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Acute Upper Extremity Injuries

Acute Upper Extremity Injuries. CPT William Cooper D.O. Department of Orthopaedic Surgery DeWitt Army Community Hospital. Topics Reviewed. Pectoralis Rupture AC joint sprains Shoulder dislocations Clavicular fractures Biceps Rupture Radial head fractures Elbow Dislocation.

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Acute Upper Extremity Injuries

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  1. Acute Upper Extremity Injuries CPT William Cooper D.O. Department of Orthopaedic Surgery DeWitt Army Community Hospital

  2. Topics Reviewed • Pectoralis Rupture • AC joint sprains • Shoulder dislocations • Clavicular fractures • Biceps Rupture • Radial head fractures • Elbow Dislocation • Skier’s thumb • Perilunate injuries • Scaphoid fractures • TFCC tears • Jersey Finger • Mallet Finger • Sagittal Band rupture

  3. Pectoralis Major Rupture • Excessive tension on maximally eccentrically contracted muscle • Weightlifters • Localized swelling and ecchymosis • Palpable defect • Weakness with adduction and internal rotation • Most common in men 20-50 • Complete rupture most common

  4. Pectoralis Major Rupture • Treatment • Surgical repair to bone for complete tears • Nonoperative for partial tears • Outcome • Less than ideal • Weakness, decreased ROM, increased muscle fatigue • Cosmesis

  5. AC joint sprains • AKA “separated shoulder” • Mechanism: • Blow to top of shoulder • May result from fall onto outstretched arm or elbow • Focal tenderness and pain with shoulder motion • Cross-chest adduction test usually positive

  6. Cross-Chest Adduction Test • AC joint • Adduct shoulder • Patient pushes elbow up against resistance • Pain in AC = + test • false + test in RC pathology

  7. Types of AC joint sprains

  8. AC joint sprains:Radiology eval • Standard AP shoulder views inadequate • usually over-penetrate the AC joint • Image both sides for comparison • Get specific AC joint view (Zanca) • AP with 10° cephalic incline • Axillary view can show posterior dislocation

  9. Normal AC joint

  10. Grade II AC joint sprain

  11. Grade III AC joint sprain

  12. Weighted AC x-rays seldom unmask unstable injures • Bossart PJ et al. Lack of efficacy of “weighted” radiographs in diagnosing acute acromioclavicular separations. Ann Emerg Med 1988; 117:20-24.

  13. Management of mild AC joint sprains (types I and II) • Ice, analgesia • Sling 1-3 weeks • Early ROM as pain permits • Strength exercises after full ROM achieved • Return to sports after pain-free function achieved

  14. Management of type IIIAC joint sprints • Initially same as for I and II • Referral to ortho advisable within 72 hours • Most authors advocate conservative management • Outcome just as good as surgery, with quicker recovery time

  15. Acute management of severe AC joint sprains (types IV, V, VI) • Ice, analgesia • Management of any complications (type VI associated with clavicle fxs, rib fxs, and brachial plexus injuries) • Sling/swath • Early referral

  16. Clavicular Fractures • One of the most common fractures • Classification • Middle third - most common (thinnest section) • Distal third • Proximal third • Image with AP thorax and 45° AP cephalic tilt • Rule out neurological or vascular compromise; pneumothorax in 3%

  17. Lateral third clavicle fracture

  18. ER Management ofClavicular Fractures • Ice, analgesics, arm support for all • Referral rule: • Any displaced, non-middle-thirdfractures • Shortening/displacement >2cm • Non-displaced fxs: sling; ROM prn comfort • Displaced middle-third fractures: figure 8 splint • Re-image in 7 days to assure reduction. If not, refer for shoulder spica cast

  19. Shoulder dislocations • Most commonly dislocated large joint • Anterior in 97% • Mechanism: force on abducted/externally rotated shoulder • Exam: • Shoulder externally rotated • Fullness anteriorly; acromion prominent post. • Neurovascular testing

  20. Radiology of shoulder dislocations • AP and axillary views; optional scapular lateral (Y) • Velpeau view • Look for fractures (not a contra-indication to reduction) • Always pre-reduction x-rays in primary cases • Optional pre-reduction x-rays in recurrent cases • Always post-reduction x-rays

  21. Anterior shoulder dislocation

  22. Anterior shoulder dislocation

  23. Posterior shoulder dislocation

  24. Hill-Sachs deformity

  25. Bankart lesion

  26. Shoulder dislocation reduction techniques • Types of maneuvers • Traction (Stimson, self-reduction, Hippocrates, Eskimo,Milch) • Scapular manipulation • Leverage (Kocher) • Combined maneuvers (slump, Snowbird)

  27. The Stimson technique for anterior shoulder dislocation reduction.

  28. J. Bone Joint Surg. Am., Dec 2009; 91: 2775 – 2782 • The FARES method • Significantly more effective, faster, and less painful method of reduction of an anterior shoulder dislocation in comparison with the Hippocratic and Kocher methods

  29. Post-reduction treatment for shoulder dislocation • Ice 72 hrs, NSAID 7-14 days • Immobilization 3-6 weeks • Capsule needs time to heal • Physical Therapy referral for rehab • Less immobilization (1 week) and quicker rehab in pts >40 (to prevent stiffness) and in recurrent dislocators

  30. Indications for early orthopedic referral for pts with shoulder dislocation • Displaced greater tuberosity fxs (>1 cm post-reduction) • Glenoid rim fxs displaced >5mm • Irreducible dislocations (soft tissue interposition) • Young athletes

  31. Biceps Tendon Rupture • Proximal rupture • Most common in age > 60 • Usually degenerative changes present initially • Usually hear/feel snap • Some may experience pain relief afterwards • Popeye deformity • Treatment nonoperative • Unless young patient with traumatic rupture

  32. Biceps Tendon Rupture • Distal Biceps Rupture • Much less common (5% of biceps ruptures) • Middle aged patients • Usually tendonopathy/degenerative changes present which predispose • Forceful, eccentric overload of the partially flexed elbow • Up to 50% loss of supination power has been documented after rupture • Treatment is surgical

  33. Biceps Tendon Rupture • The Hook Test for Distal Biceps Tendon Avulsion Am J Sports Med November 2007 35 1865-1869; published online before print August 8, 2007

  34. Does this happen in distal biceps rupture???

  35. Elbow trauma • Fractures • Dislocations • Ligament sprains • Look for compartment syndrome • Rule out neurovascular injury

  36. Axioms in elbow trauma radiograph evals • Look for fat pads signs (capsular effusion) • Anterior fat pad (from coronoid fossa) may be normal; compare to other side • Posterior fat pad (from olecranon fossa) is always abnormal • Compare to x-rays of other side in children • If elbow can’t be extended, obtain AP/lat of both humerus and forearm

  37. Fat pad signs

  38. Elbow fractures • Supracondylar, epicondylar • Radial head/neck • Olecranon • Coronoid process • **Consult current texts or your friendly local orthopedist for treatment of each.

  39. Radial head/neck fractures • Common fracture in adults • FOOSH usually • Detection may require oblique view • Assure proper alignment of head on capitellum (radiocapitellar line)

  40. Radial head fracture types • Type I: less than 2 mm displacement • Type II: angulated or >2 mm displaced • Type III: comminuted

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