Medex Objectives Winter 2003

MEDEX Northwest Physician Assistant Objectives Home: http://faculty.washington.edu/alexbert/MEDEX/

Last updated 7 Dec 2003

EM1Orthpedics Disorders of the Upper Extremity

 

1.      Identify the following regarding tendon injuries:

         a.            The most common cause of flexor tendon injuries

         b.            How soon flexor tendons are usually repaired

         c.            Why extensor tendons are the most common type of tendon injury

Zen Seeker Tinitinalli EM Fifth Edition

Anatomy of flexor digitorum superficialis (FDS) and profundus (FDP).

 

TENDON INJURIES

Flexor Tendons

The most common cause of flexor tendon injury is a laceration. Flexor tendon lacerations can be subtle; however, the careful examiner will identify these injuries. A classification system for flexor tendon injuries has been developed based on location, treatment considerations, and prognosis.

 

ZONE I

Extends from the insertion of FDS to the profundus tendon. Patients with these injuries lose flexion at the DIP. Retrieval of the proximal tendon is often difficult. 

 

ZONE II

Involves the portion of the digital canal occupied by both FDS and FDP. The close proximity of these tendons makes it essential for exact repair with minimal operative trauma. This region is often referred to as “no man´s land” because of the frequent poor outcomes prior to the 1960s when improved repair techniques were developed. Lacerations in this zone are common, and partial lacerations are more common then complete.

 

ZONE III

Extends from the distal edge of the carpal tunnel to the proximal edge of the flexor sheath. The lumbrical muscles originate from FDP in this region. Outcomes are generally favorable.

 

ZONE IV

Involves the carpal tunnel and related structures. The area must be explored carefully because so many vital structures go through the carpal tunnel. Isolated injuries are the exception.

 

ZONE V

Involves injuries to tendons proximal to the carpal tunnel. Injuries here tend to be severe and often involve multiple tendons as well as the median or ulnar nerve. It is essential to search for all major structures.

 

A hand surgeon should repair flexor tendon lacerations. Primary repair should occur within 12 h. Secondary repair can occur up to 4 weeks after the injury.

 

Another type of flexor tendon injury is the avulsion of FDP from its insertion in the distal phalanx. This can occur from a grasping motion against high-speed resistance. The patient will be unable to flex the distal phalanx. Prognosis depends on the size of the bony fragment, the length of time from injury to repair, and the blood supply to the tendon.

EChing, Tintinalli, P1757-1758

  1. The most common cause of flexor tendon injuries: laceration.

  2. How soon flexor tendons are usually repaired: a hand surgeon should repair flexor tendon lacerations.  Primary repair should occur within 12 h.  Secondary repair can occur up to 4 weeks after the injury.

  3. Why extensor tendons are the most common type of tendon injury: the superficial nature of the tendons on the dorsum of the hand.

Anonymous

a. Most common cause of flexor tendon injuries- The most common cause is laceration.

b. How soon flexor tendons are usually repaired- Should be repaired by a hand surgeon. Primary repair should occur within 12 hours, any secondary repair within 4 weeks.

c. Why extensor tendons are the most common type of tendon injury- Because of the superficial nature of the tendons on the dorsum of the hand.

Anonymous Tintinalli p 1757:

AprilT Tin. p. 1757        

a. Laceration is the most common cause of flexor injury

b. primary repair should occur wthin 12 h. and secondary repair can occur up to 4 wks. After the injury.

c.extensor tendons are the most common type of tendon injury due to their superficial nature on the dorsum of the hand.

 

2.      Describe the following regarding zone I extensor tendon injury:

         a.            “Mallet finger”

         b.            How the injury commonly occurs

         c.            How the majority of them can be treated

         d.            What happens if a mallet finger is untreated

Zen Seeker Tinitinalli EM Fifth Edition

The extensor mechanism in the finger.

 

Swan-neck deformity.

 

Extensor Tendon

The extensor tendons are the most common site of tendon injuries because of the superficial nature of the tendons on the dorsum of the hand. A classification system has been developed for assessing injury patterns, repair techniques, and rehabilitation.

 

ZONE I

Involves the area over the distal phalanx and DIP. Injury can occur from blunt or sharp trauma. Complete laceration or rupture of the tendon at this level will result in the DIP joint flexed 40°. This injury after blunt trauma is often referred to as “mallet finger,” and it is the most common tendon injury in athletes. This injury has been classified as type I if there is tendon only rupture, type II if there is a small avulsion fracture, and type III if greater than 25 percent of the articular surface is involved. Types I and II can be treated with the DIP joint immobilized in slight hyperextension continuously for 6 to 10 weeks. Some hand surgeons may prefer operative treatment. Controversy exists whether treatment of type III injuries should be conservative or operative. Chronic untreated mallet finger may develop a swan-neck deformity (Fig. 260-10). This is caused when the lateral bands are displaced proximally and dorsally, resulting in increased extension forces on the PIP joint

EChing, Tintinalli, P1758-1759

  1. “Mallet finger”: involves the area over the distal phalanx and DIP.  Injury can occur from blunt or sharp trauma.  Complete laceration or rupture of the tendon at this level will result in the DIP joint flexed 40°.  This injury after blunt trauma is often referred to as “mallet finger,” and it is the most common tendon injury in athletes.

  2. How the injury commonly occurs:  see part a.

 

  1. How the majority of them can be treated: This injury has been classified as type I if there is tendon only rupture, type II if there is a small avulsion fracture, and type III if greater than 25% of the articular surface is involved.  Types I and II can be treated with the DIP joint immobilized in slight hyperextension continuously for 6 to 10 weeks.  Some hand surgeons may prefer operative treatment.  Controversy exists whether treatment of type III injuries should be conservative or operative.

  2. What happens if a mallet finger is untreated: chronic untreated mallet finger may develop a swan-neck deformity.  This is caused when the lateral bands are displaced proximally and dorsally, resulting in increased extension forces on the PIP joint.

Anonymous

a. Mallet finger- Most common tendon injury in athletes. Results after blunt trauma at the DIP joint with complete laceration or rupture of the tendon.

b. How the injury commonly occurs- Blunt or sharp trauma with tendon only rupture.

c. How the majority of them can be treated- With DIP joint immobilized in slight hyperextension for 6-10 weeks continuously. Some surgeons prefer operative treatment. (well of course……..they’re surgeons. Surgeons cut!)

d. What happens if a mallet finger is untreated- It will develop a swan neck deformity. (come look at my finger if you want to see one)

Anonymous Tintinalli p 1758:

AprilT tin. p. 1758

a. mallet finger is an injury which describes a complete lac or ruptue of the tendon at this lecelwill result in a 40 degree flexion of of the DIP joint. Occurs after blunt trauma and is typical in athletes.  Classified as type I if only the tendon is injured and type II if there is an avulsion fx. And a type III if greater than 25% of the articular surface is involved.

c.  Treated with the DIP immobilized in slight hyperextension continuously for 6-10 wks.

d.  If untreated it may develop a swan neck deformity.  This is caused when the lateral bands are displaced proximally and dorsally, resulting in increased extension forces on the PIP joint.

 

3.      Describe the usual mechanism of injury for a PIP dislocation and how they present.  Explain how they are treated.

Zen Seeker Tinitinalli EM Fifth Edition

LIGAMENT AND DISLOCATION INJURIES

Soft tissue injuries to the hand are extremely common. Accurate diagnosis and treatment are important to avoid complications such as joint luxatio, loss of motion, chronic pain, and deformity.

 

PIP

Dislocations of the PIP joint are one of the most common ligamentous injuries of the hand. The mechanism is usually due to axial load and hyperextension. Dorsal dislocation occurs when the volar plate ruptures. Lateral dislocations occur when one of the collateral ligaments ruptures with at least a partial avulsion of the volar plate from the middle phalanx. The digit is usually ulnarly deviated because the radial collateral ligament is six times more likely than the ulnar collateral ligament to rupture. Volar dislocations are rare. Dorsal dislocations are reduced similarly to DIP dorsal dislocations. After reduction, active motion and strength is tested. If testing is normal, the joint should be splinted at 30° flexion for 3 weeks. If the joint is irreducible or there is evidence of complete ligamentous disruption, operative repair is required.

EChing, Tintinalli, P1759, 1761

Dislocation of the PIP joint are one of the most common ligamentous injuries of the hand.  The mechanism is usually due to axial load and hyperextension.  Dorsal dislocation occurs when the volar plate ruptures.  Lateral dislocations occur when on of the collateral ligament ruptures with at least a partial avulsion of the volar plate from the middle phalanx.  The digit is usually ulnarly deviated because the fadial collateral ligament is six times more likely than the ulnar collateral ligament to rupture.  Dorsal dislocations are reduced similarly to DIP dorsal dislocations (longitudinal traction and hyperextension, followed by direct dorsal pressure to the base of the distal phalanx, accomplish reduction after digital nerve block).  After reduction, active motion and strength is tested.  If testing is normal, the joint should be splinted at 30° flexion for 3 weeks.  If the joint is irreducible or there is evidence of complete ligamentous disruption, operative repair is required.  

Anonymous

The mechanism is usually axial load with hyperextension. Dorsal dislocation occurs with volar plate rupture. Treated with longitudinal traction, hyperextension, then direct dorsal pressure to the base of the middle phalanx. Lateral dislocations occur when one of the collateral ligaments rupture, with partial avulsion of the volar plate. The digit will usually be ulnarly deviated because the radial collateral ligament is 6 times more likely to rupture than the ulnar collateral. Operative repair may be indicated secondary to complete ligamentous disruption. Volar dislocations are rare.

Anonymous Tintinalli p 1761.

AprilT Tin. 1759-1760

Usually due to axial load and hyperextension.  Dorsal dislocation occurs when the volar plate ruptures.  Lateral dislocation occurs when one of the collateral ligaments ruptures with at least a partial avulsion of the middle plate from the middle phalanx.  Usually ulnarly deviated.  Longitudinal traction and hyperextension followed by direct dorsal pressure at the base of the distal phalanx.  The digit is tested for ROM and strength  if the tests are nml the digit should be splinted in 30 degrees flexion for 3 wks.  If irreducible- a surgical repair is necessary.

 

4.      Provide two other terms commonly used to describe a ruptured thumb metacarpal- phalangeal ligament and how they are treated.

Zen Seeker Tinitinalli EM Fifth Edition

Thumb MP Collateral Ligament Rupture

Rupture of the ulnar collateral ligament (gamekeeper´s thumb; skier´s thumb) occurs when the mechanism causes radial deviation (abduction) of the MP joint. The tear usually occurs at the insertion into the proximal phalanx. Often significant injury to the dorsal capsule and volar plate occurs. Stress testing of the ulnar collateral ligament is required and should be performed both in full extension and in 30° flexion. More than 40° of radial angulation indicates complete rupture and requires surgical consultation. Repair is best accomplished within 1 week. Radial collateral ligament rupture is not as common, and the mechanism is forced adduction.

EChing, Tintinalli, P1762

Rupture of the ulnar collateral ligament (gamekeeper’s thumb; skier’s thumb) occurs when the mechanism causes radial deviation (abduction) of the MP joint.  Stress testing of the ulnar collateral ligament is required and should be performed both in full extension and in 30° flexion.  More than 40° of radial angulation indicates complete rupture and requires surgical consultation.  Repair is best accomplished within 1 week.  Radial collateral ligament rupture is not as common, and the mechanism is forced adduction.

Anonymous

Gamekeeper’s thumb and Skier’s thumb are alternative terms and require a surgical consultation.

Anonymous Tintinalli p1762.

AprilT Tin. p. 1762

It is called “games keeper’s thumb” and “skiers thumb”.  Stress testing should be performed at 30 degrees and at full extension.  An angulation >40degrees radial deviation usually indicates a complete rupture and requires surgical consultation and if necessary repair should occur within 1 week.

***The book doesn’t state a treatment for a ruptured ligament.  In a dislocation at the MP it states, nerve block, reduction, and pressure directed distally on the base of the prox. Phlnx. with the MC flexed and abducted.  In a dislocation at the CMC the treatment is reduce,  and splint in a thumb spica, then a surgical referral.***

 

5.      Explain how most fractures of the distal phalanx occur, how they are classified, associated injuries, and how they are usually treated.

Zen Seeker Tinitinalli EM Fifth Edition

FRACTURES

Distal Phalanx

Fractures of the distal phalanx account for 15 to 30 percent of all hand fractures. Mechanisms are usually from crush or shearing forces. The fractures can be classified as tuft, shaft, or intraarticular. Tuft fractures can be associated with nail bed lacerations. Fractures at the base may be associated with flexor or extensor tendon involvement. Generally, these fractures are treated as soft tissue injuries with protective splinting.

EChing, Tintinalli, P1762

Mechanisms are usually from crush or shearing forces.  The fractures can be classified as tuft, shaft, or intraarticular.  Tuft fractures can be associated with nail bed lacerations.  Fractures at the base may be associated with flexor or extensor tendon involvement.  Generally, these fractures are treated as soft tissue injuries with protective splinting.

Anonymous

Mechanisms are usually from crush or shearing forces.  The fractures can be classified as tuft, shaft, or intraarticular.  Tuft fractures can be associated with nail bed lacerations.  Fractures at the base may be associated with flexor or extensor tendon involvement.  Generally, these fractures are treated as soft tissue injuries with protective splinting.

Anonymous  ER Med., p. 1762

This type of fracture account for 15-30% of all hand fractures.  Mechanisms are usually from crush or shearing forces.  The fractures can be classified as tuft, shaft, or intra-articular.  Tuft fractures can be associated with nail bed lacerations.  Fractures at the base may be associated with flexor or extensor tendon involvement.  Generally, these fractures are treated as soft tissue injuries with protective splinting.

AprilT p. 1762

These fractures occur in a crushing or shearing force.  They are classified as tuft, shaft, or intraarticular.  A tuft fx is associated with a nail bed laceration.  They are treated as soft tissue injuries and a splint is applied.

 

6.      Describe the treatment for stable fractures of the proximal and middle phalanx and treatment for unstable fractures.

Zen Seeker Tinitinalli EM Fifth Edition

Proximal and Middle Phalanx

The proximal phalanx has no tendinous attachments, therefore fractures frequently have volar angulation from the forces of the extensor and interosseous muscles. The middle phalanx has the FDS insert on the entire volar surface and the extensor tendon insert at the proximal base; therefore, fractures at the base have dorsal angulation and fractures at the neck result in volar angulation. A direct blow mechanism usually causes a transverse or comminuted fracture, while a twisting mechanism will more often result in a spiral fracture. Most often these fractures are stable and nondisplaced and can be treated with early protected motion by buddy taping. Unstable fractures amenable to closed reduction can be splinted from the elbow to the DIP with the wrist at 20° extension and the MP joint in 90° flexion. Midshaft transverse fractures, spiral fractures, and intraarticular fractures often require internal fixation.

Anonymous

Stable:  buddy taping

Unstable:  splint from the elbow to the DIP with the wrist at 20o extension and the MP joint in 90o flexion.  Midshaft transverse fractures, spiral fractures, and intraarticular fractures of ten require internal fixation.

Anonymous ER Med. 1762

The proximal phalanx has no tendinous attachments, therefore fractures frequently have volar angulation from the forces of the extensor and interosseous muscles.  The middle phalanx has the FDS insert on the entire volar surface and the extensor tendon insert at the proximal bas; therefore, fractures at the base have dorsal angulation.  A direct blow mechanism usually causes a transverse or comminuted fracture, while a twisting mechanism will more often result in a spiral fracture.  Most often these fractures are stable and non-displaced and can be treated with early protected motion by buddy taping.  Unstable fractures amenable to closed reduction can be splinted from the elbow to the DIP with the wrist at 20 degrees of extension and the MP joint in 90 degrees of flexion.  Midshaft transverse fractures, spiral fractures, and intraarticular fractures often require internal fixation.

Deb/Tin.,pg.1762

Stable fx=treated with early protected motion by buddy taping/ Unstable fx=those amenable to closed reduction can be splinted from the elbow to the DIP with the wrist at 20 degrees extension and the MP joint in 90 degree flexion.

Sarra/tin1762 Stable fractures-are nondisplaced and can be treated with early protected motion by buddy taping.

Unstable fractures-amenable to close reduction can be splinted from the elbow to the DIP with the wrist at 20 degree extension and the MP joint in 90degree flexion.  Midshaft transverse fractures, spiral fractures, and intraarticular fractures often require internal fixation.

 

7.      Describe a “boxer’s” fracture, how they occur, and how treated.

Zen Seeker Tinitinalli EM Fifth Edition

Metacarpal (II-V) Fractures

The second and third metacarpals are relatively immobile, and fractures require anatomic reduction. The fourth and fifth metacarpals have 15 to 20° AP motion, which allows for some compensation. Metacarpal fractures are categorized as head, neck, shaft, or base fractures.

 

 

NECK

Fractures of the metacarpal neck are usually due to a direct impaction force. A fracture of the fifth metacarpal neck is often referred to as a boxer´s fracture. These fractures are usually unstable with volar angulation. Angulation of less than 20° in the fourth and 40° in the fifth metacarpal will not result in functional impairment. If greater angulation in these metacarpals occur, reduction should be attempted. In the second and third metacarpal, angulation of <15° is acceptable. These fractures should be splinted with the wrist in 20° extension and the MP flexed at 90°. Fractures of the second or third metacarpal that are significantly displaced or angulated require anatomic reduction and surgical fixation.

