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BCCH Emergency Department

UPPER INJURIES

Resource pack

Developed by: RENA HEATHCOTE RN

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FRACTURES

The

Dislocation +/_ fracture of humeral head

History

• A generally follows a fall onto their , or directly onto their shoulder, causing the humeral head to dislocate from the capsule and out of the socket. • This usually results in an anterior (towards the front) dislocation of the humeral head, where it is positioned in front of the joint socket. More rarely the humeral head dislocates posteriorly (behind) or inferiorly (underneath).

Assessment

• The patient usually walks in holding their arm, and in obvious pain • There is obvious deformity to the , noted as flattening to the top of the arm at the shoulder joint (the region), and more obvious bony prominence.

Obvious deformity of the shoulder, In this case, the humeral head has dislocated inferiorly

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• The humeral head can at times be felt in the

• Caution: The can become damaged causing paralysis over the deltoid region, and the absence of sensation over a patch below the shoulder. • Sensation and radial must always be checked

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • These patients should have an immediate shoulder x‐ray to exclude any underlying accompanying fracture, followed by reduction of the dislocation under sedation ASAP to minimise pain and risk of neuro‐vascular injury • Ensure the patient has received adequate analgesia • Post reduction apply a broad arm sling, and advise patients to minimise movement to prevent the risk of the shoulder re‐dislocating • Patients should be followed up in the orthopaedic clinic, as they tend to sustain significant damage to the surrounding capsule and , and may have an accompanying underlying fracture

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Fractured humeral / shaft

History

• This injury is generally caused by a fall on out‐stretched (FOOSH), although can also be caused by direct impact, and occasionally other mechanisms • This results in a fracture through the neck or shaft of the , with varying degrees of displacement

Assessment

• There tends to be a significant deformity present to the upper arm, often with bruising and swelling • They will usually walk in holding their arm flexed at the • The patient will complain of pain at the fracture site • Caution; The runs behind the humerus, and injury may cause damage to the radial nerve, which can cause drop • Sensation, radial pulse, and wrist movement must always be checked

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure the patient has received adequate analgesia • X‐ray reveals the degree of angulation and site of fracture • Treatment is dependant upon the site/degree of angulation/pain of the patient: • These injuries are followed up in the orthopaedic clinic, and are sometimes surgically plated

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PULLED ELBOW

History

A pulled elbow is a common minor injury which usually affects children under the age of five. Normally happens because children’s are not completely developed & the ligaments around the elbow are still loose. It occurs when the , partially slips out of the ring shaped which secures the radius to the causing a ‘radial head subluxation’.

Assessment

Care giver may describe hearing a ‘crack’ or ‘popping’ sound at the time of the injury Typically child is reluctant to use arm which hangs loosely at their side, the injured elbow is pronated and partially flexed. Anterolateral tenderness over radial head The story of how it occurred and an examination of the child’s arm will normally be enough to diagnose a pulled elbow. An X‐ray is not usually necessary as the injury will not be visible.

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Treatment

Give the child simple painkillers such as Tylenol or ibuprofen. Once the examination has shown no other injury the child’s arm will need to be reduced. This is a quick and simple manoeuvre, and involves manipulating the head of the radius back into the correct position. Often a click is felt as the slips back

1. Cup affected elbow with opposite hand 2. Apply pressure over radial head 3. in antecubital fossa 4. Apply slight longitudunal traction by grasping wrist 5. Supiante, (palm up) and flex (90 degrees) 6. Palpable click felt with reduction

Shortly after this a child should be able to start using their arm, especially if distracted by playing with a toy, but sometimes this can take a few hours or more. The longer the arm has been ‘subluxed’ the longer this is likely to take, but every child is different. We usually keep the children’s in ER until the child has started to use their arm, The arm seems may appear a little sore or swollen after it has been treated, advise regular simple painkillers such as Tylenol or ibuprofen until they are using it normally.

