UPPER EXTREMITY INJURIES
Jeff Del Vecchio MPAS, PA-C, DFAAPA Mercy Clinic Orthopedics Springfield, Missouri
OBJECTIVES
IDENTIFY COMMON UPPER EXTREMITY INJURIES AND FRACTURES
REVIEW EXAMINATION TECHNIQUES FOR COMMON UPPER EXTREMITY INJURIES
DISCUSS AND REVIEW RADIOGRAPHIC FINDINGS OF UPPER EXTREMITY FRACTURES
DISCUSS AND REVIEW TREATMENT OPTIONS FOR COMMON UPPER EXTREMITY INJURIES
LATERAL EPICONDYLITIS
Tennis elbow Definition
Pain about lateral aspect of elbow Involves extensor musculature Rotation of arm and wrist extension Secondary to repetitive overuse or injury Microtears to tendon⇒ inflammation⇒fibrosis⇒degeneration Affects pt’s 30-60 yrs
Clinical symptoms
Outside elbow and back of upper forearm pain Pain lifting with palm facing down Holding lightweight objects difficult
Physical Examination
Lateral epicondylar area tender to palpation
Tennis elbow test- elbow 90 deg, extend wrist against resistance. +pain at lateral epicondaylar area Radiographs
Obtain to rule out osteoarthritis or calcifications
Treatment
NSAID’s (10-14 days) Avoid activities causing pain Heat or ice Corticosteroid injection Stretching and gradual strengthening program Tennis elbow strap
MEDIAL EPICONDYLITIS
Golfer’s elbow Definition
Inflammation of flexor-pronator’s Less common than lateral epicondylitis
Clinical Symptoms
Medial elbow pain
Physical Examination
Pain with palpation over medial condyle Pain with flexion and pronation of wrist against resistance Rule out ulnar neuropathy Treatment
Same as lateral epicondylitis
CLAVICLE FRACTURE
Most common bone injury Surgery rarely needed Closed treatment gold standard
Clinical symptoms
Fall onto tip of shoulder or struck with object Unable to lift arm due to pain Physical Examination
Inspection ● Obvious deformity or “bump” ● Skin may be “tented” Palpation ● Pain and/ or grinding Range of motion ● Painful and limited
Radiographs
AP
Differential Diagnosis
AC separation Adverse outcomes
Nonunion- rare Malunion- resulting in cosmetic deformity
Treatment
Ice acutely Arm sling 4-6 weeks 3 weeks begin light shoulder exercises, as pain allows Indications for referral
Open fracture- emergency Painful nonunion after 4 months conservative treatment
SCAPULAR FRACTURES
Fractures of glenoid, acromion, shoulder blade, and coracoid process Definition
Results from high energy trauma
Clinical symptoms
Usually occur with serious injuries Pain about back of shoulder
Physical Examination
Inspection ● Abrasions and swelling post. shoulder Palpation ● Tenderness over back of shoulder Radiograph
Plain AP Axillary view- fracture of acromion CT scan- displaced fracture of glenoid
Differential Diagnosis
AC separation Fracture of proximal humerus or ribs Shoulder dislocation
Adverse outcomes
Loss of motion and chronic pain Malunion Suprascapular nerve injury Treatment
Sling immobilization Early ROM usually 1-2 weeks, as tolerated Glenoid fractures displaced 2mm require open fixation
PROXIMAL HUMERUS FRACTURES
Definition
Common in elderly women Most are minimally displaced and treated with sling and early motion Clinical Symptoms
Severe pain, swelling, and discoloration Occur following fall or other injury May report loss of feeling- brachial plexus injury Pale forearm and hand- axillary artery injury
Physical Examination
Inspection ● Swelling and discoloration Palpation ● Pain ● Don’t forget neuro/vascular checks
Radiographs
AP, lateral, and axillary views Adverse outcomes
Nonunion, malunion, and shoulder stiffness
Treatment
Minimally displaced <1 cm ● Sling immobilization 1-2 weeks ● Progressive ROM exercises Displaced >1cm ● Surgical stabilization Referral Decisions
Displaced fracture Neurovascular symptoms
HUMERAL SHAFT FRACTURES
Result from direct blow Majority treated conservatively Close to 100% union rate
Clinical Symptoms
Severe arm pain, swelling, and deformity Radial nerve injury- unable to extend wrist or fingers, loss of sensation over back of hand Physical Examination