Anonymous  Tintinalli, Pg. 1763

Description:  Fracture of the neck of the fifth metacarpal.

Occurrence:  Usually due to a direct impaction force.

Treatment:  If angulation is < 40%: splint with the wrist in 20 degree extension ant the MP flexed at 90

degrees.  Angulations of > 40% require anatomic reduction and surgical fixation.

Anonymous  ER Med., p. 1762 & Reider, p.104-105

Fractures of the metacarpal neck are usually due to a direct impaction force.  A fracture of the fifth metacarpal neck is often referred to as a boxer’s fracture.  Such fractures often produce a dropped knuckle; the metacarpal head is depressed and its normal prominence disappears. These fractures are usually unstable with volar angulation.  Angulation of less than 20 degrees in the fourth and 40 degrees in the fifth metacarpal will not result in functional impairment.  If greater angulation in these metacarpals occur, reduction should be attempted.  In the second and third metacarpal, angulation of <15 degrees is acceptable.  Treatment – These fractures should be splinted with the wrist in 20 degree extension and the MP flexed at 90 degrees.  Fractures of the second or third metacarpal that are significantly displaced or angulated require anatomic reduction and surgical fixation.

Deb/Tin.,pg.1762

Fx of the fifth metacarpal neck. They are usually unstable with volar angulation.  Anulation of less than 20 degrees in the 4th and 40 degrees in the 5th metacarpal will not result in functional impairment, but if greater angulation in these metacarpals occur, reduction should be attempted.  These fx are due to direct impaction force/ Tx=splinted with the wrist in 20 degree extension and the MP flexed at 90 degrees.  Fx of the 2nd or 3rd metacarpal that are significantly displaced or angulated require anatomic reduction and surgical fixation.

Sarra/Tin 1762 Fractures of the metacarpal neck are usually due to a direct force.  A fracture of the fifth metacarpal neck is often referred to as a boxer’s fracture.

 

8.      Describe the following regarding subluxation of the radial head in children:

         a.            Another name by which this is commonly known

         b.            Come age in which it is seen

         c.            Mechanism of injury

         d.            How the child presents

         e.            How it is reduced

Zen Seeker Tinitinalli EM Fifth Edition

Subluxation of the Radial Head (Nursemaid´s Elbow)

Subluxation of the radial head is common among preschool children. The peak age is between 1 and 4 years, and it is usually not seen in children older than 7 years. The mechanism of injury is sudden traction on the hand with the elbow extended and the forearm pronated. Anatomically, during forceful traction, some fibers of the annular ligament, which encircles the radial neck, slip and become trapped between the radial head and capitellum. In the child up to age 5, the radial head is about the same size as the neck. After age 7, the size of the radial head is larger than the neck and subluxation does not occur.

 

Clinically the child sits comfortably with the parent, may even be playful, but does not use the injured arm. The arm is held in slight flexion and pronation. Supination is painful, and any effort to move the arm is resisted, although movement is free. The neurovascular examination is normal.

 

It is important to elicit the history of traction on the hand; the act may have been unrecognized by the parent or playmate or the history withheld because of a feeling of guilt or fear. Recently, an atypical history has been reported to occur in as many as 49 percent of radial head subluxations. Any child not using an arm that is flexed and pronated and without signs of trauma should be considered to have a radial head subluxation unless the history strongly suggests another diagnosis. Radiographs are unnecessary unless another diagnosis is being considered or if reduction is not accomplished.

 

Reduction is carried out by firmly placing the thumb over the radial head while the other hand is placed on the wrist. The forearm is fully supinated, and if a “click” is not felt, the elbow is flexed. This maneuver may be repeated if the initial attempt does not reduce the subluxation. Alternatively, the elbow may be extended. Both maneuvers are reported to be equally effective. Reduction as evidenced by a click is highly predictive and will result in relief from pain and, shortly thereafter, use of the affected arm.

 

After the first subluxation, no immobilization is required. For recurrent subluxations, however, orthopedic referral is needed. The patient´s arm should be immobilized in a sling; some recommend a long-arm cast. Teach et al found a recurrence rate of 23.7 percent in either arm and 19.4 percent in the ipsilateral arm. Children 24 months or younger had a relative risk of 2.6 for recurrence when compared to children older than 24 months.

Anonymous Tintinalli, Pg.  1763-1764.

a. Another name by which this is commonly known:  Nursemaid’s elbow

b. Common age in which it is seen:  Peak – 1 to 4 yrs, usually not seen after 7 yrs.

c. Mechanism of injury:  Sudden traction on the hand with the elbow extended and the forearm pronated.

d. How the child presents:  Child usually sits comfortably with the parent, may even be playful, but does not use the injured arm.  The arm is held in slight flexion and pronation.

How it is reduced:  Firmly place the thumb over the radial head while the other hand is

placed on the wrist.  The forearm is fully supinated, and if a “click” is not felt, the elbow is flexed.  This maneuver may be repeated if the initial attempt does not reduce the subluxation.  Alternatively, the elbow may be extended.  Both manuevers are reported to be equally effective.  Reduction as evidenced by a click is highly predictive and will result in relief from pain and, shortly thereafter, use of the affected arm.

Anonymous ER Med., p.1763-1765

Deb/Tin.,pg.1763-1764

A.  AKA=Nursemaids Elbow

B.  Peak age is between 1 and 4 years and usually not seen in children older than 7yo

C.  Mech. Of injury is sudden traction on the hand with the elbow extended and the forearm pronated.

D.  Clinically, child sits comfortably with parent, may even be playful, but does not use the injured arm.  Arm is held in slight flexion and pronation.  Supination is painful, and any effort to move the arm is resisted, although movement is free. Neurovascular exam is normal

E.  Reduction is carried out by firmly placing the thumb over the radial head while the other hand is placed on the wrist.  The forearm is fully supinated, and if a “click” is not felt, the elbow is flexed.  May repeat maneuver if initial attempt doesn’t reduce it.

Sarra/Tin 1763

  1. Another name by which this is commonly known-nursemaid’s elbow

  2. Come age in which it is seen-peek age between 1 and 4 yrs. and is not usually seen in children older than 7.

  3. Mechanism of injury-sudden traction on the hand with the elbow extended and the forearm pronated.

  4. How the child presents-child sits comfortably with parent, may even be playful, but doesn’t use the injured arm.  Arm is held in slightly flexion and pronation.  Supination is painful, and any effort to move the arm is resisted, although movement is free.  Neurovascular exam is normal.

  5. How it is reduced-carried out by firmly placing the thumb over the radial head while the other hand is placed on the wrist.  The forearm is fully supinated, and if a “click” is not felt, the elbow is flexed.  May repeat maneuver if initial attempt doesn’t reduce it.

 

9.      Describe supracondylar fractures regarding the following:

         a.            Age group in which they most commonly occur

         b.            How most of them are displaced

         c.            An important sign seen on radiographs (see Tintinalli Fig. 261-5)

Zen Seeker Tinitinalli EM Fifth Edition

Anterior and posterior fat pad signs.

 

Supracondylar Fractures

These extraarticular fractures occur most commonly in children. Ninety-five percent are displaced posteriorly as a result of an extension force. When the mechanism of injury is due to a flexion force, the much less common anterior displacement occurs. There can also be various degrees of abduction, adduction, and rotation of the distal fragment.

 

EXTENSION-TYPE FRACTURES

In an extension-type fracture, the patient will have significant swelling and tenderness at the elbow. The olecranon is prominent, and there is a depression proximally over the area of the triceps muscle. This appearance may be easily mistaken for a posterior elbow dislocation.

 

Radiographs may reveal a fat-pad sign in undisplaced fractures (Fig. 261-5). This is due to visualization of fat from the olecranon fossa (posterior fat pad) as it is displaced by the hemarthrosis. This may also occur anteriorly (anterior fat pad), although this is a less reliable sign. In some undisplaced fractures, the fracture line may not be seen, with the fat-pad sign being the only evidence of injury. Treatment should be initiated as though a fracture were identified, with splint immobilization and orthopedic consultation. In displaced fractures, the anteroposterior radiograph usually reveals a transverse fracture line. More severely displaced fractures may show medial or lateral displacement or rotation along the axis of the humerus (Fig. 261-6). The lateral radiograph will reveal the fracture line extending obliquely from posterior proximal to anterior distal. The distal fragment will be displaced proximally and posteriorly.

 

Treatment of undisplaced fractures consists of plaster immobilization. Displaced fractures have the best results when reduced by closed methods followed by traction or pin fixation. Patients with displaced fractures or severe swelling should be admitted for observation of neurovascular status.

 

FLEXION-TYPE FRACTURES

Flexion-type fractures occur in fewer than 5 percent of supracondylar fractures. The mechanism is direct anterior force against a flexed elbow. This results in anterior displacement of the distal fragment. Since the mechanism is direct force, these fractures are often open.

 

Radiographs reveal an oblique fracture from anterior proximal to posterior distal. The distal fragment is anterior to the humerus.

 

Management consists of closed reduction and plaster immobilization or surgery if reduction cannot be maintained by closed methods.

Anonymous

a.   Age group in which they most commonly occur:  Most common in children (no age given).

How most of them are displaced:  95% displaced posteriorly as a result of extension force.

An important sign seen on radiographs (see Fig. 261-5):  May reveal a fat-pad sign in undisplaced fractures.

Anonymous ER Med., p. 1765-66

•        Age group in which they most commonly occur – These extra-articular fractures occur most commonly in children

•        How most of them are displaced – 95% are displaced posteriorly as a result of an extension force.  When the mechanism of injury is due to a flexion force, the much less common anterior displacement occurs.  There can also be various degrees of abduction, adduction, and rotation of the distal fragment

•        An important sign seen on radiographs (see figure 261-5) – Radiographs may reveal a fat-pad sign in undisplaced fractures.  This is due to visualization of fat from the olecranon fossa (posterior fat pad) as it is displaced by the hemarthrosis.  This may also occur anteriorly (anterior fat pad), although this is a less reliable sign.  In some undisplaced fractures, the fracture line may not be seen, with the fat-pad sign being the only evidence of injury

•        Treatment – Treatment should be initiated as though a fracture were identified, with splint immobilization and orthopedic consultation.  Treatment of undisplaced fractures consists of plaster immobilization

Deb/Tin.,pg.1765-1766

A.  Most commonly in children

B.  95% are displaced posteriorly as result of an extension force.

C.  Radiographs may reveal a fat-pad sign in undisplaced fx’s.  This is due to visualization of fat from the olecranon fossa (posterior fat pad) as it is displaced by the hemarthrosis.

Sarra/ Tin1765

  1. Age group in which they most commonly occur-commonly in children-most common in children.

  2. How most of them are displaced-a result of an extension force-95%are displaced posteriorly as result of an extension force.

  3. An important sign seen on radiographs (see Tintinalli Fig. 261-5)-flat pad-radiographs may reveal a fat-pad sign in undisplaced fx’s.  This is d/t visulization of fat from the olecronon fossa.

 

10.    Describe radial head fractures regarding the following:

         a.            Usual mechanism of injury

         b.            An important sign seen on radiographs

         c.            How they are treated

Zen Seeker Tinitinalli EM Fifth Edition

Radial Head Fractures

Radial head fracture is the most commonly encountered fracture about the elbow. The mechanism of injury is a fall on the outstretched hand with the force transmitted along the radius to the radial head, where it impacts on the capitellum. The result is a fracture of the weaker radial head or neck. An alternative mechanism is direct trauma to the lateral aspect of the elbow directly over the radial head. The patient complains of pain in the elbow, and examination reveals swelling and tenderness laterally. Rotation of the forearm with firm pressure over the radial head will elicit pain. Careful examination of the wrist and forearm for tenderness must be performed to determine whether there has been injury to the distal radioulnar ligaments or to the interosseus membrane. The latter injuries result in radioulnar dissociation (Essex-Lopresti) and proximal migration of the radius if the radial head is excised. Anteroposterior and lateral radiographs are generally sufficient, but occasionally radiocapitellar views are required. A fat-pad sign in a patient with an appropriate mechanism of injury is sufficient to make a presumptive diagnosis of a radial head fracture regardless of whether or not the fracture is visualized (Fig. 261-5).

 

Undisplaced and minimally displaced fractures are treated with sling immobilization and early ROM. Such patients have excellent results with little morbidity. All other fractures should be referred acutely to an orthopedist, since treatment varies from early motion to radial head excision and prosthetic radial head implantation.

Anonymous Tintinalli, pg. 1768

a. Usual mechanism of injury is a fall on the outstretched hand (FOOSH) with the force transmitted along the radius to the radial head, where it impacts the capitellum.  The result is a fracture of the weaker radial head or neck.

b. An important sign seen on radiographs.  A fat-pad sign in a patient with an appropriate mechanism of injury is sufficient to make a presumptive diagnosis of a radial head fracture regardless of whether or not the fracture is visualized.

c. How they are treated.  Undisplaced and minimally displaced fractures are treated with sling immobilization and early ROM.  Such patients have excellent results with little morbidity.  All other fractures should be referred to an othopedist, since treatment varies from early motion to radial head excision and prosthetic radial head implantation.

Anonymous ER Med., p.1768

Deb/Tin.,1768

A.     Mech. Of injury is a fall on the outstretched hand with the force transmitted along the radius to the radial head, where it impacts on the capitellum

B.       A fat-pad sign in a pt with an appropriate mech. Of injury is sufficient to make a presumptive diagnosis of radial head fx regardless of whether or not the fx is visualized.

C.       Undisplaced and minimally displaced fx’s are treated with sling immobilization and early ROM.  All other fx’s should be referred acutely to an orthopedist, since tx varies from early motion to radial head excision and prosthetic radial head implantation.

Sarra/Tin 1768

  1. Usual mechanism of injury-a fall on the outstretched hand with the force transmitted along the radius to the radial head where it impacts the capitellum.  The result is a fracture of the weaker radial head or neck.  An alternative mechanism is direct trauma to the lateral aspect of the elbow directly over the radial head.

  2. An important sign seen on radiographs-A fat pad sing in a patient with an appropriate mechanism of injury is sufficient to make a presumptive diagnosis of a radial head fracture regardless of weather or not the fracture is visualized.   

  3. How they are treated-undisplaced and minimally displaced fractures are treated with sling immobilization and early ROM.  Such patients have excellent results with little morbidity.  All other fractures should be referred acutely to an orthopedist, since treatment varies from early motion to radial head excision and prosthetic radial head implantation.   

 

11.    Discuss lateral epicondylitis as to how it presents and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

EPICONDYLITIS

Lateral Epicondylitis

In this condition, also known as tennis elbow, pain is noted at the origin of extensors of the distal arm. While it occurs from racquet sports and repetitive manual labor, it may also occur spontaneously. When it is from racquet sports, a faulty backhand stroke is usually to blame. The extensor mass, especially the deep extensor carpi radialis brevis, rubs and rolls over the lateral epicondyle and radial head. In addition, there is pulling on the extensor origin, resulting in microtears.

 

Pain is increased over the lateral epicondyle with pronation of the forearm and concomitant dorsiflexion of the wrist against resistance. Lifting a chair with the affected hand in pronation should also exacerbate symptoms. Picking up a full cup of liquid also reproduces the pain.

 

Treatment includes avoidance of the painful activity and use of NSAIDs. Utilizing supination in daily grasping activities will aid in rest of the area. In the case of racquet sports, instruction in a quality backhand should be sought after the acute injury heals. Those who use a two-handed backhand are rarely afflicted. Orthopedic referral is advised for further evaluation and treatment.

Anonymous Tintinalli, pgs. 1768-9

-In this condition, also known as tennis elbow, pain is noted at the origin of extensors of the distal arm.  Pain is increased over the lateral epicondyle with pronation of the forearm and concomitant dorsiflexion of the wrist against resistance.  Lifting a chair with the affected hand in pronation should also exacerbate symptoms.  Picking up a full cup of liquid also reproduces the pain.

-Treatment includes avoidance of the painful activity and use of NSAIDs.  Utilizing supination in daily grasping activities will aid in rest of the area.  Othopedic referral is advised for further evaluation and treatment.

Anonymous  ER Med., p.1768-69

This condition is also known as tennis elbow.  It will present with pain noted at the origin of extensors of the distal arm.  While it occurs with some racquet sports and repetitive manual labor, it may also occur spontaneously.  Pain is increased over the lateral epicondyle with ponatation of the forearm and concomitant dorsiflexion of the wrist against resistance.  Lifting  a chair with the affected hand in pronation should also exacerbate origin, resulting in Micortears.   Treatment includes avoidance of the painful activity and use of NSAISA.  Utilizing supination in daily grasping activities will aid in rest of the area.  In the case of racquet sports, instruction in a quality backhand should be sought after the acute injury heals.  Those who use a  two-handed backhand are rarely afflicted.  Orthopaedic referral is advised for further evaluation and treatment.

