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 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 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 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 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 - 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 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 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 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 ?

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