Inspection ● Swelling, deformity, and ecchymosis Palpation ● Motion at fracture site ● Neuro/vascular
Radiographic evaluation
AP and lateral CT and MRI not indicated unless pathologic fracture Adverse outcome
Radial nerve injury, stiffness
Treatment
Coaptation splint- 4-6 weeks
Collar and cuff
Exercise wrist and fingers, elbow motion
ROM Indications for referral
Neuro/vascular injury Open fracture Nonunion after 3 months
SUPRACONDYLAR FRACTURES Uncommon, require high level of energy Common in children <15yo rare in adults >20yo Adults, usually involve both condyles, joint involvement common Displaced fx. requires ORIF Nondisplaced tx. with splinting and early motion
Clinical Symptoms
Marked swelling, ecchymosis, deformity, & pain Increased pain with elbow flexion Exam
Evaluate neurovascular status first! Inspect skin for open wound Palpation: effusion & crepitus Deformity visible with displaced fx. Check wrist & shoulder for injury
Diagnostic
AP & lateral plain x-rays If no evidence of fx. check fat pad sign (bleeding into joint) Treatment
Refer!! Displaced fractures: OR Nondisplaced: splinting and early gentle ROM OLECRANON FRACTURES
Results from direct blow Displaced vs. nondisplaced Clinical Symptoms ● Swelling, ecchymosis, & decreased ROM ● Deformity if dislocated ● Numbness 2° to swelling (ulnar n.)
Olecranon Fracture
Exam ● Marked swelling ● Palpation: defect ● ROM limited ● check neuro/vascular status Diagnostic ● AP & lateral x-rays Olecranon Fracture
Treatment ● Nondisplaced: sling 10-14 days, obtain films, check for displacement ● ROM important! ● Displaced: Surgery
ELBOW DISLOCATION
Relationship between ulna and hurmerus Most common dislocation in children Adults 25-30y.o. affected Fall on outstretched hand Other injury possible (radial head fx, neuro/vascular injury) Elbow Dislocation
Clinical Symptoms ● Extreme pain, swelling, inability to bend Exam ● Neuro/vascular important!! Diagnostic ● AP & lateral x-rays Elbow Dislocation
Treatment ● Reduce ASAP! ● Asses neuro/vascular status ● Perform postreduction x-ray ● Posterior splint 10 days ● ROM exercises RADIAL HEAD FRACTURE
Results from fall on outstretched hand Elbow dislocation may be seen Clinical Symptoms ● Pain and swelling about outside of elbow ● Loss of flexion, extension, & rotation about elbow
Radial Head Fracture
Exam ● Unable to pronate or supinate forearm ● Flexion & extension painful and limited ● Palpation produces pain ● Swelling possible Diagnostic ● AP & lateral x-rays (fat pad sign) Radial Head Fracture
Treatment ● Nondisplaced: sling 3 days, gradual ROM ● Displaced: Surgery
RADIAL HEAD SUBLUXATION “Nursemaid’s Elbow”
Common in 2-3 y.o. Occurs from pulling child's forearm when pronated and extended Radial head wedged in annular ligament Child cries and will not use arm Tender on exam, resisted supination Radial Head Subluxation
Treatment ● Reduce: thumb over radial head & supinate forearm ● Snap produced ● Immobilization not necessary MONTEGGIA’S Fracture-Dislocation Ulna fracture with dislocation of radial head Occur with fall on outstretched arm C/O pain, tenderness, and swelling Exam ● Asses neuro/vascular status Monteggia’s
Diagnostic ● AP & lateral of forearm, including wrist and elbows ● Radial head should line up with capitellum Treatment ● Closed reduction and long arm casting ● Surgery: severe displacement
BAD INJURIES
THANK YOU!
QUESTION #1
You suspect a radial head subluxation in a young child. What is the reduction technique?
A) Pronate and flex B) Supinate and extend C) Pronate and extend D) Supinate and flex E) None of the above QUESTION #2
Which nerve do you need to be concerned about with a mid shaft humerus fracture?
A) Median B) Long thoracic C) Ulnar D) Axillary E) Radial
QUESTION #3
What exam finding is seen with a Radial Nerve injury?
A) Weak or absent wrist and finger extension B) Decreased sensation of 5th digit and medial half 4th digit C) Thenar atrophy D) Winged scapula E) Decreased sensation about deltoid