AnaughtyMouse

            Aka tennis elbow – Presents with pain over lateral epicondyle with pronation of forearm and concomitant dorsiflexion of the wrist against resistance. Picking up a full glass of liquid reproduces the pain. Treatment is avoidance of painful activity and NSAIDS. Use supination in daily grasping activities allows the area to rest

 

12.    Describe the clinical features of proximal biceps rupture and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

Proximal Biceps Rupture (Long Head)

CLINICAL FEATURES

Patients with acute ruptures usually relate a long history of tendinitis. Symptoms include anterior shoulder pain and an audible “pop” or “snap” during strenuous activity. Examination demonstrates tenderness, swelling, and crepitus over the bicipital groove. Flexion of the elbow elicits pain. Weakness in flexion and supination is minimal (10 to 20 percent) because of the function of the short head of the biceps. Ecchymoses and a visible gap in the muscle, caused by distal migration of the muscle mass with resulting egg-shaped swelling, are usually obvious. Slow contraction of the biceps makes this deformity more prominent. Rupture usually occurs in the proximal one- third of the tendon at the top of the bicipital groove. Occasionally this injury involves an avulsed fragment of bone. Radiographs are necessary to rule out an avulsion fracture.

 

DIFFERENTIAL DIAGNOSIS

The differential diagnosis includes biceps tendinitis, subluxation- dislocation, rotator cuff disease, impingement syndrome, partial rupture, and osteochondral fracture.

 

TREATMENT

Treatment is surgical repair of the tendon in the young athletic patient. The older patient can be treated conservatively with immobilization, followed by early and progressive mobilization and strengthening exercises as soon as pain subsides. Orthopedic consultation should be obtained in the emergency department. Admission is required only for surgical repair. Emergency department treatment consists of ice and analgesia. Outpatient treatment requires immobilization in a sling, analgesia, and intermittent application of ice for 48 to 72 h

Anonymous Tintinalli, pg. 1769

-Patients with acute ruptures usually relate a long history of tendinitis.  Symptoms include anterior shoulder pain and an audible “pop” or “snap” during strenuous activity.  Examination demonstrates tenderness, swelling, and crepitus over the bicipital groove.  Flexion of the elbow elicits pain.  Weakness in flexion and supination is minimal (10-20%) because of the function of the short head of the biceps.  Eccymoses and visible gap in the muscle, caused by distal migration of the muscle mass with resulting egg-shaped swelling, are usually obvious.  Slow contraction of the biceps makes this deformity more prominent.  Rupture usually occurs in the proximal one-third of the tendon at the top of the bicipital groove.  Occasionally this injury involves an avulsed fragment of bone.  Radiographs are necessary to rule out an avulsion fracture.

-Treatment is surgical repair of the tendon in the young athletic patient.  The older patient can be treated conservatively with immobilization, followed by early and progressive mobilization and strengthening exercises as soon as pain subsides.  Othopedic consultation should be obtained in the ED.  Admission is required only for surgical repair.  ED treatment consists of ice and analgesia.  Outpatient treatment requires immobilization in a sling, analgesia, and intermittent application of ice for 48-72 hours.

Anonymous ER Med., p. 1769

Patients with acute ruptures usually relate a long history of tendonitis.  Symptoms include anterior shoulder pain and an audible “op” or “snap” during strenuous activity.  Examination demonstrates tenderness, swelling, and crepitus over the bicipital groove.  Flexion of the elbow elicits pain.  Weakness in flexion and supination is minimal (10-20%) because of the function of the short head of the biceps.  Ecchymoses and a visible gap in the muscle, caused by distal migration of the muscle mass with resulting egg-shaped swelling, are usually obvious.  Slow contraction of the biceps makes this deformity more prominent.  Rupture usually occurs in the proximal one-third of the tendon at the top of the bicipital groove.  Occasionally this injury involves an avulsed fragment of bone.  Radiographs are necessary to rule out an avulsion fracture.  Treatment:  surgical repair of the tendon in younger pt; older pt can be treated with immobilizer & PT; ED tx consists of ice, analgesia, sling.

AnaughtyMouse

            Usually long history of tendonitis – anterior shoulder pain with an audible “pop” or “snap”. Tender swollen crepitus over bicipital groove. Flexion of elbow causes pain.  Echymoses and a visible gap in the muscle. Slow contraction of the bicep makes the deformity prominent. Rupture usually occurs in the proximal 1/3 of the tendon. X-ray needed to rule out an avulsion.  Treatment is surgical repair in young athlete. Older patient may immobilize. Orthoconsult. E.D. treatment ice and NSAID.

 

13.    Describe the usual mechanism of fractures to both the radius and ulna and how they are usually treated.  

Zen Seeker Tinitinalli EM Fifth Edition

Fractures of Both Radius and Ulna

A great amount of force is necessary to fracture both the radius and ulna. This injury occurs most often from vehicular trauma, falls from a height, or a direct blow to the forearm. The magnitude of the force determines the type of injury. A moderate force produces transverse or mildly oblique fractures. Comminuted and segmental fractures are produced by a high- impact force. As one might expect, these fractures are often displaced. Open fractures of the radius and ulna are second only to tibia fractures because of the subcutaneous location of the entire ulna and the distal portion of the radius.

 

Nondisplaced fractures of both bones are exceedingly rare because the force necessary to produce the injury is also sufficient to displace it. However, in this event, a long-arm cast is applied, and frequent reevaluation for potential displacement is necessary.

 

Displacement of both bones is generally the rule. Examination reveals swelling, deformity, and tenderness of the forearm. Careful assessment of the neurovascular status is imperative. Nerve injuries can be seen with severe open fractures but fortunately are uncommon with most closed injuries. Because of the excellent collateral circulation of the forearm, vascular compromise is generally not a major problem if either the radial or ulnar circulation is intact.

 

The fractures are clearly visible on the radiographs. Angulation and longitudinal alignment are easily evaluated, but changes in rotational alignment may be subtle. A rough estimate of rotational alignment can be made by noting the normal orientation of various bony prominences of these bones. On the anteroposterior radiograph, the radial styloid and radial (bicipital) tuberosity normally point in opposite directions, whereas the ulnar styloid and coronoid process do so on the lateral view. A change in this arrangement suggests rotation malalignment. Since these bones are also oblong rather than circular in their cross-sectional appearance, a sudden change in the bone´s width at the fracture site is another clue to a rotational deformity.

 

Although there are some reports of adequate reduction using closed techniques, the potential for these injuries to subsequently displace, in spite of cast immobilization, makes this alternative unpredictable. An exception is the injury in a child. A child´s ability to remodel bone and compensate for some malalignment makes closed reduction possible. Otherwise, these injuries invariably require open reduction and internal fixation, most commonly with compression plating and screws. The use of external fixation may be necessary in situations where infection is possible, such as severe open fractures, comminution, or bone loss. Internal fixation is delayed until the risk of infection is diminished. 

 

Potential complications include reduced ability to supinate and pronate, osteomyelitis, nonunion, malunion, neurovascular injury, and compartment syndrome. Recognizing the development of a compartment syndrome is particularly important to prevent debilitating ischemic contractures of the forearm. The diagnostic findings are palpable induration of the area, pain with passive movement of the fingers, and pain that appears to be disproportionate to the physical findings. The presence of a palpable pulse does not exclude the diagnosis of compartment syndrome. Alterations in sensation and the pulse are late findings. Direct measurements of elevated compartment pressures confirm the diagnosis.

Anonymous

This injury occurs most often from vehicular trauma, falls from a height or a direct blow to the forearm. Except in children (where closed reduction may be an option), these fractures are treated with open reduction and internal fixation, most commonly with compression plates and screws. External fixation may be necessary in cases where infection is possible. Tintinalli, p. 1771

Anonymous ER Med., p. 1771

•        Mechanism:  A great amount of force is necessary to fracture both the radius and ulna.  This injury occurs most often from vehicular trauma, falls from a height, or a direct blow to the forearm.  The magnitude of the force determines the type of injury.  A moderate force produces transverse or mildly oblique fractures.  Comminuted and segmental fractures are produced by a high-impact force.  As one might expect, these fractures are often displaced.  Open fractures of the radius and ulna are second only to tibia fractures because of the subcutaneous location of the entire ulna and the distal portion of the radius.  

•        Treatment:  Although there are some reports of adequate reduction using closed techniques, the potential for these injuries to subsequently displace, in spite of cast immobilization, makes this alternative unpredictable.  An exception is the injury in a child.  A child’s ability to remodel bone and compensate for some malalignment makes closed reduction possible.  Otherwise, these injuries invariably require open reduction and internal fixation, most commonly with compression plating and screws.  The use of external fixation may be necessary in situations where infection is possible, such as severe open fractures, comminution, or bone loss.  Internal fixation is delayed until the risk of infection is diminished.

AnaughtyMouse

            Great amount of force necessary to fracture both bones. Usually fall from heights or direct blow to the forearm.  Bones often displaced due to high impact force. Open fractures occur due to subcutaneous location. Displacement of both bones is usally the rule. Swelling, deformity, and tenderness of forearm. Needs neurovascular assessment – nerve damage often occurs with open fractures. Treatment orthoconsult.

 

14.    Identify the location of the scapholunate ligament and describe the usual mechanism by which it is injured.  Describe how it is identified on an x-ray and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

A. Key elements on a normal PA view. (1) The carpal bones form three smooth arcs; (2) carpal bones are separated by a 1- to 2- mm space; (3) scaphoid has an elongated shape; (4) radius has an ulnar inclination of 15 to 25 degrees; (5) radial styloid projects 8 to 18 mm (average 13 mm). Half the lunate articulates with the radius, and the ulna and adjacent radial surface are equal in length (neutral ulnar variance). B. Bony anatomy. (With permission from Chin HW: Injuries of the wrist, in Hart RG, Rittenberry JJ, Uehara DT (eds): Handbook of Orthopaedic Emergencies. Philadelphia, Lippincott-Raven, 1998.)

 

Key elements on a normal lateral view. (1) three Cs sign; (2) capitolunate angle is <10 to 20 degrees; (3) scapholunate angle is <60 degrees; (4) radial volar tilt of 10 to 15 degrees. (With permission from Chin HW: Injuries of the wrist, in Hart RG, Rittenberry JJ, Uehara DT (eds): Handbook of Orthopaedic Emergencies. Philadelphia, Lippincott-Raven, 1998.)

 

A. Normal wrist. Axis of the radius (R), lunate (L), and capitate (C) are colinear. The capitolunate angle (CL) is less than 20 degrees and the scapholunate angle (SL) is between 30 and 60 degrees. B. Dorsal intercalated segment instability (DISI). The lunate tilts dorsal and slides palmar, increasing the capitolunate angle. The scaphoid tilts more palmar and increases the scapholunate angle. The axes of the radius, lunate, and capitate take on a zigzag pattern (dark line). C. Volar intercalated segment instability (VISI). The lunate tilts palmar and the capitolunate increases, but the scapholunate angle is maintained. The zigzag pattern is in the opposite direction.

 

Scapholunate dissociation with accompanying rotatory subluxation of the scaphoid. The scaphoid and lunate are separated by a gap of more than 3 mm (arrowhead) and the scaphoid appears shorter from rotation with a dense ring (cortical ring sign, arrow).

 

LIGAMENTOUS INJURIES

The lunate is located in the middle of the wrist, so it is not surprising that the majority of ligamentous injuries are centered on the lunate. These injuries usually result from forceful dorsiflexion of the wrist, most often from a fall on the outstretched hand. The various injuries occur sequentially depending on the degree of force, and range from isolated tears to perilunate and lunate dislocations.

 

Scapholunate Ligament Instability

The scapholunate ligament is the intrinsic ligament that binds the scaphoid and lunate. Because the scaphoid bridges the proximal and distal carpal rows, it is not surprising that the scapholunate ligament also has a greater propensity for injury. It is the most common ligament injury of the wrist. Injury most often is from a fall on the outstretched hand with impact on the thenar eminence. These individuals will complain of pain and swelling on the radial side of the wrist and sometimes a clicking sensation with wrist movement. Examination reveals localized tenderness on the dorsum of the wrist in the area immediately distal to Lister´s tubercle. Ballottement of the scaphoid may also produce pain in this area.

 

This injury is often referenced to the various radiographic appearances it may take. There are three different radiographic signs that may occur separately or in combination with one another. Scapholunate dissociation is a widening of the scapholunate joint space on the PA projection of more than 3 mm (Fig. 262-4). This has been called the “Terry Thomas” sign, named after a British comedian with notable dental diastema between his upper front incisors. If it is not apparent on routine views, a grip-compression stress view or motion study may be necessary to demonstrate the abnormal gap. These maneuvers are particularly helpful in identifying an incomplete tear of the ligament. Rotatory subluxation of the scaphoid is another abnormality that often accompanies scapholunate dissociation. A torn scapholunate ligament can cause the scaphoid to tilt more palmar and increase the scapholunate angle to greater than 60 degrees on the lateral view (normal angle is 30 to 60 degrees). On the PA view, the scaphoid tilts toward the observer. The scaphoid appears shorter as it is viewed more on its end and the circular cortex of the bone becomes visible like a ring (cortical ring sign; see Fig. 262-4). A third possible radiographic abnormality is a carpal instability pattern, Dorsal intercalated segment instability (DISI). The normal flexed posture of the scaphoid produces a flexion torque on the lunate that is counterbalanced by an extension torque from the triquetrum. When the scapholunate ligament is torn, this balance is disrupted. The lunate tilts dorsal from the unopposed extension torque from the triquetrum, while the scaphoid tilts more palmar (rotatory subluxation of the scaphoid) because it has lost support from the lunate. The dorsal tilt of the lunate also causes a slight flexion tilt of the capitate. In the lateral view, the normal colinear arrangement of the axes of the radius, lunate, and capitate are replaced by a characteristic zigzag pattern. Both the scapholunate and capitolunate angles are increased. The concept of the proximal carpal row being the middle-link or “intercalated segment” in this system, combined with the lunate´s pathological dorsal tilt and zigzag pattern, is how this abnormality came to be named dorsal intercalated segment instability, DISI (see Fig. 262-3 B).

 

These injuries are treated acutely with a radial gutter splint or posterior mold. Appropriate orthopedic referral is necessary because these injuries require either closed reduction and pinning or, more often, open reduction and surgical repair of the ligament. Early severe degenerative arthritis is a possible sequelae if left untreated.

Anonymous Tintinalli, p. 1776

Location- the scapholunate ligament is the intrinsic ligament that binds the scaphoid and lunate.

Mechanism of injury- most often from a fall on the outstretched hand with impact on the thenar eminence.

X-ray ID- 3 signs- “Terry Thomas” sign is scapholunate dissociation, a widening of the scapholunate joint space on the PA projection of more than 3 mm. Rotary subluxation of the scaphoid is another sign. On the PA view, the scaphoid tilts toward the observer. A third sign is a carpal instability pattern, dorsal intercalated segment instability (DISI). The lunate tilts dorsal from the unopposed extension torque from the triquetrum, while the scaphoid tilts more palmar because it has lost support from the lunate. In the lateral view, the normal collinear arrangement of the axes of the radius, lunate and capitate are replaced by a characteristic zigzag pattern.

Tx- acutely with a radial gutter splint or posterior mold. Orthopedic referral is needed because these injuries require either closed reduction and pinning or, more often, open reduction and surgical repair of the ligament.

Anonymous ER Med., p.  1776

•        Where:  The scapholunate ligament is the intrinsic ligament that binds the scaphoid and the lunate.  Because the scaphoid bridges the proximal and distal carpal rows, it is not surprising that the schapolunate ligament also has a greater propensity for injury.  It is the most common ligament injury of the wrist.  

•        Mechanisms:  Injury most often is from a fall on the outstretched hand with impact on the thenar eminence.   These individuals will complain of pain and swelling on the radial side of the wrist and sometimes a clicking sensation with wrist movement.  Exam reveals localized tenderness on the dorsum of the wrist in the area immediately distal to Lister’s tubercle.  Ballottement of the scaphoid may also produce pain in this area.  

•        X-Ray:  There are three different radiographic signs that may occur separately or in combination with one another.  Scapholunate dissociation is a widening of the scapholunate joint space on the PA projection of more than 3mm, this is called the “Terry Thomas” sign.  If it is not apparent on routine views, a grip-compression stress view or motion study may be necessary to demonstrate the abnormal gap.  A torn scapholunate ligament can cause the scaphoid to tilt more palmar and increase the scapholunate angle to greater than 60 degrees on the lateral view (normal is 30-60 degrees).  On the PA view, the scaphoid tilts toward the observer.  The scaphoid appears shorter as it is viewed more on its end and the circular cortex of the bones becomes visible like a ring (cortical ring).  A third possible radiographic abnormality is a carpal instability pattern, dorsal intercalated segment instability (DISI).  The normal flexed posture of the scaphoid produces a flexion torque on the lunate that is counterbalanced by an extension torque from the triquetrum.  When the scapholunate ligament is torn, this balance is disrupted.  The lunate tilts dorsal from the unopposed extension torque from the triquetrum, while the scaphoid tilts more palmar because it has lost support from the lunate.  The dorsal tilt of the lunate also causes a slight flexion tilt of the capitate.  In the lateral view, the normal colinear arrangement of the axes of the radius, lunate, and capitate are replaced by a characteristic zigzag pattern.  

•        Treatment:  These injuries are treated acutely with a radial gutter splint or posterior mold.  Appropriate orthopaedic referral is necessary because these injuries require either closed reduction and pinning or more often open reduction and surgical repair of the ligament.  Early severe degenerative arthritis is a possible sequelae if left untreated.

AnaughtyMouse

         Ligament binds the scaphoid and lunate bones. Greater chance of injury as the scaphoid bridges the carpals rows. Injury usually occurs from falling an outstretched arm. Identified on x-rays by 3 means:

1.      PA view showing a 3mm gap

2.      Grip-compression stress view

3.      DISI-dorsal intercalated segment instability

Treated in ED with ulnar-gutter splint then open reduction and surgical repair.

