UPPER EXTREMITY INJURIES

1. UPPER EXTREMITY INJURIES Ken Jackimczyk M.D. Vice Chair, Department of Emergency Medicine Maricopa Medical Center, Phoenix Arizona Medical Director, Eagle Air Med, Blanding Utah

2. PRINCIPLES OF ORTHOPEDICS • Early adequate pain control -Splint -Ice • The ability to use a limb does not rule out the possibility of a fracture • Do not accept bad films

7. PRINCIPLES OF ORTHOPEDICS • Obtain xrays on all dislocations before reduction unless delay would injure the patient • If a fracture is suspected clinically and xrays are negative—splint for fracture • Circumferential plaster casts should be left for the orthopedic surgeon

8. ORTHOPEDICS IS EASY If It’s Crooked---- Straighten it If it’s short----- Lengthen it If you’re not sure--- Look at the other side

9. THE ROLE OF EMPATHY “Everything will be OK” “It will never be the same as it was”

10. CARPAL DISLOCATIONS

11. CARPAL DISLOCATIONS • Lunate and perilunate dislocations • It is essential to obtain a true lateral • Carefully check the alignment of the carpal bones

14. PERILUNATE DISLOCATION • More common of the two entities • Carpal bones look shortened in AP view • Make diagnosis on true lateral

17. LUNATE DISLOCATION • Less common than perilunate • Lunate rotates palmarly • Lunate has triangular appearance on AP radiograph

20. POSTERIOR SHOULDER DISLOCATION • Shoulder is a mobile unstable joint • 98% are anterior dislocations • 50% of posterior are missed initially • Etiology: seizure and electrical shock • Can’t externally rotate

21. POSTERIOR DISLOCATION TIPS • Films may look normal • Increased distance between humeral head and glenoid • Greater tuberosity internally rotated • Need axillary or transthoracic view

25. BEWARE THE SINGLE BONE FOREARM FRACTURE

26. MONTEGGIA-GALEAZZIFRACTURES • Beware of the single bone forearm fracture • Forearm acts as ring with radius, ulna and radioulnar joints

27. MONTEGGIA FRACTURE • Proximal 1/3 ulna fracture with radial head dislocation • 80% anterior 20% posterior • Mechanism—direct blow on posterior ulna or fall on pronated forearm • Search for dislocated radial head on all proximal ulna fractures

30. GALEAZZI FRACTURE • Fracture at junction of middle and distal 1/3 of radius with subluxation or dislocation of distal radioulnar joint • Always get wrist film on fracture of distal-middle third of radius

33. High Pressure Injection Injuries

34. High-Pressure Injections • Initially innocuous but devastating sequella • Inexperienced or careless worker -finger used to wipe plugged nozzle -test of gun on finger or palm

36. High Pressure Injections - Epidemiology

37. Pathophysiology • Breakage of skin 100 psi • Grease 5,000-10,000 psi thick, inert 3. Spray 3,000-7,000 psi inflammatory 4. Diesel fuel 2,000-12,000 psi injectors injuries to mechanics

38. Degree of Injury Type of material -Paint has 60% amputation rate -Grease has 25% amputation rate • Amount of material

39. Clinical Presentation • Initially -Innocuous looking PW • After 1-2 hours -Pain unrelieved by narcotics • Late complications -Granulomas or contractions

41. ED MANAGEMENT • Remove constrictive dressings or casts • Limb at neutral, not elevated position • Immediate surgical consultation

42. ED Evaluation • Physical exam -Amount and location of swelling -Neurovascular/Motor • Plain films -Must x-ray at least to elbow

45. A FINAL QUICK CASE • 27 year old female with forearm pain • What is her life threatening condition?

47. DOMESTIC VIOLENCE • Physical, sexual or psychological attacks against intimate partner • Injury inconsistent with history or suggestive of defensive posture • Think of it!!