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Upper Limb Injuries

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Upper Limb Injuries - 1 - BCCH Emergency Department UPPER LIMB INJURIES Resource pack Developed by: RENA HEATHCOTE RN Rena Heathcote BCCH Emergency Department 2012 - 2 - FRACTURES The shoulder Dislocation +/_ fracture of humeral head History • A dislocated shoulder generally follows a fall onto their arm, or directly onto their shoulder, causing the humeral head to dislocate from the joint 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 shoulder joint, noted as flattening to the top of the arm at the shoulder joint (the deltoid muscle region), and more obvious bony prominence. Obvious deformity of the shoulder, In this case, the humeral head has dislocated inferiorly Rena Heathcote BCCH Emergency Department 2012 - 3 - • The humeral head can at times be felt in the axilla • Caution: The axillary nerve can become damaged causing paralysis over the deltoid region, and the absence of sensation over a patch below the shoulder. • Sensation and radial pulse 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 ligaments, and may have an accompanying underlying fracture Rena Heathcote BCCH Emergency Department 2012 - 4 - Fractured humeral neck/ shaft History • This injury is generally caused by a fall on out‐stretched hand (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 humerus, 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 elbow • The patient will complain of pain at the fracture site • Caution; The radial nerve runs behind the humerus, and injury may cause damage to the radial nerve, which can cause wrist 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 Rena Heathcote BCCH Emergency Department 2012 - 5 - 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 joints are not completely developed & the ligaments around the elbow are still loose. It occurs when the radius, partially slips out of the ring shaped ligament which secures the radius to the ulna 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. Rena Heathcote BCCH Emergency Department 2012 - 6 - 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 bone slips back 1. Cup affected elbow with opposite hand 2. Apply pressure over radial head 3. Thumb in antecubital fossa 4. Apply slight longitudunal traction by grasping wrist 5. Supiante, (palm up) and flex (90 degrees) forearm 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. Rena Heathcote BCCH Emergency Department 2012 - 7 - 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 olecranon 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 artery, 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 Rena Heathcote BCCH Emergency Department 2012 - 8 - Supracondylar Fracture History • This is an extremely common elbow fracture 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 brachial artery 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 Rena Heathcote BCCH Emergency Department 2012 - 9 - History • Caused by the mechanism of FOOSH, leading to a fracture through the head of the radius AssA sessmentessments • 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 Rena Heathcote BCCH Emergency Department 2012 - 10 - 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 bones 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
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