 

15.    Describe the following regarding scaphoid fractures:

         a.            Usual mechanism of injury

         b.            How it presents

         c.            Serious consequences of not recognizing and treating it

         d.            How it is treated

Zen Seeker Tinitinalli EM Fifth Edition

Scaphoid fracture in the middle third or waist (arrow).

 

CARPAL BONE FRACTURES

Carpal bone fractures account for 7 to 10 percent of all hand injuries. Unfortunately, they are among the most commonly missed wrist injuries. It is important that a high index of suspicion is maintained and a focused examination is used to recognize these injuries. The following carpal fractures are listed in descending order of occurrence.

 

Scaphoid Fracture

The scaphoid is an oblong bone that has the unique role of linking and stabilizing the two rows of carpal bones. This, unfortunately, increases its propensity to injury, making it the most common carpal fracture. The injuries usually result from a fall on an outstretched dorsiflexed hand or by an axial load directed along the thumb´s metacarpal. There is pain along the radial side of the wrist and localized tenderness in the anatomical snuffbox. Examining the wrist in ulnar deviation exposes more of the scaphoid to direct palpation in the anatomical snuffbox. Eliciting pain in this area, when the patient resists supination or pronation of their hand, or pain with axial pressure directed along the thumb´s metacarpal is also suggestive of injury.

 

Standard and scaphoid views should be carefully examined for any cortical disruption (see Fig. 262-8). The scaphoid view profiles the bone lengthwise and may assist in detecting subtle fractures. Distortion of a soft tissue fat stripe that lies adjacent to the radial side of the scaphoid is also suggestive of injury. Two-thirds of the fractures occur at the waist or middle third of the bone, 16 to 28 percent in the proximal third, and 10 percent in the distal third. A scaphoid fracture may also have an associated injury in 12 percent of cases involving either the radius, neighboring carpals, a carpal instability pattern, or dislocation.

 

A scaphoid fracture can develop avascular necrosis of the proximal fracture segment that can lead to disabling arthritis. There are several reasons that this occurs. The vascular supply to the scaphoid enters the distal portion of the bone through small branches off the radial artery and the palmar and superficial arteries. A fracture could therefore disrupt the blood supply to the proximal segment. In general, the more proximal, oblique, or displaced the fracture, the greater the risk of developing avascular necrosis. A scaphoid fracture is considered unstable if there is even as little as 1 mm of displacement, rotation, angulation, shortening, or if a carpal instability pattern is present. Two thirds of the scaphoid´s surface is also articular. This only adds to the scaphoid´s problems, because articular fractures are more difficult to heal.

 

Because 10 percent of initial radiographs fail to detect a fracture, it is imperative that initial treatment also be directed by clinical suspicion until follow up studies can exclude the diagnosis. Nondisplaced fractures and those that are only clinically suspected can be treated in a short-arm thumb spica splint or cast. Displaced or unstable fractures should be placed in a long- arm thumb spica splint or cast, and should be seen promptly by the orthopedic surgeon for definitive treatment. The main complications are avascular necrosis, delayed union, nonunion, malunion, and subsequent early degenerative arthritis.

Anonymous Tintinalli, pp 1778-1779

Usual mechanism of injury usually results from a fall on an outstretched dorsiflexed hand or by an axial load directed along the thumb’s metacarpal.

How it presents pain along the radial side of the wrist and localized tenderness in the anatomical snuffbox. Eliciting pain in the anatomical snuffbox area when the patient resists supination or pronation of their hand, or pain with axial pressure directed along the thumb’s metacarpal is also suggestive of injury.

Serious consequences of not recognizing and treating it most serious consequence is avascular necrosis, which can lead to disabling arthritis.

How it is treated Nondisplaced fractures or clinically suspected fractures can be treated in a short-arm thumb spica cast or splint. Displaced or unstable fractures should be placed in a long-arm thumb spica splint or case and should be seen promptly by an orthopedic surgeon for definitive treatment.

Anonymous ER Med., p. 1778-79

The scaphoid is an oblong bone that has the unique role of linking and stabilizing the two rows of carpal bones.

•        usual mechanism of injury: The injuries usually result from a fall on an outstretched dorsiflexed hand or by an axial load directed along the thumb’s metacarpal.  

•        how it presents:  There is pain along the radial side of the wrist and localized tenderness in the anatomical snuffbox.  Examining the wrist in ulnar deviation exposes more of the scaphoid to direct palpation in the anatomical snuffbox.  Eliciting pain in this area, when the patient resists supinaton or pronation of their hand, or pain with axial pressure directed along the thumb’s metacarpal is also suggestive of injury.

•        serious consequences of not recognizing it:   A scaphoid fracture can develop avascular necrosis of the proximal fracture segment that can lead to disabling arthritis.  The vascular supply to the scaphoid enters the distal portion of the bone through small branches off the radial artery and the palmar and superficial arteries.  A fracture could therefore disrupt the blood supply to the proximal segment.

•        how it is treated:  A scaphoid fracture is considered unstable if there is even as little as 1mm of displacement, rotation , angulation, shortening , or if a carpal instability pattern is present.  Nondisplaced fractures and those that are only clinically suspected can be treated in a short-arm thumb spica splint or cast.  Displaced or unstable fractures should be placed in a long-arm thumb spica splint or cast, and should be seen promptly by an orthopaedic surgeon for definitive treatment.  

•        serious consequences of not treating it:  The main complications are avascular necrosis, delayed union, non-union, malunion and subsequent early degenerative arthritis.

AnaughtyMouse

a)      Fall on outstretched hand or excess load along thumbs metacarpal

b)      Wrist tenderness-pain in supination or pronation or direct pressure along thumbs metacarpal

c)      Develop a vascular necrosis leading to disabling arthritis

Thumbs spica for clinical suspicion or non-displaced fracture. A long arm spica splint or cast and referral to ortho for displaced or unstable fracture.

 

16.    Discuss the following regarding Colles’ fractures:

         a.            Definition

         b.            Usual mechanism of injury

         c.            Type of wrist deformity it causes

         d.            What is considered an unstable fracture and how they are treated

         e.            Treatment of stable fractures

Zen Seeker Tinitinalli EM Fifth Edition

Colles´ fracture. (With permission from Chin HW, Visotsky J: Wrist fractures. Em Med Clin North Am 11:3, 1993.)

 

Colles´ Fracture

Colles´ fracture results most often from falls on the outstretched hand. This mechanism produces a distal radial metaphysis fracture that is dorsally angulated and displaced. Compression forces on the dorsal side often produce dorsal comminution of bone. The fracture line may also comminute and extend into the radioulnar or radiocarpal joint (“die-punch” fracture). A fracture of the ulnar styloid is often present and may be suggestive of injury to the triangular fibrocartilage complex (Fig. 262-12).

 

The wrist has the characteristic dorsiflexion, or “silver-fork,” deformity. These individuals may complain of palmar paresthesias from tension or pressure on the median nerve. Anteroposterior radiographs reveal a distal metaphyseal fracture of the radius that often appears shortened from the angulation or comminution of the bone. The lateral view provides the best view of the dorsal angulation and comminution. In general, potentially unstable fractures have more than 20 degrees of angulation, intra-articular involvement, marked comminution, or more than a centimeter of shortening. These injuries are more likely to develop loss of reduction, distal radioulnar joint instability, radiocarpal instability patterns, and subsequent arthritis.

 

Stable fractures may be treated with a compression dressing and splint until they can be evaluated by an orthopedic surgeon. Otherwise, closed reduction is performed, with traction provided by finger traps while the fracture fragment is pushed distal and palmar while the patient´s forearm is firmly held. The goal is to restore the volar tilt, radial inclination, and proper length to the radius. This is particularly important in younger patients. The volar tilt ideally should be restored to its normal position, but a minimum of neutral or zero degrees of angulation may be acceptable. Although most Colles´ fractures can be treated with closed reduction and cast immobilization, those that are unstable, severely comminuted, or intra-articular may require casting with pinning, external fixation with possible bone grafting, or open reduction and internal fixation. Good to excellent results are achieved in 56 to 81 percent of patients with these more aggressive treatment alternatives. All open and neurovascularly compromised fractures require prompt evaluation by the orthopedic surgeon.

 

Complications include malunion, median nerve injuries, triangular fibrocartilage complex injuries, secondary radioulnar and radiocarpal instability patterns, and arthritis. These can produce a weak, stiff, and painful wrist.

Anonymous

Definition a distal radial metaphysis fracture that is dorsally angulated and displaced. Compression forces on the dorsal side often produce dorsal comminution of bone. Fracture line may also comminute and extend into the radioulnar or radiocarpal joint (“die-punch” fracture) and a fracture of the ulnar styloid is often present.

Usual mechanism of injury results most often from falls on the outstretched hand.

Type of wrist deformity it causes dorsiflexion or “silver fork” deformity.

What is considered an unstable fracture and how they are treated more than 20 degrees of angulation, intra-articular involvement, marked comminution or more than 1 com of shortening. Treatment often requires casting with pinning, external fixation with possible bone grafting or open reduction and internal fixation.

Treatment of stable fractures compression dressing and splint until orthopedic surgeon consult. Otherwise, closed reduction and cast immobilization. Tintinalli, pp 1780-1781

Anonymous ER Med., p. 1780-81

•        usual mechanism of injury:  Colles’ fracture results most often from falls on the outstretched hand.  This mechanism produces definition:  a distal radial metaphysic fracture that is dorsally angulated and displaced.  Compression forces on the dorsal side often produce dorsal comminution of bone.  The fracture line may also comminute and extend into the radioulnar or radiocarpal joint (die-punch fracture). A fracture of the ulnar styloid is often present and may be suggestive of injury to the triangular fibrocartilage complex.

•        type of wrist deformity it causes:  The wrist has the characteristic dorsiflexion, or “silver-fork”, deformity.  

•        what is considered an unstable fracture:  Potentially unstable fractures have more than 20 degrees on angulation, intra-articular involvement, marked comminution, or more than a centimeter of shortening.  These injuries are more likely to develop loss of reduction, distal radioulnar joint instability, radiocarpal instability patterns, and subsequent arthritis.  

•        how unstable fx’s are treated:  Although, most Colles’ fractures can be treated with closed reduction and cast immobilization, those that are unstable, severely comminuted, or intra-articular may require casting with pinning, external fixation with possible bone grafting, or ORIF.  

•        treatment of stable fractures:  Stable fractures may be treated with a compression dressing and splint until they can be evaluated by an orthopaedic surgeon.  Otherwise, closed reduction is performed, with traction provided by finger traps while the fracture fragment is pushed distal and palmar while the patient’s forearm is firmly held.  The goal is to restore the volar tilt, radial inclination, and proper length to the radius.  Complications include malunion, median nerve injuries, triangular fibrocartilage complex injuries, secondary radioulnar and radiocarpal instability patterns, and arthritis.  These can produce a weak, stiff, and painful wrist.

Kevin; Tabers 19, 434

Definition:

•   A transverse fracture of the distal end of the radius just above the wrist with displacement of the hand backward and outward.

         Tintinalli 1780

Usual Mechanism

•   Falls

 

Type of Wrist deformity it causes:

•   Comminuted

 

What is considered an unstable fracture and how they are treated

•   > than 20 degrees of angulation is unstable

•   intra articular involvement

•   marked comminution

•   > 1cm of shortening

 

TX:  Unstable are treated with pinning, external fixation

Bone grafting, open reduction and internal fixation

 

Treatment of Stable Fractures:

•         Closed reduction and cast immobilization

Stephen/Tintinalli 1780-1781

Distal radial metaphysic FX that is dorsally angulated and displaced.

Colles’ FX results most often from falls on the outstretched hand.

The wrist has the characteristic dorsiflexion, or “silver-fork”, deformity.

Unstable FX’s have more than 20 degrees of angulation, intra-articular involvement, marked comminution, or more than a centimeter of shortening…. May require casting with pinning, external fixation with possible bone grafting, or open reduction and internal fixation.

TX of stable FX’s = compression dressing and splint until evaluated by orthopedic surgeon.

….Fx’s of the distal metaphysic of the radius are among the most common injuries affecting the wrist (along with ulna FX’s).

 

17.    Describe a Smith’s fracture and how it differs from a Colles’ fracture.

Zen Seeker Tinitinalli EM Fifth Edition

Smith´s fracture.

 

Smith´s Fracture

Smith´s fracture, or “reverse Colles´ fracture,” is a volar angulated fracture of the distal radius. These injuries result from a fall or direct blow on the dorsum of the hand and wrist or from falls on the outstretched hand in supination that then shifts into a pronated position. The hand is displaced palmar in a “garden-spade deformity.” The anteroposterior radiograph looks much like the Colles´ fracture, with a distal metaphyseal radius fracture that may be shortened and comminuted. The lateral radiograph shows the volar angulated and displaced fracture (Fig. 262-13).

Anonymous

AKA “reverse Colles’ fracture”. A volar angulated fracture of the distal radius. Injuries result from a fall or direct blow on the dorsum of the hand and wrist or from falls on the outstretched hand in supination that then shifts into a pronated position. The hand is displaced palmar in a “garden-spade” deformity. Tintinalli, p. 1781

Anonymous see P16.  ER Med., p. 1781

Smith’s fracture or “reverse Colles’ fracture,” is a volar angulated fracture of the distal radius.  These injuries result from a fall or direct blow on the dorsum of the hand and wrist or from falls on the outstretched hand in supination that then shifts into a pronated position.  The hand is displaced palmar in a “garden-spade deformity.”  The anteroposterior radiograph looks much like the Colles’ fracture, with a distal metaphyseal radius fracture that may be shortened and comminuted.  The lateral radiograph shows the volar angulated and displaced fracture.

Kevin; Tintinalli 1781

Description:

•         Reverse Colles Fracture

 

SMITH VS COLLE’S

•         Both are fractures of the Distal Radius

•         The diff lies in the direction of angulation as seen in a picture in Essentials page 249

•         Colle’s fracture is angulated toward the ulna while the Smith is angulated away from the ulna

Stephen/Tintinalli 1781

Smith FX, or “reverse Colles’ FX” is a volar angulated FX of the distal radius.

Results from a fall or direct blow on the dorsum of the hand and wrist or falls on the out-stretched hand in supination that then shifts into a pronated position.

The hand is displaced palmar in a “garden-spade deformity”.

TX objectives and complications are much like those seen with Colles’ FX….but opposite direction.

 

18.    Describe the following for clavicular fractures:

         a.            How common they are in children

         b.            Common mechanism of injury

         c.            Which part of the clavicle sustains the most fractures

         d.            Treatment for the majority of fractures

Zen Seeker Tinitinalli EM Fifth Edition

CLAVICLE

Clavicle fractures account for 5 percent of all fractures seen in the emergency department and for 44 percent of significant injuries to the shoulder girdle. This is the most common fracture of childhood, with almost half of these injuries occurring by the age of 7. The clavicle functions as a strut, connecting the shoulder girdle to the trunk, and provides support and mobility for upper-extremity function. The clavicle also protects the adjacent lung, brachial plexus, and subclavian and brachial blood vessels.

 

The most common mechanism of injury is a blow to the shoulder. Transmission of the compressive force results in a buckling of the clavicle, which fractures once a critical force is achieved. Children will often have a greenstick or buckle-type fracture or a bowing deformity without a definite fracture. Open fractures, due to extreme tenting of the overlying skin, may occasionally be seen.

 

Eighty percent of clavicle fractures involve the middle third, 15 percent the distal third, and 5 percent the medial third. Patients typically present with swelling, deformity, and tenderness localized to the clavicle. The arm is slumped inward and downward and is supported by the other extremity. Routine clavicle radiographs may miss fractures due to overlap of surrounding structures, particularly with fractures at either end of the bone. Diagnosis of these may require special views or specialized techniques, such as tomography or computed tomography (CT) scan.

 

Numerous forms of treatment have been described for this common injury. Simple immobilization with a sling is often successful, with displaced fractures often treated with a figure- of-eight brace. A shoulder spica or open reduction may be required for severely displaced fractures, poor patient compliance, or for complications. Healing may occur as rapidly as 2 weeks for infants, with most adults healing in a 4- to 6-week period.

 

Although the vast majority of these fractures have a benign course, serious associated injuries and complications may occasionally occur. Penetrating or blunt trauma may result in associated lung, neurovascular, or first-rib injuries. Injury to the adjacent vascular structures, usually the subclavian artery, subclavian vein, internal jugular vein, or axillary artery, may be life-threatening. Distal clavicle fractures with displacement typically are associated with rupture of the coracoclavicular ligament and may require operative intervention to avoid nonunion. Medial clavicle fractures may be associated with intrathoracic injuries or develop late complications, such as arthritis. Significant callus formation may result in subsequent compression of adjacent neurovascular structures and is cosmetically deforming.

Anonymous Tintinalli, p. 1784

How common they are in children the most common fracture of childhood, with almost half of these injuries occurring by age 7.

Common mechanism of injury a blow to the shoulder.

Which part of the clavicle sustains the most fractures the middle third (80% of fractures)

Treatment for the majority of fractures simple immobilization with a sling or figure-of-eight brace for displaced fractures.

Anonymous ER Med., p. 1784

•        Clavicle fractures account for 5% of all fractures seen in the ER and for the 44% of significant injuries to the shoulder girdle.  