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Dislocated elbow

History

• Dislocation of the elbow joint results from fall on outstretched hand. It requires a fairly significant force • This typically causes posterio‐lateral dislocation of the and radial head

Obvious deformity Posterior dislocation

Assessment • There is obvious marked deformity and pain • The patient will not want to move their arm, and will be holding it against their body • This can be mistaken for a supracondylar fracture (see below),especially in children • Caution: Dislocation can cause damage to the ulna or medial nerve or brachial , but is uncommon (McRae, 2003) • Distal sensation and radial pulse/ capillary refill must always be checked

Treatment • Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • These patients should have an immediate elbow x‐ray to confirm the dislocation and exclude any underlying accompanying fracture, followed by urgent reduction of the dislocation under sedation • Ensure the patient has received adequate analgesia

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Supracondylar Fracture

History • This is an extremely common in children, although can occur in adults as well • The injury generally occurs from a FOOSH, which may displace the elbow backwards, incurring the fracture • The term applies to fractures of the humerus in the distal third, lying just above the trochlea and capitellum (McRae, 2003)

Assessment • The patient will be reluctant to move their arm, and a child will not be using it / reluctant to let it be examined • The patient will complain of tenderness / pain around the distal region of the humerus • Caution: In significantly displaced fractures, there is high risk of damage to the causing limb threatening arterial obstruction • The medial nerve can also be compromised • Distal sensation and radial pulse/ capillary refill, and wrist movement must always be checked

Treatment • Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered • X‐ray reveals the severity and angulation of the fracture • Treatment is dependant on the severity of the fracture, any neurovascular compromise, and the age of the patient • Generally, non complicated / displaced fractures are placed in an above elbow backslab and collar and cuff, and are followed up in forthopaedic clinic • Complicated / displaced fractures, or fractures with evidence of arterial obstruction/ nerve compromise, are referred urgently to the orthopaedic team for manipulation and reduction

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History • Caused by the mechanism of FOOSH, leading to a fracture through the head of the radius

AsAssessmentsessment • The patient will be reluctant to straighten and move elbow/forearm, as this will reproduce pain • The may be some degree of swelling • The patient will complain of tenderness over the radial head on palpation of the region

Treatment • Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered • An elbow x‐ray may show a fracture through the radial head, or and effusion within the joint that indicates significant injury • If the fracture is minimally displaced or impacted, the arm is placed in a collar and cuff, and the patient is referred to orthopaedic clinic

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Forearm fractures

History

• These injuries are often sustained from falling onto forearm, direct impact, or FOOSH • There are varying types of fracture varying from simple mid shaft fractures of the radius or ulna, or more complicated fractures involving both and/or associated dislocations at the elbow or wrist joint

Assessment

• The patient will complain of pain at the site of the injury in their forearm • There may be swelling or deformity • They will be reluctant to move their arm, and may be supporting the injured area • They may complain of pain at a further site e.g. the elbow/wrist or shoulder • Damage to the arterial supply and nerves must always be considered, and a radial pulse and sensation should always be checked

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered • An x‐ray needs to be requested dependant upon the site of bony tenderness / suspected injuries • Treatment is dependant upon the site / severity of the fracture and/or dislocation • Simple mid shaft isolated fractures are treated in an above elbow POP backslab, with a broad arm sling and orthopaedic clinic follow‐up • Complicated fractures and/or associated joint dislocations are referred immediately to the orthopaedic team for reduction and plating under G.A

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Children with .

Children's bone has the ability to bend before it breaks. It therefore doesn't crack like a dry twig but rather buckles like a green stick. These are stable fractures and heal quickly in a plaster cast. If the fracture is right at the wrist end of the bone a simple below elbow cast is sufficient. If the fracture is more than 3 cm from the wrist a plaster which extends above the elbow is preferred.

Bone always grows straight. Therefore children have the ability to 'remodel' their bone as they grow. In children under 8, the ability to do this is amazing and significant deformity can be accepted. Sometimes the bone is too bent and needs to be straightened; this can be done with manipulation under anaesthetic (MUA).

