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.