (subluxation) • Dislocation

31. ACJ Injury Grade 1 Grade 2 Grade 3………

32. ACJ Injury • Presentation: • Type 1/Grade 1 – local tenderness without deformity • Type 2,3,4,5,6/ Grade 2,3 – local tenderness with deformity

33. ACJ Injury • Simple sling! • Collar and cuff • Ice

34. Humerus Injuries

35. Bony Anatomy: Humerus • Distally – 2 condyles forming articular surfaces of trochlea and capitellum • Proximally – neck and head articulate with glenoid fossa of scapula

36. Humeral FracturesMOI • 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

37. Humeral Head fractureDiagnosis • Upper humeral fractures usually involve the surgical neck of the bone • extracapsular • low incidence of avascular necrosis (AVN) • Anatomical Neck • intracapsular • higher incidence of AVN

38. Humeral Head FracturesNEER Classification * *Velpeau view if cannot abduct arm

39. Humeral Head FracturesTreatment • One part fractures (no fracture fragments displaced < 1cm or 45 deg) • Non-operative immobilization in sling1-2 weeks • Early motion started immediately • 75% good to excellent results; 10% poor • Any other fracture • Closed reduction with percutaneous pinning • ORIF • 2-6 weeks to allow pain free movement

40. Humeral FracturesComplications • Avascular Necrosis of Humeral Head • Especially at risk with 4 part fractures • Non-union • 3-6 mos after injury • Shoulder stiffness with prolonged immobilization

41. Humeral Shaft FractureDiagnosis • Fractures of the shaft of the humerus • 1-3% of all fractures • Up to 18% have radial nn palsey

42. Humeral Shaft Fracture

43. Humeral FracturesTreatment • Non-operative • Acceptable alignment • 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

44. Humeral FracturesTreatment • Operative • Absolute Indications • Failure of closed treatment • Associated articular involvement • Vascular injuries • Ipsilateral forearm fractures • Pathological fractures • Open fractures • Polytrauma • Relative Indications • Short oblique or transverse fracture in an active individual • Body habitus • Patient compliance • Staff considerations

45. Humeral FracturesComplications • Radial nerve palsy • Most at risk – distal 1/3 fractures • Occurs up to 18% of fractures • 90% neurapraxias and heal in 3-4 mos • Exploration indicated • No recovery in 3-4 mos (clinical or EMG) • Loss of function with closed reduction • Open fractures • Holstein-Lewis distal 1/3 spiral fractures

46. Supracondylar fractureDiagnosis • Supracondylar fractures • Most common pediatric elbow fracture (65% of fractures and dislocations of the elbow) • Commonly associated with neurovascular injury

47. Supracondylar fracturesDiagnosis • Classification • 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

48. Supracondylar FracturesDiagnosis • Radiology • AP view • Baumann’s angle • Medial epichondylar epiphyseal angle (MEE) • Lateral view • Humero- trochlear angle • Oblique

49. Supracondylar FractureTreatment • Non-displaced fxs – cast immobilization • Displaced fxs – close reduction with percutaneous pinning

50. Suprachondylar fractureComplications • Vascular injury – brachial aa • Neurologic deficits – median nerve; possible radial nerve • Volkmann’s contracture • Cubitus varus