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FRACTURE OF DISTAL RADIUS History

• Generally a fall onto the outstretched hand (FOOSH)

Assessment

• There is often a characteristic dinner‐fork deformity • The patient complain of tenderness to the distal radius, and a ‘step’ in the bone is often felt on palpation • Radial pulse, sensation and capillary refill must always be checked to ensure no neuro‐vascular compromise

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Distal Radius Fracture

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered • An x‐ray will show the degree of angulation and/or impaction, and any other associated fractures • Simple, minimally displaced fractures are treated conservatively in a cast and followed up in the orthopaedic clinic • More severely angulated and/or impacted fractures require manipulation. This is often undertaken in the ER as a procedural sedation

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SCAPHOID INJURIES (Caution – scaphioid Injuries are rare in children below 12 years and highly unlikely in children under 6 years)

History

• Injuries to the classically occur from FOOSH. They can sometimes also occur from forced hyperextension e.g.: hand being forced back by a ball, or putting hand up against a heavy closing door.

• This can cause a fracture through various areas of the scaphoid bone; a ‘banana’ shaped carpal bone in the wrist, sitting between the base of the thumb and the radius

• The scaphoid has a blood supply coming from the distal (furthest) end, which supplies the proximal areas (a ‘backwards blood supply). Hence, If there is a fracture through the (middle) of the bone, this can cut off the supply to the nearest fragment, causing . As a result of this, serious disability, instability

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and can occur, and it is an area of high litigation within the medical profession • In view of above, this injury is taken extremely seriously, and any patient that exhibits signs of a potential , along with an appropriate mechanism of injury, is suspected of having a possible fracture and treated as such, regardless of initial x‐ray findings

Assessment

• The patient will describe the classic ‘FOOSH’ mechanism, or similar mechanism • They will complain of pain in the region of the scaphoid, and there may well be swelling/bruising to the same region • The patient will have tenderness when pressed in the ‘anatomical snuff box’ of the wrist

The anatomical snuff box where The scaphoid bone is underlying

• Patients with scaphoid fractures have the potential for accompanying injuries e.g. distal radius and radial head fractures

Treatment • Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered • X‐rays including scaphoid views may be requested dependant on clinical suspicion, time since injury, and main point of bony tenderness • If the clinical suspicion / examination means that a scaphoid fracture is suspected, regardless of whether the x‐rays show a fracture at the time of the injury, the wrist is put into a scaphoid plaster • The injury is then followed up 10‐14 days post injury, and if still clinically suspected, is re‐xrayed to look for any evidence of fracture or periosteal reaction to the bone that could indicate an underlying fracture. The orthopaedic doctors then treat the injury accordingly

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Bennetts fracture / fracture to base of thumb metacarpal

History

• These fractures often arise from a ‘punch’ injury, or from forced abduction • They can be classified as 1) a simple fracture across the base of the thumb metacarpal OR

2) a Bennetts fracture which consists of an oblique, intra articular (extends into the joint) fragment to the base of the thumb metacarpal, with subluxation (displacement) of the thumb metacarpal

Assessment

• Deformity may be obvious • There will be tenderness to the base of the thumb metacarpal, and possibly a palpable deformity • The patient will be reluctant to move the thumb, and may be unable due to swelling / bruising

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered • An x‐ray will show the type of fracture and degree of joint involvement / displacement • Simple, non displaced fractures are placed in a Bennetts POP, broad arm sling, and are reviewed in the next ortho clinic • Complicated fractures are discussed urgently with the hand surgeons, as they require urgent reduction and sometimes fixation

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Ulna collateral ligament injury (gamekeepers/ skiers thumb)

History • This injury is sustained from forced abduction (the thumb being forced outwards to the side or upward) • It involves a rupture or partial tear of the ulna collateral ligament, which stabilises the thumb metacarpophalyngeal joint, on the ulna aspect

• It is considered a serious injury, as if left untreated there may be progressive subluxation (partial dislocation) of the joint, leading to instability and permanent disability (McRae, 2003) • It is common to get an from where the ligament attaches onto the bone

Assessment

• This injury is suspected with the appropriate mechanism • There may be swelling and bruising around the thumb web space, and the patient will complain of pain in this area