•        which part of the clavicle sustains the most fractures:  Eighty percent of clavicle fractures involve the middle third, 15 percent the distal third, and 5 percent the medial third.  

•        common mechanism of injury:  The most common mechanism of injury is a blow to the shoulder.  Transmission o f the compressive force results in a buckling of the clavicle, which fractures once a critical force is achieved.  Children will often have a greenstick or buckle-type fracture or a bowing deformity with out a definite fracture.  

•        how common they are in children:  This is the most common fracture in children, with almost half of these injuries occurring by the age of 7.  Patients typically present with swelling, deformity, and tenderness localized to the clavicle.  The arm is slumped inward and downward and is supported by the other extremity.  

•        treatment for the majority of fractures:  Numerous forms of treatment have been described for this common injury.  Simple immobilization with a sling is often successful, with displaced fractures often treated with a figure-of-eight brace.  A shoulder spica or open reduction may be required for severely displaced fractures, poor patient compliance, or for complications.  Healing may occur as rapidly as 2 wks. in infants, with most adults healing in a 4-6 wk period.

Kevin; Tintinalli 1784

How common they are in children:

•         Most common fracture in childhood, over half before age 7

 

Common Mech of Injury

•         Blow to the shoulder

 

Par of Clav with most FX’s

•         80% are middle 1/3

 

TX of majority:

•         Immobilization with a sling

Stephen/Tintinalli 1784

Most common FX of childhood, with almost half of these injuries occurring by age 7.

Most common mechanism = blow to shoulder which buckles clavicle.

Highest percent of FX’s are in the distal third.

TX = Simple immobilization with sling is often successful, …with displaced FX’s often TX with a figure-of-eight brace.

… could be life-threatening with vascular involvement (subclavian artery, subclavian vein, internal jugular vein, or axillary artery).

 

19.    Explain why there are usually associated injuries with scapular fractures and how they are treated.

Zen Seeker Tinitinalli EM Fifth Edition

Sites of scapula fractures. A. Body. B. Glenoid rim. C. Intraarticular glenoid. D. Neck. E. Acromion. F. Spine. G. Coracoid.

 

SCAPULA

The scapula links the axial skeleton to the upper extremity and serves as a stabilizing platform for motion of the arm. Fracture of the scapula is an infrequent occurrence, accounting for less than 1 percent of all fractures. Due to the high energy typically required to fracture this protected bone, there is a greater than 80 percent association of injuries to the ipsilateral lung, thoracic cage, and shoulder girdle.

 

Significant scapular injury occurs most frequently in men between 25 and 40 years of age, usually as a result of motor vehicle accidents, falls, or other severe trauma. The mechanism of injury is from a direct blow, trauma to the shoulder sometimes with injury of the acromion or coracoid, or a fall on the outstretched arm. An indirect axial load transmitted via the outstretched arm may result in a scapular neck fracture, while the indirect force of a shoulder dislocation may result in fracture of the glenoid. Scapular fractures may be classified by their anatomic location: body, glenoid neck, intraarticular glenoid, spine, coracoid, and acromion (Fig. 263-2) Fractures of the body and glenoid neck are the most common.

 

A patient with an isolated scapular fracture typically will present with localized tenderness over the scapula and the ipsilateral arm held in adduction. The shoulder may have a flattened appearance. Radiographs consisting of an anteroposterior shoulder, lateral scapula, and axillary will identify most fractures. However, scapula fractures are often associated with other significant injuries, and hence diagnosis may be delayed or initially missed entirely. In Ada and Miller´s series, 96 percent of scapular fractures had associated injuries, of which rib fractures were the most common, followed by pulmonary, humeral head, and shoulder girdle injuries. Other injuries may include neurovascular, abdominal, and spine trauma.

 

Rarely, significant trauma may result in scapulothoracic dissociation. This syndrome consists of lateral scapular displacement, clavicular disruption, and severe soft-tissue injury. This injury is sometimes associated with brachial plexus avulsion, subclavian artery disruption, or both. Its presence may be suspected by neurovascular findings or by lateral displacement of the scapula visualized on a nonrotated chest radiograph.

 

The vast majority of scapular fractures are treated nonsurgically, with a sling for immobilization, ice, analgesics, and early range-of-motion exercises. Surgical intervention may be necessary for significant or displaced articular fractures of the glenoid, angulated glenoid neck fractures, acromial fractures associated with a rotator cuff tear, and some coracoid fractures. Fractures of the glenoid, acromion, or coracoid are more likely to be associated with long-term disability.

 

Complications of scapular fractures themselves are uncommon. Although many of these fractures heal with some degree of malunion, typically this does not result in significant disability. Most long-term disability is a result of other, associated injuries.

Anonymous Tintinalli Handbook pg 882.

Scapular fractures present with localized tenderness over the scapula and the affected extremity held in adduction.  They usually result from significant trauma, such as MVC’s or falls.

Anonymous Tintinalli 1784-1785

Scapular fractures occur with such high-energy impacts that energy usually transfers to surrounding tissue.  Treatment of these fractures is usually nonsurgical, with a sling for immobilization, ice, and analgesia, and early range of motion exercises.  Surgical intervention is necessary for significant or displaced articular fractures of the glenoid, angulated glenoid neck fractures, acromial fractures associated with rotator cuff tear, and some are coracoid fractures.

Kevin; Tintinalli 1784

Why there are associated injuries with scap fx

•         Because of the great amount of force needed to fracture the scapula there is greater than 80% association of injuries to the ipsilateral lung, thoracic cage, and shoulder girdle.

TX

•         Sling and analgesics

Stephen/Tintinalli 1784

Due to the high energy typically required to FX this protected bone, there is a greater than 80% association of injuries to the ipsilateral lung, thoracic cage, and shoulder girdle.

Pt. with isolated scapular FX typically will present with localized tenderness over scapula and the ipsilateral arm held in adduction.

…vast majority TX’ed nonsurgically, with a sling for immobilization, ice, analgesics, and early ROM exercises.

…complications uncommon.

 

20.    Identify the following regarding AC joint injuries:

         a.            In whom they typically occur

         b.            Usual mechanism of injury

         c.            Physical exam findings

         d.            Treatment for the majority of AC injuries

Zen Seeker Tinitinalli EM Fifth Edition

Anatomy of the acromioclavicular joint.

 

Classification of acromioclavicular joint injuries. (From Rockwood CA, Green DP, Bucholz RW: Rockwood & Green ´s Fractures in Adults, 3d ed. Philadelphia, Lippincott, 1991, with permission.)

 

ACROMIOCLAVICULAR JOINT INJURIES

Injuries to the acromioclavicular joint are commonly seen in emergency practice. Although they may occur in any age group, the majority occur in young, active males. Emergency management consists of identifying the severity of injury, recognizing associated injuries, and managing selected patients as outpatients.

 

Anatomy

The acromioclavicular joint is a diarthrodial joint that, together with the sternoclavicular joint, connects the upper extremity to the axial skeleton. The support of the acromioclavicular joint is through the acromioclavicular and coracoclavicular ligaments and the strong attachment of the trapezius and deltoid muscles (Fig. 263-3). The acromioclavicular joint is surrounded by a thin capsule, which is reinforced by the acromioclavicular ligaments. The superior fibers of this ligament blend with the fascia of the trapezius and deltoid, which attach to the clavicle and acromion. The acromioclavicular ligaments provide horizontal stability to the joint. The tough coracoclavicular ligaments consist of two parts, the more lateral trapezoid and the medial conoid. They attach the distal inferior clavicle to the coracoid process of the scapula. The coracoclavicular ligament is the major suspensory ligament of the upper extremity and provides vertical stability to the acromioclavicular joint.

 

Mechanism of Injury

The mechanism of injury is usually direct trauma to the acromioclavicular joint from a fall with the arm adducted, as typically may occur in a sporting activity. An indirect mechanism is a fall on the outstretched hand with transmission of force to the acromioclavicular joint. The result is that the scapula and shoulder girdle are driven inferiorly while the clavicle remains in its normal position. This is confirmed by observing the opposite clavicle, which is at the same level as the injured one.

 

Clinical Features

The diagnosis of acromioclavicular joint injuries is made clinically. The typical mechanism of injury, as well as tenderness and deformity at the acromioclavicular joint, is confirmatory. Radiographs are useful for identifying other fractures and determining the severity of injury. Acromioclavicular radiographs should specifically be ordered because they require only one-third to one-half the penetration of standard shoulder films. Shoulder technique will overpenetrate the acromioclavicular joint, and small fractures may be missed. Although standard acromioclavicular radiographs are generally sufficient, an axillary view is required to identify posterior clavicular dislocation (type IV, see below). Routine use of stress radiographs has been standard practice. Recently, however, Bossart and colleagues have called this practice into question. Their study suggests that stress radiographs are of low yield and that their routine use should be abandoned. Although some agree, others disagree, citing occult type III (see below) injuries that can be unmasked only with stress radiographs.

 

Classification of Injury

The classification of acromioclavicular joint injuries classically describes three types of injuries. Rockwood describes three others (Fig. 263-4). Types I, II, and III are common; types IV, V, and VI are rare. The anatomic injury, radiographic findings, and physical findings are summarized in Table 263-1.

 

Treatment

Treatment of type I injuries consists of rest, ice, analgesics, and immobilization, followed by early range-of-motion exercises. Most agree that type II injuries should be similarly treated. Various straps and braces have been used to reduce the dislocation, but none has proven successful. A simple sling remains the most convenient and effective. Prognosis for type I and II injuries is excellent, with only a small percentage who develop late symptoms requiring excision of the distal clavicle. Treatment of type III injuries (Fig. 263-5) is controversial, with proponents for both conservative and operative philosophies. A recent trend among directors of orthopedic residency programs, however, reveals a shift to conservative treatment with sling immobilization. Both strategies have yielded good results in selected patients, with the specific management operator dependent. Treatment decisions are based on such factors as age, occupation, and activity level. Types IV, V, and VI are severe injuries, and most authors recommend surgical repair. Because other injuries are associated with these more severe forms of acromioclavicular joint injuries (especially type VI), a careful clinical and radiographic examination must be performed.

 

 

TABLE 263-1         Classification and Physical Findings in Acromioclavicular Joint Injuries

Type

Injury

Radiograph

Examination

I

Sprained acromioclavicular ligaments

Normal

Tenderness over acromioclavicular joint

II

Acromioclavicular ligaments ruptured; coracoclavicular ligaments sprained

Slight widening of acromioclavicular joint; clavicle elevated 25–50% above acromion; may be slight widening of the coracoclavicular interspace

Tenderness and mild step-off deformity of acromioclavicular joint

III

Acromioclavicular ligaments ruptured; coracoclavicular ligaments ruptured; deltoid and trapezius detached

Acromioclavicular joint dislocated 100%; coracoclavicular interspace widened 25–100%

Distal end of clavicle prominent; shoulder droops

IV

Rupture of all supporting structures; clavicle displaced posteriorly in or through the trapezius

May appear similar to type II and III; axillary radiograph required to visualize posterior dislocation

Possible posterior displacement of clavicle

V

Rupture of all supporting structures (more severe form of type III injury)

Acromioclavicular joint dislocated; generally 200–300% disparity of coracoclavicular interspace compared to normal shoulder

More pain; gross deformity of clavicle

VI

Acromioclavicular ligaments disrupted; coracoclavicular ligaments, deltoid, and trapezius may be disrupted

Acromioclavicular joint dislocated; clavicle displaced inferiorly

Severe swelling; multiple associated injuries

Anonymous

In whom they typically occur – children

Usual mechanism of injury – direct trauma (i.e. fall onto a shoulder)

Physical exam findings – swelling, obvious deformity, support arm is slumped inward and downward.

Treatment for the majority of AC injuries – check for radiculopathy, simple immobilization with a sling, ice, analgesics and early ROM exercises.  Ortho f/u and referral for unusual or complicated injuries.

Anonymous Tintinalli 1785-1786

Kevin; Tintinalli 1786

Whom they typically occur

•         Young active males

Usual Mech:

•         Direct trauma from a fall from sporting injury

Physical Exam Findings

•         Tenderness and deformity at the AC joint is confirmatory

TX for majority of AC inj.

•         Rest, Ice, Sling, Analgesics

Stephen/Tintinalli 1785

Young, active males.

…usually direct trauma to the AC joint from a fall with arm adducted, as typically may occur in a sporting activity.

An indirect mechanism is a fall on the outstretched hand with transmission of the force to the AC joint.

…tenderness and deformity at the AC joint, is confirmatory.

TX decisions are based on such factors as age, occupation, and activity level.

A simple sling remains the most convenient and effective.

 

21.    Describe the following regarding shoulder dislocation:

         a.            Percentage that are anterior and posterior

         b.            Usual presentation

         c.            How the axillary nerve is tested

         d.            Hippocratic method of shoulder reduction

         e.            Stimson method of shoulder reduction

         f.             Common complications in anterior dislocations

Zen Seeker Tinitinalli EM Fifth Edition

Modified Hippocratic technique.

 

Milch technique.

 

Scapular manipulation technique.

 

DISLOCATION OF THE GLENOHUMERAL JOINT

Dislocation of the glenohumeral joint is the most common major joint dislocation. Anterior dislocations are by far the most common. Posterior dislocations are described but occur in less than 2 percent of cases. Other dislocations include inferior (luxatio erecta) and superior (very rare).

 

Anterior Glenohumeral Dislocations

There are four types of anterior dislocations. In subcoracoid dislocation, the commonest type, the humeral head is displaced anterior to the glenoid and inferior to the coracoid. In a subglenoid dislocation, the humeral head lies inferior and anterior to the glenoid fossa. In a subclavicular dislocation, the head of the humerus is displaced medial to the coracoid below the clavicle. In the very rare intrathoracic dislocation, the head of the humerus lies between the ribs and thoracic cavity.

 

The mechanism of injury may be direct force, but an indirect force is commoner. The combination of abduction, extension, and external rotation with sufficient force will cause an anterior dislocation.

 

The patient is usually in severe pain. The arm is in slight abduction and external rotation. The shoulder is “squared off,” lacking the normal rounded contour. The patient resists abduction and internal rotation. The humeral head can often be palpated anteriorly. Because neurovascular injuries occur, a careful examination must be performed. The axillary nerve is most commonly injured. This nerve may be tested by pinprick sensation over the skin of the deltoid muscle.

 

Anteroposterior and scapular lateral or Y radiographs should be obtained before reduction is attempted. Although the anteroposterior radiograph will reveal the dislocation, the scapular Y radiograph will indicate the direction of dislocation: anterior or posterior. Bony injuries reported in the literature include fractures of the anterior glenoid lip, greater tuberosity, coracoid, and acromion, and compression fractures of the humeral head (Hill-Sachs lesion).

 

Many reduction techniques have been described. The three main categories are traction, leverage, and scapular manipulation. Success rates are between 70 and 90 percent regardless of technique. The use of conscious sedation is recommended, but any reduction technique may be attempted without medication when performed slowly and atraumatically. It is important for the physician to be comfortable with two or three techniques in case of a failed first attempt. Considerations in selection of a technique include ease of performance, effectiveness, as little trauma and pain as possible, requirement for medication, number of assistants, and time for procedure.

 

HIPPOCRATIC (MODIFIED)

A modification of the Hippocratic method uses traction- countertraction (Fig. 263-6). The patient is supine with the arm abducted and elbow flexed at 90°. A sheet is tied and placed across the thorax of the patient and then around the waist of the assistant. Another sheet is tied and placed around the forearm of the patient at the elbow and the waist of the physician. The physician gradually applies traction as the assistant provides countertraction. Gentle internal and external rotation or outward pressure on the proximal humerus may aid reduction.

 

STIMSON

The patient is placed prone on a gurney with the dislocated extremity hanging over the side and a 10-pound weight attached to the wrist. Complete muscle relaxation is required. Twenty to 30 min is required to allow reduction to occur.  Although safe, effective, and easy to learn, the time involved and constant monitoring by a nurse are drawbacks to this technique.

 

MILCH

The patient is supine. The physician slowly abducts and externally rotates the arm to the overhead position (Fig. 263- 7). With the elbow fully extended, traction is applied. With the other hand, pressure may be placed on the humeral head to manipulate it over the lip of the glenoid.  This technique is well tolerated by the patient, effective, and atraumatic. It is the technique of choice for many physicians

 

SCAPULAR MANIPULATION

The patient is positioned with weights in the same manner as the Stimson technique (Fig. 263-8). After adequate sedation, the physician pushes the tip of the scapula medially using the thumbs, while stabilizing the superior aspect with the cephalad hand.  Several reports have recently been published. Physicians have found this technique relatively painless, fast, and in one study 90 percent successful.

 

EXTERNAL ROTATION

The patient is supine with the arm adducted to the patient´s side. With the elbow at 90° of flexion, the arm is slowly externally rotated. No longitudinal traction is applied. It is important to perform the movement slowly to allow time for spasm and pain to resolve. Reduction is usually complete prior to reaching the coronal plane and is often not noted either by the patient or physician.  This method has been reported to be 78 percent successful, relatively atraumatic, safe, and easily learned.

 

COMPLICATIONS

Complications are frequently encountered in patients with anterior glenohumeral dislocations. The most common complication is recurrent dislocation, which is age dependent. Those patients less than 20 years of age have a greater than 90 percent recurrence; those older than 40 years have a 14 percent recurrence. Other complications include fractures and injuries to nerves and the rotator cuff. Vascular injuries are rare but when they occur tend to involve the axillary artery in elderly patients. Clinical findings of vascular injury include absent radial pulse, axillary hematoma, bruising of the lateral chest wall, and an axillary bruit.

