Ski injuries to the upper extremities

1. Ski injuries to the upper extremities Eugene Bailey, MD Department of Family Medicine SUNY Upstate Medical University Toggenburg Ski Patrol 2008

2. General Comments Humerus fractures Head Shaft Suprachondylar Elbow Anterior/Posterio dislocation Olecrenon fracture Radial head fracture Chorocoid 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. Self-splinting

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

9. Prevention

10. Ski Injuries - Statistics

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

12. 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.

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

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

15. Humerus Injuries

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

17. 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

18. 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

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

20. 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

21. 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

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

23. Humeral Shaft Fracture

24. 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

25. 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

26. 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

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

28. 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

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

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

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

32. Humerus InjuriesEmergency Care • Sling • Ladder splint

33. Elbow Injuries

34. Radial Anatomy • Radial head articulates with capitellum • Radial neck tapers to radial tuberosity which is insertion for biceps brachii tendon

35. Ulnar Anatomy • Sigmoid/semilunar/ trochlear notch • Anteriorly composed of coronoid process • Posteriorly composed of olecranon process • Articulates with trochlea of humerus

36. Elbow Joint Articulation - Elbow consists of articulations: • Ulnohumeral (elbow flexion/extension) • Radiohumeral (forearm pronation/supination) • Radioulnar (forearm pronation/supination)

37. Elbow InjuriesMOI • Fall onto outstretched hand with elbow extended or direct trauma

38. Elbow dislocationDiagnosis • Second to shoulder dislocations • Posterior dislocation account for 80-90% • Most occur without fracture

39. Elbow dislocationTreatment • Immediate reduction vs splint and refer • Children should be splinted; increase incidence of fractures • Need for radiographs • After relocation • Assess neurovascular status • Assess joint stability • Rehab early

40. Elbow fracture • Radial head – 30% • Olecrenon – 20% • Coronoid fractures – 10 to 15% of elbow dislocations

41. Elbow fat pads

42. Elbow Fat Pads

43. Elbow FracturesTreatment • Radial Head • Non-displaced (type I) • sling and or splint until no pain • Displaced (type II) • Longer immobilization (1-2 weeks) • removal of bone fragments if necessary • Comminuted (Type III) • Surgery to remove bone fragments • Repair ligament damage

44. Elbow FracturesTreatment • Olecrenon Fracture • Non-displaced (type I) • Sling, splint and or cast for 3-4 weeks • Follow by x-ray for dislocation of fracture • Displaced (type II) • ORIF • Comminuted (Type III) • ORIF

45. Elbow FracturesTreatment • Coronoid Fracture • Type 1 • Immobilization for 2 weeks • Type 2 • Immobilization for 2 weeks • Displaced or humeroulnar joint instability may consider ORIF • Type 3 • ORIF

46. Elbow dislocation or fractureEmergency Care • Immobilize • Sling • Posterior elbow splint using ladder splint or SAM splint • ice

47. Wrist Injuries

48. Anatomy of the wrist

49. Wrist fracture • Incidence of fracture is 2x for snowboarding vs. skiing • With loss of balance, the natural tendency is to break fall with outstretched hand (FOOSH)

50. Wrist fracture (distal radial) • Most common - Distal radius or Colles fracture • Silver fork deformity