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• Upon examination by an ENP / doctor, there will be laxity (looseness) when gently stressing (pulling upon) this ligament, with accompanying pain

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, if the patient finds it more comfortable • Ensure adequate analgesia is administered • Examination by a medical practitioner will provide clinical suspicion / confirmation of this injury • An x‐ray will be taken to rule out an accompanying avulsion fracture or any other fractures to the same region • Minor of the ligament without any fracture are treated conservatively in a thumb spica and review clinic • Significant laxity / rupture or accompanying fracture is referred to plastics • These injuries can be treated in a cast, or can require surgical repair

Boxers Fracture / fractures to the fifth metacarpal

History

• As the name suggests, this injury is most commonly sustained from punching a hard surface or person • A boxers fracture is a fracture through the neck of the 5th metacarpal, with common angulation and impaction of the fracture • Other fractures can occur of the 5th metacarpal shaft or base

Assessment

• The mechanism gives the diagnosis! • There may well be swelling over the 5th Metacarpal, most markedly around the site of the fracture • Often there is obvious deformity to the knuckle joint, and the little

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Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered • An x‐ray will show the degree of angulation / severity of the fracture • Simple, minimally displaced fractures are treated with buddy strapping and referred to the ortho clinic • Complicated / displaced fractures are referred to the hand surgeons

Fractures to 2nd/3rd/4th metacarpals

History

• Metacarpals may fracture in three places: ‐ The neck ‐ The shaft (including spiral fractures) ‐ The base (often involving dislocation of the joint with the )

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Assessment

• As for boxers fracture Treatment

• As for boxers fracture – dependant upon severity of the fracture

Phalyngeal Fractures / Dislocations

History

• Occurs from varying mechanisms, often sports injury related, or crush injures • Fractures are common injures, which if improperly treated lead to stiffness and bony deformity • Finger fractures often have accompanying soft tissue injuries, which are often overlooked • Dislocations need prompt reduction to reduce pain, avoid further tissue damage, and increase ease of reducing the dislocation

Assessment

• There may be obvious deformity / swelling / bruising

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Place the patients’ arm in a broad arm sling, according to the patients’ comfort • Ensure adequate analgesia is administered as required • If there is a possibility of dislocation, seek help from an ENP / doctor for prompt x‐ ray and reduction • An x‐ray shows the severity / displacement of the fracture, and whether it extends into the joint surfaces • Simple fractures are treated with neighbour strapping, and review clinic / fracture clinic follow up

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Mallet Finger

History

• This is caused by forcible flexion of a straight finger (McRae, 2003) e.g: being hit ‘end on’ by a cricket ball, stubbing finger against something, or from a laceration to the tendon • The extensor tendon (the tendon running along the top of the finger) normally inserts at the base of the distal phalanx. This tendon can rupture, become lacerated, or can avulse from the base of the distal phalanx • This causes an ‘extensor lag’ to the distal phalanx, as there is no tendon to hold the phalanx up

Assessment

• An obvious extensor lag (drooping to the end of the finger) will be apparent

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• There may or may not be swelling /bruising or tenderness • The distal phalanx can be easily passively extended (the medical practitioner performs this for them), but the patient is unable to actively extend (lift it up themselves)

Treatment

• Remove all rings on digits to prevent swelling and neuro‐vascular compromise • Elevate limb as required • Ensure adequate analgesia is administered as required • An x‐ray is taken to look for an associated avulsion fracture • The distal phalanx is re‐positioned in a straight position, with very slight hyperextension, and placed in a mallet splint, or a form of zimmer splint. This splint stays on at all times for the next 6 weeks, to maintain the extended position, so that the two ends of the tendon or bone can heal together • The patient is taught how to self care with the splint, and wash the finger, whilst the finger maintains the straight position throughout • If the splint is removed and the finger is allowed to ‘droop’, the tendon ends will ‘split apart’ again and form scar tissue, and will most likely stay permanently deformed • If there is a large avulsion fracture, the patient is referred to the hand surgeons for follow up, as possible fixation of the fragment

References

McRae, R (2003) Orthopaedics and Fractures, Churchill Livingstone, Oxford

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