 

Bony injuries are common and include fractures of the humeral head (Hill-Sachs lesion), anterior glenoid lip, and greater tuberosity. Neural injuries occur in 10 to 25 percent of acute dislocations. Of these injuries, which are the result of traction neuropraxia, most occur in the axillary nerve. This injury is temporary and resolves spontaneously. The common test of sensation over the skin of the deltoid muscle may not be reliable, with only an electromyogram providing an accurate evaluation. Other nerves injured are the radial, ulnar, median, musculocutaneous, and brachial plexus.

 

A frequent but often missed injury is a tear of the rotator cuff. This injury, which increases with age, has a greater than 80 percent occurrence in patients older than 60 years. Treatment is surgical.

Zen Seeker Tintinallii 1787

a. Percentage that are anterior and posterior – Anterior dislocations are by far the most common.  Posterior dislocations are described as occurring in less than 2 percent of cases.  Other dislocations include inferior (luxatio erecta) and superior (very rare).

b. Usual presentation –

Anterior – The patient is usually in severe pain.  The arm is in slight abduction and external rotation.  The shoulder is “squared off,” lacking the normal rounded contour.  The patient resists abduction and internal rotation.  The humeral head can often be palpated anteriorly.

Posterior – The arm is adducted and internally rotated.  The anterior shoulder is flat and the posterior aspect full.  The coracoid process is prominent.  The patient will not allow external rotation or abduction because of severe pain.

c. How the axillary nerve is tested – Because neurovascular injuries occur, a careful examination must be performed.  The axillary nerve is most commonly injured.  This nerve may be tested by pinprick sensation over the skin of the deltoid muscle.

d. Hippocratic method of shoulder reduction – A modification of the Hippocratic method uses traction-countertraction (Fig 263-6). The patient is supine with the arm abducted and elbow flexed at 90°.  A sheet is tied and placed across the thorax of the patient and then around the waist of the assistant.  Another sheet is tied and place around the forearm of the patient at the elbow and the waist of the physician.  The physician gradually applies traction as the assistant provides countertraction.  Gentle internal and external rotation or outward pressure on the proximal humerus may aid reduction. (not in book: Hippocratic method - the physician's foot is placed in the patient's axilla while gentle longitudinal traction is applied).

e. Stimson method of shoulder reduction – The patient is placed prone on a gurney with the dislocated extremity hanging over the side and a 10 pound weight attached to the wrist.  Complete muscle relaxation is required.  Twenty to 30 min is required to allow reduction to occur.  Although safe, effective, and easy to learn, the time involved and constant monitoring by a nurse are drawbacks to this technique.

f. Common complications in anterior dislocations – Complications are frequently encountered in patients with anterior glenohumeral dislocations.  The most common complication is recurrent dislocation, which is age dependent.  Those patients less than 20 years of age have a greater than 90 percent recurrence; those older than 40 years have a 14 percent recurrence.  Other complications include fractures and injuries to nerves and the rotator cuff.  Vascular injuries are rare but when they occur tend to involve the axillary artery in elderly patients.  Clinical findings of vascular injury include absent radial pulse, axillary hematoma, bruising of the lateral chest wall, and an axillary bruit.

            Bony injuries are common and include fractures of the humeral head (Hill-Sachs lesion), anterior glenoid lip, and greater tuberosity.  Neural injuries occur in 10 to 25 percent of acute dislocations.  Of these injuries, which are the result of traction neuropraxia (a temporary nerve dysfunction), most occur in the axillary nerve.  This injury is temporary and resolves spontaneously.  The common test of sensation over the skin of the deltoid muscle may not be reliable, with only an electromyogram providing an accurate evaluation.  Other nerves injured are the radial, ulnar, median, musculocutaneous, and brachial plexus.

            A frequent but often missed injury is a tear of the rotator cuff.  This injury, which increases with age, has a greater than 80 percent occurrence in patients older than 60 years.  Treatment is surgical.

Anonymous

a.    Percentage that are anterior and posterior - Anterior 98%, Posterior 2%

Usual presentation – severe discomfort, resistance to abduction and internal rotation, shoulders lack normal founded contour and the humeral head can be palpated anteriorly and inferiorly.

How the axillary nerve is tested – decreased sensation over deltoid

Hippocratic method of shoulder reduction – traction-countertraction: the patient is supine with arm abducted.  A sheet is placed across the thorax of the patient and tied around the waist of the assistant.  The clinician gradually apples traction while the assistant provides countertraction.  Gentle internal and external rotation may aid reduction.  

Stimson method of shoulder reduction – patient is prone on a gurney with dislocated extremity hanging over the side, 10lbs weight is attached to the wrist, complete muscle relaxation is required, 20-30 min is needed to allow reduction to occur.  

Common complications in anterior dislocations – recurrent dislocation which is age dependent (<20 y.o. have a >90% chance, > 40 y.o. =14%)

Anonymous Tintinalli 1787-1789

 

22.    Describe the following regarding a fracture of the proximal humerus:

         a.            Typical patient

         b.            Mechanism of injury

         c.            Typical presentation

         d.            Assessing the axillary nerve and axillary artery

         e.            General treatment in over 80% of all cases

Zen Seeker Tinitinalli EM Fifth Edition

The Neer classification system for proximal humerus fractures.

 

HUMERUS FRACTURES

Proximal Humerus

Fractures of the proximal humerus are a relatively common problem in the emergency department, representing 5 percent of all fractures. They typically occur in elderly osteoporotic patients via an indirect mechanism, such as a fall on an outstretched hand with the elbow extended. Eighty percent of such fractures can be easily managed by the emergency physician, but the remainder have significant displacement and are a challenge to correctly diagnose and treat. Fortunately, the shoulder joint has an intrinsic reserve of range of motion, which can often provide a surprisingly functional outcome despite seemingly crippling injuries.

 

The proximal humerus is composed of the articular segment, the greater and lesser tuberosities, and the proximal humeral shaft. Muscles of the rotator cuff insert on the humeral tuberosities, and the biceps tendon travels between them. The humeral circumflex arteries enter in the area of the bicipital groove and the tuberosities to supply blood flow to the articular segment.

 

Patients with fractures typically present with pain, swelling, and tenderness about the shoulder. Crepitus and ecchymosis may be present, and the arm is generally held closely against the chest wall. A neurovascular examination should be performed, since the brachial plexus and axillary arteries are near the coracoid process and not uncommonly injured. The axillary nerve is the most commonly injured nerve, and sensation over the skin of the deltoid muscle should be tested routinely. Injury to the axillary artery is the commonest vascular injury and may be suggested by paresthesias, pallor, pulselessness, or an expanding hematoma. Vascular injuries may occur with even trivial trauma in atherosclerotic elderly patients.

 

Radiographs consisting of anteroposterior, lateral shoulder, and axillary views will correctly diagnose most proximal humerus fractures. Fractures of the articular surface may be suggested by a fat fluid level or by a superior joint hematoma that appears to push the humerus downward in the joint as a “pseudosubluxation.” A transthoracic lateral radiograph, tomograms, CT scan, and magnetic resonance imaging scan may also be of value.

 

The Neer classification system uses the relationship of the proximal humerus segments (greater and lesser tuberosities, anatomic neck, and surgical neck) to guide the management of these fractures. Significant fragment displacement is defined as greater than 1-cm separation or greater than 45° of angulation between fragments. The number of fracture fragments significantly displaced determines the classification in the Neer system (Fig. 263-10).

 

A one-part fracture may have any number of fracture lines, but no major segment is significantly displaced. The surrounding soft tissue and periosteum hold fracture fragments together. One- part fractures comprise over 80 percent of all proximal humerus fractures. Treatment generally consists of immobilization with a sling and swathe or collar and cuff, ice, analgesics, and referral. Early exercise is important to avoid adhesive capsulitis. The overall prognosis is generally good.

 

Two-part fractures account for 10 percent of proximal humerus fractures, with the remaining 10 percent evenly split between three-part and four-part fractures. Such displaced fractures are more frequently associated with complications and are often difficult to manage. Treatment considerations include integrity of the blood supply, integrity of the rotator cuff, likelihood of union, associated dislocations and neurovascular injuries, and the functionality of the patient. Closed reduction, intraoperative treatment, or a combination of the two may be necessary. Emergent orthopedic consultation for multipart fractures facilitates subsequent reduction and referral.

 

Any fracture involving the anatomic neck or the articular surface may result in compromise of the blood supply to the articular segment. Ischemic necrosis of the articular segment may ultimately require insertion of a humeral head prosthesis for these relatively uncommon fractures. Greater tuberosity fractures accompany up to 15 percent of anterior shoulder dislocations. Significant displacement of a greater tuberosity fragment implies a concomitant rotator cuff tear, with surgical repair often necessary for the active patient. Fracture of the lesser tuberosity should alert the examiner to a potential posterior shoulder dislocation. Significantly angulated surgical neck fractures are at risk for neurovascular damage (axillary neurovascular structures and brachial plexus) and should be immediately immobilized and radiographed in the position of presentation. Children may have significant displacement or separation of the proximal humeral epiphysis and may require exact reduction if near skeletal maturity. A shoulder spica is often used after reduction.

Zen Seeker Tintinallii 1789-1790

Typical patient- Fractures of the proximal humerus are a relatively common problem in the emergency department, representing 5 percent of all fractures.  They typically occur in elderly osteoporotic patients

Mechanism of injury - via an indirect mechanism, such as a fall on an outstretched hand with the elbow extended.

Typical presentation- patients with fractures typically present with pain, swelling, and tenderness about the shoulder.  Crepitus and ecchymosis may be present, and the arm is generally held closely against the chest wall.  A neurovascular examination should be performed, since the brachial plexus and axillary arteries are near the coracoid process and not uncommonly injured.  

Assessing the axillary nerve and axillary artery- The axillary nerve is the most commonly injured nerve, and sensation over the skin of the deltoid muscle should be tested routinely.  Injury to the axillary artery is the commonest vascular injury and may be suggested by paresthesias, pallor, pulselessness, or an expanding hematoma.  Vascular injures may occur with even trivial trauma in atherosclerotic elderly patients.

General treatment in over 80% of all cases- eighty percent of such fractures can be easily managed by the emergency physician, but the remainder have significant displacement and are a challenge to correctly diagnose and treat.  Fortunately, the shoulder joint has an intrinsic reserve of range of motion, which can often provide a surprisingly functional outcome despite seemingly crippling injures.

            A one-part fracture may have any number of fracture lines, but no major segment is significantly displaced.  The surrounding soft tissue and periosteum hold fracture fragments together.  One-part fractures comprise over 80 percent of all proximal humerus fractures.  Treatment generally consists of immobilization with a sling and swathe or collar and cuff, ice, analgesics, and referral.  Early exercise is important to avoid adhesive capsulitis (frozen shoulder).  The overall  prognosis is generally good.

Anonymous pg 1789-90

Typical patient- elderly osteoporotic patients

Mechanism of injury- indirect mechanisms, such as a fall on an outstretched hand with the elbow extended.

Typical presentation- is pain, swelling, and tenderness about the shoulder.  Crepitus and ecchymosis may be present, and the arm is generally held closely against the chest wall.

Assessing the axillary nerve and axillary artery- A neurovascular examination should be performed, since the brachial plexus and axillary arteries are near the coracoid process and not uncommonly injured.  The axillary nerve is the most commonly injured nerve, and sensation over the skin of the deltoid muscle should be tested routinely.  Injury to the axillary artery is the commonest vascular injury and may be suggested by paresthesias, pallor, pulselessness, or an expanding hematoma.  

General treatment in over 80% of all cases- consists of immobilization with a sling and swathe or collar and cuff, ice, analgesics, and referral.  Early exercise is important to avoid adhesive capsulitis.

Anonymous Tintinalli 1789-1799

 

23.    Describe treatment of humeral shaft fractures.

Zen Seeker Tinitinalli EM Fifth Edition

The actions of the muscles inserting on the humeral shaft determine fracture angulation and displacement. Humeral fractures anterior view: A. Angulation of fragments with fracture line distal to rotator cuff insertion. B. Angulation of fragments with fracture line distal to pectoralis major insertion. C. Angulation of fragments with fracture line distal to deltoid insertion.

 

Humeral Shaft

Fractures of the humeral shaft occur in a bimodal age distribution, with peaks in the third and seventh decades of life, representing active young men and osteoporotic elderly women, respectively. The most common site of fracture is the middle third. Neurovascular injuries are a common complication of these fractures and are a direct result of the anatomy of the upper extremity. Displacement of fracture fragments is common as a result of the insertions and actions of the various muscles (deltoid, biceps, triceps, supraspinatus, and pectoralis major) that act on the upper arm (Fig. 263-11).  

 

Humeral shaft fractures may be caused by a direct blow that produces a bending force, which results in a transverse fracture. It may also be caused by an indirect mechanism, such as a fall on the outstretched hand that produces a torsion force, resulting in a spiral fracture. A combination of bending and torsion forces results in an oblique fracture, sometimes with comminution, producing the “butterfly” fragment. The humerus is also a common site of pathologic fractures, especially from metastatic breast cancer.

 

Clinical examination reveals localized tenderness, swelling, pain, and abnormal mobility or crepitus on palpation. Displaced fractures are associated with shortening of the upper extremity. Attention must be given to the initial neurovascular status, and reevaluation must be performed, especially after manipulation. Radiographs should include two views of the humerus, and consideration should be given to radiographic examination of the shoulder and elbow as well. 

 

The vast majority of closed fractures of the shaft of the humerus are managed nonoperatively. The treatment of uncomplicated fractures includes immobilization, ice, analgesia, and referral. Closed treatment options include the coaptation splint (sugar tong), a hanging cast, functional bracing, and external fixation. A simple sling and swathe are adequate for most emergency management. Some surgeons favor internal fixation for patients with transverse fracture lines, very proximal or very distal humerus fractures, pathologic fractures, multiple trauma, and fractures associated with neurovascular injuries.

 

Complications include injury to the brachial artery or vein, or the radial, ulnar, or median nerves. A radial nerve injury, which is the most common, may be manifested by a wrist drop and altered sensation at the dorsal first web space. The incidence of radial nerve palsy ranges from 10 to 20 percent. Fractures of the distal third are particularly prone to entrapment of the radial nerve either as a result of the initial injury or after closed reduction. The majority of patients have eventual return of nerve function without operative intervention.

Zen Seeker Tintinallii 1791

            The vast majority of closed fractures of the shaft of the humerus are managed nonoperatively.  The treatment of uncomplicated fractures includes immobilization, ice, analgesia, and referral.  Closed treatment options include the coaptation splint (sugar tong), a hanging cast, functional bracing, and external fixation.  A simple sling and swathe are adequate for most emergency management.  Some surgeons favor internal fixation for patients with transverse fracture lines, very proximal or very distal humerus fractures, pathologic fractures, multiple trauma, and fractures associated with neourovascular injures.

Anonymous pg 1790

Closed fx’s of the shaft are managed non-operatively.  The tx of uncomplicated fx’s includes immobilization, ice, analgesia, and referral.  Closed tx options include the coaptation splint (sugar tong), a hanging cast, functional bracing, and external fixation.  T simple sling and swathe are adequate for most emergency management.  Some surgeons favor internal fixation for patients with transverse fx lines, very proximal or very distal humerus fx’s, pathologic fx’s , multiple trauma, and fx’s associated with neurovascular injuries.

Anonymous  1790-1791

Managed non-operatively with immobilization, ice, analgesia, and referral.  Immobilization may involve: coaptation (sugar tong) splint, hanging cast, functional bracing and external fixation.

 

24.    Identify the patient with subacromial bursitis and describe how it presents.

Zen Seeker Tinitinalli EM Fifth Edition

SUBACROMIAL BURSITIS

Pathophysiology

Subacromial bursitis is associated with stage 1 impingement and is typically characterized by localized edema and inflammation in the subacromial bursa. More importantly, an early inflammation of the rotator cuff tendon usually coexists. Subacromial bursitis typically is seen in patients under 25 years of age and usually results from mechanical irritation from repetitive overhand activities. It is important that this condition be recognized because it is reversible. If left unrecognized and untreated, it progresses to the irreversible conditions associated with stage 2 and stage 3 impingement.

 

Primary subacromial bursitis is rare but should be considered in patients with shoulder pain who have rheumatoid arthritis, tuberculosis, gout, or pyogenic infections.

 

Clinical Features

Patients usually describe the pain of subacromial bursitis as a dull aching sensation deep within the shoulder, frequently following activity and usually improving with rest. Patients usually seek medical attention only when the symptoms affect their work, performance, or ability to compete. On physical examination, no muscular atrophy or asymmetry is present unless the symptoms have been chronic. Little if any tenderness is elicited on palpation; however, when tenderness is present it typically will be found on the lateral aspect of the proximal humerus or on deep palpation in the subacromial space. Full range of motion in the shoulder is usually preserved but may be painful, especially between 60° and 100° of abduction. The pain is worse when resistance is applied to the arm in 90° of abduction. Muscle strength in the deltoid and rotator cuff muscles is usually not affected. Impingement signs and impingement injection tests are usually positive.

 

Radiographic Findings

Most often radiographs are normal in the early stages of impingement associated with bursitis.

 

 

 

Emergency Department Treatment

The goals of treatment of subacromial bursitis and early rotator cuff tendinitis are twofold: to reduce pain and inflammation and, more importantly, to prevent progression of this reversible process to the irreversible stages of rotator cuff tendinitis and degeneration.

 

More than 90 percent of patients with subacromial bursitis respond to conservative measures. An effective conservative treatment plan has been outlined previously in this section. Since inflammation of the bursa is typically due to overuse, a short period of relative rest is indicated. Immobilization is not indicated and, in fact, can be detrimental, leading to adhesions and loss of motion. Total inactivity usually is not necessary. Relative rest implies avoidance of those activities that reproduce symptoms; e.g., a tennis player should avoid serving but can continue to hit ground strokes, and a laborer should avoid working with his or her arms over the head. Nonsteroidal anti- inflammatory agents are effective in reducing pain and inflammation. Analgesics are rarely needed to control pain. Localized ice treatment for 10 to 15 min two to three times per day will help reduce pain and inflammation. As pain diminishes, the patient should begin gentle range of motion, stretching, and strengthening exercises.

 

Follow-up

Clinical follow-up is recommended in 7 to 14 days. To simply diagnose “bursitis” and treat the symptoms does the patient a disservice and places the patient´s shoulder at risk for future dysfunction. At the time of follow-up, if the patient´s symptoms have diminished, a supervised course of therapy with emphasis on rotator cuff strengthening may be prescribed. If symptoms persist or have worsened, a subacromial injection of a glucocorticoid may help arrest the inflammatory response. If symptoms persist despite full conservative measures after 6 to 12 weeks of treatment, further workup with arthrography or MRI to rule out rotator cuff disease may be initiated at the discretion of the patient´s primary clinician.

Zen Seeker Tintinallii 1876

Subacromial bursitis is associated with stage 1 impingement and is typically characterized by localized edema and inflammation in the subacromial bursa.  More importantly, an early inflammation of the rotator cuff tendon usually coexists.  Subacromial bursitis typically is seen in patients under 25 years of age and usually results from mechanical irritation from repetitive overhand activities.  It is important that this condition be recognized because it is reversible.  If left unrecognized and untreated, it progresses to the irreversible conditions associated with stage 2 and stage 3 impingement.

            Primary subacromial bursitis is rare but should be considered in patients with shoulder pain who have rheumatoid arthritis, tuberculosis, bout, or pyogenic infections.

Clinical features -   Patients usually describe the pain of subacromial bursitis as a dull aching sensation deep within the shoulder, frequently following activity and usually improving with rest.  Patients usually seek medical attention only when the symptoms affect their work, performance, or ability to compete.  On physical examination, no muscular atrophy or asymmetry is present unless the symptoms have been chronic.  Little if any tenderness is elicited on palpation; however, when tenderness is present it typically will be found on the lateral aspect of the proximal humerus or on deep palpation in the subacromial space.  Full range of motion in the shoulder is usually preserved but may be painful,  especially between 60° and 100° of abduction.  The pain is worse when resistance is applied to the arm in 90° of abduction.  Muscle strength in the deltoid and rotator cuff muscles is usually not affected.  Impingement signs and impingement injection tests are usually positive.

Anonymous

Subacromial bursitis is associated with sage 1 impingement and is typically characterized by localized edema and inflammation in the subacromial bursa.  More importantly, an early inflammation of the rotator cuff tendon usually coexists.  Subacromial bursitis typically is seen in pts under 25 yrs of age and usually results from mechanical irritation from repetitive overhand activities.  Pt’s usually describe the pain of it subacromial bursitis as a dull aching sensation deep within the shoulder, frequently following activity and usually improving with rest.  On PE, no muscular atrophy or asymmetry is present unless the symptoms have been chronic.  Little if any tenderness is elicited on palpation; however, when tenderness is present it typically will be found on the lateral aspect of the proximal humerus or on deep palpation in the subacromial space.  Full ROM in the shoulder is usually preserved but may be painful especially between 60-100 degrees of abduction.  Pain is worse when resistance is applied to the arm in 90 degrees of abduction.  Muscle strength in the deltoid and rotator cuff muscles is usually not affected.  Impingement signs are usually positive.  Most radiographs are normal in the early stages of impingement associated with bursitis.

Anonymous  Tintinalli 1876

Patients are 25 years of age with pain resulting from mechanical irritation from repetitive overhand activities.  Presents as a dull aching sensation deep within the shoulder, following activity and usually improving with rest.

 

25.    Describe the clinical features of rotator cuff tendonitis and how it is generally treated in the ED.

Zen Seeker Tinitinalli EM Fifth Edition

ROTATOR CUFF TENDINITIS

Pathophysiology

Inflammation of the rotator cuff tendons occurs initially in stage 1 of impingement. Continued repetitive mechanical impingement leads to irreversible fibrosis and thickening of the tendons of the rotator cuff, the hallmark of rotator cuff tendinitis. These findings are thought to represent the second stage of impingement. The supraspinatus is the tendon most commonly affected; however, any of the rotator cuff tendons may be involved.

 

Clinical Features

Patients with rotator cuff tendinitis are typically between the ages of 25 and 40 years, but the duration of the symptoms is more useful than age in making this diagnosis. The patient will report prior episodes of shoulder pain or a long duration of pain before seeking treatment. Since the lesion is not reversible, time and activity modification alone will not improve the symptoms. Patient describe the pain as a deep, aching discomfort that interferes with work and normal daily activities. Night pain, especially sleeping on the affected arm or with the arms above the head, will interfere with sleep. On examination, disuse atrophy of the shoulder musculature may be present if symptoms have been chronic. Palpation of the rotator cuff insertion at the lateral aspect of the proximal humerus will usually produce pain and tenderness. During range-of-motion maneuvers, fibrosis and scarring within the tendon can cause crepitus. A sensation of catching also may be present if scar tissue is trapped beneath the acromion. Both active and passive motion may be limited due to the scarring. Rotator cuff strength testing will reveal mild to moderate weakness. Pain will usually be present when resistance is applied. The individual muscles of the rotator cuff can be isolated and tested individually. To test the supraspinatus, abduct the arm to 90° and place it forward 30° with the thumb pointed down in the so-called empty beer can position. Pain or weakness against resistance in this position suggests injury to the supraspinatus. External rotation tests the infraspinatus and the teres minor. To test external rotation, place the patient´s arm against the body with the elbow bent to 90° and the forearm in neutral position. Stabilize the elbow against the patient´s waist and instruct the patient to rotate the arm outward. In this same position, with the elbow flexed and fixed against the patient´s body, have the patient rotate the arm inward around the front of the body against resistance. This internal rotation tests subscapularis function.

 

The impingement sign is usually positive because the inflamed tendons are compressed beneath the coracoacromial arch. Injection of subacromial anesthetic may diminish pain but generally does not improve motion or strength significantly.

 

Radiographic Findings

Radiographs are most often normal but may yield helpful diagnostic clues. The presence of osteophytes off the inferior clavicle or acromion represents a long-standing process. These osteophytes can contribute to further injury to the underlying tendons. The soft tissues of the subacromial space should be inspected for evidence of calcification.

 

Emergency Department Treatment

Treatment of tendinitis emphasizes controlling symptoms, preserving motion, and improving strength and flexibility. Immobilization should be avoided, although an arm sling may be provided for comfort and support during acute symptoms. Nonsteroidal anti-inflammatory agents can help reduce pain and inflammation, and occasionally analgesics are necessary. Gentle range-of-motion exercises are recommended as early as symptoms allow to prevent further contraction and scarring.

 

Follow-up

Referral for follow-up is recommended in 7 to 14 days. Early physical therapy with treatment to reduce inflammation along with a supervised stretching and strengthening program are an integral part of treatment. Most patients with tendinitis respond to conservative management, experiencing no significant dysfunction. However, if symptoms persist despite conservative measures, further investigation for a possible degenerative rotator cuff tear may be pursued by the patient´s primary physician.

Zen Seeker Tintinallii 1791

Patients with rotator cuff tendonitis are typically between the ages of 25 and 40 years, but the duration of the symptoms is more useful than age in making this diagnosis.  The patient will report prior episodes of shoulder pain or a long duration of pain before seeking treatment.  Since the lesion is not reversible, time and activity modification alone will not improve the symptoms.  Patients describe the pain as a deep, aching discomfort that interfere with sleep.

            On examination, disuse atrophy of the shoulder musculature may be present if symptoms have been chronic.  Palpation of the rotator cuff insertion at the lateral aspect of the proximal humerus will usually produce pain and tenderness.  During range-of-motion maneuvers, fibrosis and scarring within the tendon can cause crepitus.  A sensation of catching also may be present if scar tissue is trapped beneath the acromion.  Both active and passive motion may be limited due to the scarring.  Rotator cuff strength testing will reveal moderate weakness.  Pain will usually be present when resistance is applied.  The individual muscles of the rotator cuff can be isolated and tested individually.  To test the supraspinatus, abduct the arm to 90° and place it forward 30° with the thumb pointed down in the so-called empty beer can position.  Pain or weakness against resistance in this position suggests injury to the supraspinatus.  External rotation tests the infraspinatus and the teres minor.  To test external rotation, place the patient’s arm against the body with the elbow bent to 90° and the forearm in neutral position.  Stabilize the elbow against the patient's body, have the patient rotate the arm inward around the front of the body against resistance.  This internal rotation tests subscapularis function.

            The impingement sign is usually positive because the inflamed tendons are compressed beneath the coracoacromial arch.  Injection of subacromial anesthetic may diminish pain but generally does not improve motion or strength significantly.

Emergency Department Treatment

            Treatment of tendonitis emphasizes controlling symptoms, preserving motion, and improving strength and flexibility. Immobilization should be avoided, although an arm sling may be provided for comfort and support during acute symptoms.  Nonsteroidal anti-inflammatory agents can help reduce pain and inflammation, and occasionally analgesics are necessary.  Gentle range-of-motion exercises are recommended as early as symptoms allow to prevent further contraction and scarring.

Anonymous Tintinalli Ch.275,p.1876

Clinical features include reproducible pain on the Neer + the Hawkins impingement tests that are described on p.1875.

ED Tx: The goals are to reduce pain + inflammation; prevent further progression regardless of the stage of impingement identified. Conservative treatment initiated in the ED should include:

meds to reduce pain + inflammation

cryotherapy (ice packs)

followed by pt. education on:

gentle ROM exercises  

relative rest + modification of activities

stretching + strengthening

Anonymous Tintinalli 1876-1877

Ages 25-40.  Episodes of pain, or long duration of pain before seeking care.  The pain is described as a deep, aching discomfort that interfere with a work in daily activities.  Pain affects sleep.  Palpation of rotator cuff insertion at the lateral aspect of the proximal humerus produces tenderness.  Disuse atrophy of the shoulder if the symptoms are chronic.  Crepitus on range of motion maneuvers.  Active and passive motion is limited.  Rotator cuff strength test reveals mild to moderate weakness in the affected shoulder.  Pain with resistance to movement.  Impingement sign is positive.  Treatment emphasizes control of symptoms, preserving motion, and improving strength and flexibility.  Immobilization is avoided, though a sling may be provided for discomfort during acute symptoms.  NSAIDs and analgesics, gentle range of motion exercises are recommended.

 

26.    Describe the etiology of calcific tendonitis, how it presents, and how it can be diagnosed by x-ray.

Zen Seeker Tinitinalli EM Fifth Edition

CALCIFIC TENDINITIS

Pathophysiology

Calcific tendinitis is considered a unique and still poorly understood disease process. It is characterized by the deposition of calcium hydroxyapatite crystals within one or more tendons of the rotator cuff. In time, the calcium deposition undergoes spontaneous resorption, with subsequent healing of the tendon. Calcific tendinitis does not appear to be related to any generalized disease process nor does its presence correlate with episodes of trauma or incidence of rotator cuff tears.

 

Primary tendon degeneration as a result of chronic repetitive microtrauma, age, or tissue hypoxia is considered to be the primary cause of this disorder. The supraspinatus is by far the most commonly affected tendon, with calcium deposition usually occurring 1 to 2 cm proximal to the insertion on the humerus; however, any of the rotator cuff tendons as well as the tendon of the long head of the biceps may be affected. After a variable period following the deposition of the calcium, spontaneous resorption occurs. The factors triggering resorption are unclear. With resorption of the calcium, the defect in the tendon remodels and heals.

 

The initial formation of the deposit is associated with few, if any, symptoms and little dysfunction. However, significant pain is associated with the resorption of the calcium deposit. This pain is thought to be due to the relative increase in pressure and volume within the tendon caused by vascular proliferation and the formation of granulation tissue.

 

Clinical Features

Patients in their thirties and forties are most commonly affected. This process is rarely seen in patients over 70. Of patients older than age 30 with shoulder pain, calcification in the rotator cuff tendons is found in approximately 7 percent. However, in asymptomatic patients between 31 and 40, 10 to 20 percent demonstrate rotator cuff calcification on routine radiographs. Of these patients, 35 to 45 percent will eventually become symptomatic. Females are affected more commonly than males, and calcification is often present bilaterally.

 

The onset of pain typically coincides with the resorption of the calcium deposit rather than the formation of it. Symptomatic patients experience sudden onset of shoulder pain, usually at rest. Any shoulder motion reproduces significant pain. The pain is often worse at night and interferes with sleep. The symptoms are usually self-limited, lasting 1 to 2 weeks in most cases. However, occasionally symptoms may be more indolent, producing less acute pain but lasting several weeks.

 

During an acute attack with intense pain, patients hold their arm across their body and often are reluctant to move it. Often a point of maximum tenderness can be palpated, usually over the proximal humerus near the tendinous insertion of the rotator cuff. Active and passive motion both are limited due to pain. Patients often report a sensation of catching when they move their shoulder through an arc of motion. Crepitus is frequently present with motion.

 

Radiographic Findings

Routine shoulder radiographs will reveal the calcific deposits. Deposits in the supraspinatus are readily visible on films in neutral rotation. Internal rotation of the humeral head best reveals deposits in the infraspinatus and teres minor. In patients with acute pain where resorption is actively occurring, calacium deposition may be ill defined or barely visible. However, during the formative phase, the deposit is usually dense, well defined, and easily visualized.

Anonymous Tintinalli Ch.275,p.1879

Etiology: Calcium hydroxyapatite crystals deposit in 1 or more rotator cuff tendons. The deposits spontaneously resorb over time w/ subsequent healing of the tendon. It is not understood why this happens + is not associated w/ trauma or a disease process.

Presents most commonly in pts. 30 – 40 y/o. Females affected more than males. Pain coincides w/ resorption of crystals as opposed to the formation. The onset of pain is sudden +usually occurs at rest. It is often present bilaterally. Any shoulder movement reproduces significant pain. Pain is often worse at night + interferes w/ sleep. The symptoms are self-limiting + usually last 1 to several wks.

Dx : Calcific deposits will be found in the supraspinatus in neutral rotation. Internal rotation of the humerus gives best visualization of deposits in the infraspinatus. During resorption, deposits may be ill defined + barely visible.  During formation they are well defined + easily seen.

Anonymous Tintinalli 1879

Calcific tendinitis is the deposition of calcium hydroxyapatite crystals within one or more tendons of the rotator cuff.  Primary tendon degeneration results from chronic repetitive microtrauma, age, or tissue hypoxyia which is considered the primary cause of the disorder.  Patients are in their 30s-'40s, rarely seen in patients over 70.  Patients experience of the onset of shoulder pain, usually at rest.  Shoulder motion reproduces pain.  Pain is worse at night and interferes with sleep.  Symptoms are usually self-limited lasting one to two weeks; occasionally pain may last for several weeks.  During acute attack with intense pain, patients hold arm across their body and are reluctant to move it.  Often a point of maximum tenderness may be palpated over the proximal humerus near the tendon insertion of the rotator cuff.  Patients report a sensation during arc of motion, and crepitus is frequently present with motion.  Radiographs will reveal calcific deposits in the supraspinatus in the neutral position.  Internal rotation of the humeral head reveals deposits in the infraspinatus and teres minor.

Jennyb Tintinalli p. 1879

            Calcific tendonitis is characterized by the deposition of calcium hydroxyapatite crystals within one or more tendons of the rotator cuff.  The disease is poorly understood and does not correlate with episodes of traum or incidence of rotator cuff tears.  The supraspinatus is the most commonly affected tendon and after the calcium deposits spontaneous resorption  occurs.  The pt has few initial symptoms although pain is associated with the resorption of the calcium.  Pts in their 30’s and 40’s are most commonly affected.  Routine X-rays will show calcium deposits.   

VB. Tintinalli pg 1879

Characterized by deposition of calcium bydrozyapatite crystals within one or more tendons of the rotator cuff.

Does not appear to be related to any generalized disease process.

Presents with sudden onset pain at rest and often worse at night lasting 1-2 weeks.

Pain due to calcium reabsorption rather than deposits.

X-ray presents- calcific deposits in the supraspinatus.

 

27.    Identify the four cardinal signs of flexor tenosynovitis, what usually causes it, and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

FLEXOR TENOSYNOVITIS

Flexor tenosynovitis is a surgical emergency that must be diagnosed promptly by the examining physician and managed aggressively by both the emergency physician and the hand surgeon. Failure to accurately diagnose and manage a flexor tenosynovitis will lead to loss of function of the digit and eventually loss of function of the entire hand. Diagnosis is made by recognizing the classic clinical findings described by Kanavel. The four cardinal signs are tenderness over the flexor tendon sheath, symmetric swelling of the finger, pain with passive extension, and a flexed posture of the involved digit at rest.9,10  

 

The infection usually is associated with penetrating trauma of the affected area, although the patient may be unaware of this injury. Staphylococcus is the most common bacteria isolated; however, infections often harbor anaerobes and are routinely polymicrobial in origin.5,6,11 One should suspect disseminated Neisseria gonorrhoeae in any patient who has a recent history consistent with a sexually transmitted disease.

 

The emergency physician should initiate treatment with parenteral antibiotics. This should include a β-lactamase inhibitor or first-generation cephalosporin and penicillin. Vancomycin should be considered for patients who abuse drugs intravenously because they may harbor methicillin-resistant S. aureus (MRSA).1 Any spontaneous exudate from the infection should be sent for Gram stain and culture with sensitivities.

 

The hand should be immobilized and elevated, and a hand surgeon should be consulted on an emergent basis. If the infection is identified early in its course, conservative therapy may be indicated initially. The patient would then be treated with parenteral antibiotics, immobilization, elevation, and reevaluation within 24 h. The decision to manage the patient without operative intervention must be made with involvement of the hand surgeon

Anonymous Tintinalli Ch.277, p1886

a/ tenderness over the flexor tendon sheath

b/ symmetrical swelling of the finger

c/ pain w/ passive extension

d/ flexed posture of involved digit

Flexor tenosynovitis is a surgical emergency commonly caused by s. aureus, strep. + pseudomonas.

Tx: Pt. is admitted for splinting, elevation + IV antibiotics. Pt. should be seen immediately by a qualified hand surgeon for surgical decompression of the tendon sheath + placement of irrigation catheters.

Anonymous  Tintinalli 1886-1887

Jennyb Tintinalli p.1886

Flexor tenosynovitis is a surgical emergency.  Failure to diagnose will lead to loss of function to the digit and eventually to the whole hand.  The 4 cardinal signs are:

1.  Tenderness over the flexor tendon sheath

2.  Symmetric swelling of the involved digit

3.  Pain with passive extension

4.  A flexed posture of the involved digit at rest

The infection is usually associated with penetrating trauma and staph is the most common bacteria.  However, neisseria gonorrhoeae should be suspected in a pt with a recent history of a STD.  Treatment includes parenteral abx with a beta-lactamase inhibitor or 1st generation cephalosporin and penicillin.  The hand should be immobilized and elevated and reevaluated in 24 hours with a consultation to a hand surgeon.

VB. Tintinalli pg 1886

•  Tenderness over flexor tendon sheath

•  Symmetric swelling of finger

•  Pain with passive extension

•  Flexed posture of involved digit at rest.

 

28.    Describe what a paronychia is, what causes it, and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

Paronychia. A. The eponychial fold is elevated using a flat probe or no. 11 blade in order to allow the wound to drain. B. Alternately, a no. 11 blade may be used to incise the area of greatest fluctuation directly into the epionychium. The wound may then be gently probed with a small clamp to ensure drainage.

 

PARONYCHIA

A paronychia is an infection of the lateral nail fold or paronychium (Greek: para, “beside” + Greek: onyx, “nail”). Occasionally this may extend to the cuticle or eponychium (Greek: epi, “upon” + onyx). These common conditions are usually caused by minor trauma such as nail biting, manicures, or hang nails. The infection starts as a small area of induration that may be erythematous and tender.4  

 

Most paronychia contain both aerobic and anaerobic bacteria. S. aureus and Streptococcus species are the most common aerobic bacteria cultured from these abscesses.7 Chronic peronychium may occur, particularly in patients who are immunocompromised. Atypical bacterial or fungal infections such as C. albicans have been identified in these cases.

 

If no fluctuance is identified, the paronychia may be treated with warm soaks, elevation, and antibiotics (see Table 277-1). Early intervention may prevent the need for surgical drainage. After suppuration has occurred, the infection will exhibit either fluctuance or identifiable pus that will necessitate drainage. Minor infections can be treated with elevation of the paronychium or epionychium with a flat probe or no. 11 blade (Fig. 277-4). This procedure sometimes can be performed without placing a digital block or providing analgesia. 

 

More extensive infections that do not communicate directly with the nail fold may require incision directly into the area of greatest fluctuance. A digital block should be performed using lidocaine or bupivicaine prior to these more invasive procedures. Severe infections with pus beneath the nail require removal of a portion of the lateral or proximal nail to ensure adequate drainage.9 Rarely, a free-floating nail will be encountered on a bed of pus, necessitating removal of the entire nail.

 

Following incision and drainage, the patient should be instructed to keep the hand elevated and immobilized. Warm soaks may be initiated to keep the wound open and clean. The patient should be scheduled for reevaluation in 24 to 48 h. If significant cellulitis is present, a short course of antibiotics should be prescribed.

Anonymous Tintinalli Ch.277,p.1888

Paronychia is an infection between the eponychium + nail root. It usually occurs in the lateral nail fold + is quite painful. It is most commonly caused by s. aureus +strep.

Tx: Treatment is by incision + drainage. Extensive infections may need to be packed. Antibiotics are usually not necessary.

Anonymous  Tintinalli 1888

Infection of the lateral nail fold (paronychium).  May extend into the cuticle.  Caused by minor trauma (nail biting, manicures, hangnails).  Infection may contain aerobic or anaerobic bacteria.  With no fluctuance, paronychia is treated with warm soaks; elevation and antibiotics.  With fluctuance incision and drainage is necessary, with revaluation in 24-48 hours.  With cellulitis, antibiotics should be prescribed.

Jennyb Tintinalli p. 1888

            Paronychia is an infection of the lateral nail fold or paronychium.  These are usually caused by minor traum such as nail biting, manicures, or hang nails.  Most paronychia contain both aerobic and anaerobic bacteria.  Staph and strep are the most common.  Treatment includes warm soaks, elevation, and abx.  Surgical drainage may be necessary if pus is identified.

VB. Tintinalli pg 1888

Parynchychia is an infection of the lateral nail fold or paronchium.  

Cause- minor trauma such as nail biting, manicures, or hang nails.

Most common pathogens- S. aureus, and strep.  In chronic- C.abicans

Treated- warm soaks, elevation and antibiotics if no fauctuance.  If pus then I/D, irrigate and dress

 

29.    Describe felon, how it presents, most common organism involved, and how it is treated.  

Zen Seeker Tinitinalli EM Fifth Edition

Felon. A. The unilateral longitudinal approach is the most frequently used method for draining felons. This approach minimizes interference with sensate areas of the finger pad. B. If the felon is pointing on the volar surface of the finger pad, the longitudinal volar approach may be used.

 

FELON

A felon is a subcutaneous pyogenic infection of the pulp space of the distal finger or thumb. The septa of the finger pad produce multiple individual compartments and confine the infection under pressure. The patient presents with marked throbbing pain and a red, tense distal pulp space. Infection typically begins with minor trauma to the dermis overlying the finger pad. With time, the bacterial infection gradually spreads between septa forming multiple compartmentalized abscesses. Left untreated, the infection may spread to the flexor tendon sheath and the interphalangeal joints, or eventually, osteomyelitis may develop.

 

S. aureus is the most common organism; however, Streptococcus species, anaerobes, and gram-negative organisms are encountered frequently. A Gram stain and culture should be obtained because these infections may be difficult to eradicate, and chronic infections may be caused by atypical organisms.1,4 If osteomyelitis has developed, positive identification of the offending organism is necessary because long-term antibiotic therapy will be indicated.

 

If the finger pad is swollen and tense, or if there is any palpable fluctuance, drainage must be undertaken for healing to begin. A digital block must be performed because the procedure would be extremely painful without adequate anesthesia. A long-acting anesthetic such as bupivacaine should be used because postoperative discomfort is considerable. Most felons can be drained adequately with a limited incision and drainage procedure. A unilateral longitudinal approach is the most frequently used technique because it spares the sensate volar pad and achieves adequate drainage (see Fig. 277-5 A).

 

A no. 11 blade is introduced lateral to the paronychium and is directed in a volar direction until pus is encountered. The incision should be extended to ensure adequate drainage, although it should not extend to the distal interphalangeal (DIP) flexor crease. Likewise, the incision should not carry through the distal end of the finger pad because this would likely cause instability and loss of sensation to the distal fingertip. A small clamp may be used to bluntly dissect septa to ensure complete drainage. If the wound is large enough, a small wick may be placed to encourage continued drainage.9,10  

 

If the felon is pointing toward the volar fat pad, a longitudinal volar approach may be used, as depicted in Fig. 277-5 B. Care should be exercised to avoid extending the incision to the flexor crease of the DIP joint. More extensive incisions such as the fishmouth, hockey stick, and through-and-through incisions are rarely, if ever, indicated. These incisions are routinely associated with loss of sensation to the fingertip and instability of the finger pad.9,10  

 

Following drainage, the wound should be irrigated and then dressed with a dry, sterile dressing. The patient should be instructed to keep the extremity elevated, and the wound should be reevaluated in 24 to 48 h. Warm soaks may be initiated to keep the wound clean and promote continued drainage.

 

Most felons have significant associated cellulitis that should be treated with oral antibiotics.12 A first-generation cephalosporin or antistaphylococcal penicillin should be prescribed for 7 to 10 days or until the infection has abated. Felons not responding to treatments outlined earlier should be referred to a hand specialist for more definitive management and long-term follow- up.

Anonymous Tint 1888

Felon is a subcutaneous pyogenic infection of the pulp space of the distal finger or thumb.  The septa of the finger pad produce multiple individual compartments and confine the infection under pressure.  

The pt presents with marked throbbing pain and a red tense distal pulp space.  Infections begin with minor trauma to the dermis overlying the finger pad.  With time, the bacterial infection gradually spreads between septa forming multiple compartmentalized abscesses.  Left untreated the infection may spread to the flexor tendon sheath and the interphalangeal joints, or eventually, osteomyelitis may develop.

Organisms  S. aureus is the most common organism.  Streptococcus species, anaerobes and gram-negative organisms are encountered frequently.

Treatment.  A gram stain and culture should be obtained; these organisms are difficult to eradicate and chronic infections may be caused by atypical organisms.  If osteomyelitis has developed + identification is necessary because long term antibiotic therapy will be indicated.  If the finger pad is swollen and tense drainage may be necessary.  Digital block with long acting anesthetic (bupivicaine) longitudinal approach with #11 blade until pus is encountered.  (A wick may be introduced to encourage drainage if the wound is large enough) , irrigation of the wound and a dry sterile dressing.  Pt should be instructed to keep the extremity elevated and the wound reevaluated in 24h-48h.  Warm soaks may be initiated to keep the wound clean and promote drainage.  Oral antibiotics for cellulitis, 1st gen cephalosporin or antistaph penicillin for 7-10 days.  Felons not responding to tx should be referred to a hand specialist.

Anonymous Tintinalli 1888-1889

Subcutaneous pyogenic infection of the pulp space of the distal finger or thumb.  Presents with marked throbbing pain and a red tense distal pulp space.  S. aureus is the most the common organism.  Incision and drainage after digital block is the treatment.

Jennyb Tintinalli p.1888

            A felon is a subQ pyogenic infection of the pulp space of the distal finger or thumb.  The pt presents with marked throbbing pain and a red tense distal pulp space.  Infection begins with a minor trauma to the dermis overlying the finger pad, and the bacterial infection gradually spreads between the septa forming multiple abscesses.  Most common organisms are staph and strep, but gram neg. and anaerobes are also encountered.  If the finger pad is swollen and tense drainage must occur followed by irrigation and a dry sterile  dressing.  The wound should be elevated and reevaluated in 24 hours.  Oral abx like a first gen. cephalosporin should be administered for 7-10 days until the infection clears.

VB. Tintinalli pg 1888

Felon-subcutaneous pyogenic infection of the pulp space of the distal finger or thumb.

Presents with marked throbbing pain and a red, tense distal pulp space.

S. aureus most common organism.  Step species, anerobes, and gram negative are also likely.

Treated- gram stain and culture obtained.  If finger pad is swollen and tense, or if ther is a palpable fluctuance, then I/D, irrigate, and dress with dry, sterile dressing.  If infected or cellulites, then first-generation cephalosporin or anti-staph penicillin for 7-10 days.

 

30.    Describe DeQuervain’s stenosing tenosynovitis and explain how it can be diagnosed with Finkelstein’s test.

Zen Seeker Tinitinalli EM Fifth Edition

The Finkelstein test is shown. The thumb is cupped in the closed fist and ulnar deviation reproduces pain along the extensor pollicis and abductor pollicis.

 

DeQuervain´s Stenosing Tenosynovitis

DeQueirvain´s tenosynovitis is a common condition that occurs in patients who have experienced excessive use of the thumb. Often no good cause can be found. This is a tenosynovitis of the extensor pollicis brevis and abductor pollicis tendons, where they lie in the groove of the radial styloid.

 

The patient presents with pain along the radial aspect of the wrist that extends into the forearm. The definitive examination that confirms the diagnosis is Finkelstein´s test (Fig. 277-7), in which the patient grasps the thumb in the palm of the hand and the examiner ulnar deviates the thumb and hand. This produces sharp pain along the involved tendons.

 

DeQuervain´s tenosynovitis can be treated with injection into the tendon sheath of 1 mL of 0.5% bupivacaine mixed with 40 mg (1 mL) triamcinolone. This is accomplished by palpating the tendon with the thumb in hyperextension, and injecting 1 cm proximal to the tip of the radial styloid. Distention of the tendon sheath should be seen distal to the retinacular ligament. The tendon itself must not be injected, and care must be taken to avoid subcutaneous or intradermal injection of steroid because this may cause cutaneous thinning and depigmentation. A thumb spica splint should be applied to keep the thumb in a neutral position for 3 weeks. Instruct the patient to remove the splint briefly each day and perform range of motion exercises to prevent joint stiffness. Anti-inflammatory medication should be prescribed for 10 to 14 days. Recurrence of this condition is not uncommon, particularly when related to occupational stress. Persistent cases should be referred to a hand surgeon

Anonymous Tintinalli  p. 1890

A common condition in patients who have experienced excessive use of the thumb.  This is a tenosynovitis of the extensor pollicis brevis and abductor pollicis tendons, where they lie in the groove of the radial styloid.  Pt presents with pain along the radial aspect of the wrist that extends into the forearm.  

Finkelstein’s is the definitive..the patient grasps the thumb in the palm of the hand and the examiner deviates the thumb and hand.  This produces sharp pain along the involved tendons.  

Anonymous  Tintinalli 1890-1891

The condition that occurs in patients who experience excessive use of the thumb.  Finkelstein's test confirms diagnosis when the patient grasps the thumb in the palm of the hand and examiner ulnar deviates the thumb and hand producing pain in the involved tendons.

Jennyb Tintinalli p. 1890

            DeQuervain’s stenosing tenosynovitis is a common condition of pts with excessive and overuse of the thumb.  The pt presents with pain along the radial aspect of the wrist that extends into the forearm.  The definitive test is the finkelstein test in which the pt grasps the thumb in the palm of the hand and the examiner ulnar deviates the thumb and hand.  This produces a sharp pain along the involved tendons.

VB. Tintinalli pg 1890

DeQuarvain’s stenosing tenosynovitis- common condition that occurs in pt’s who experienced excessive use of thumb.   Involves extensor pollicis brevis and abductor pollicis tendon where they lie in the groove of the fadial styloid.

Presents with pain along radial aspect of wrist and extends into forearm.

Dx with Finkelsten’s test-  pt. grasps the thumb in the palm and examiner deviates thumb and hand.  This produces sharp pain along involved tendons.

Tx- injection of 1ml of 0.5% bipivacaine mixed with 1ml triamcinolone proximal to radial styloid.  Thumb spica for 3 weeks.

 

31.    Discuss carpal tunnel syndrome in regard to the following:

         a.            Definition

         b.            Presentation

         c.            Risk factors

         d.            Tinel’s and Phalen’s signs

         e.            Initial treatment

Zen Seeker Tinitinalli EM Fifth Edition

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a peripheral mononeuropathy that involves entrapment of the median nerve in the carpal canal or tunnel, which is covered by the tense transverse carpal ligament. Whenever a condition causes swelling in the carpal tunnel, the median nerve is compressed, causing parasthesias that extend into the index and long fingers and the radial aspect of the ring finger and along the palmar aspect of the thumb.16 The patient often complains of awakening at night with pain in the hand. In addition, patients often complain of numbness when driving a car or maintaining the hand in an extended position for a prolonged period of time.

 

Direct trauma to the wrist may exacerbate symptoms; however, a more common scenario involves overuse syndromes where the patient relays a history of repeated flexion and extension of the wrist that results in edema in the carpal tunnel. Other edematous conditions such as pregnancy and congestive heart failure may acutely exacerbate symptoms in patients with a predisposition for carpal tunnel syndrome.17 It is also more common in diabetes and rheumatoid arthritis.16  

 

Tinel´s sign may support the diagnosis and involves tapping the volar aspect of the wrist over the median nerve. A positive sign produces paresthesias that extend into the index and long finger. Phalen´s sign is more sensitive (50 percent) and specific (75 percent) and involves flexing the wrist maximally and holding it in this position for at least 1 min. The patient complains of tingling and numbness along the median nerve distribution. Both signs are subject to false-positive and false-negative results and electrodiagnostic techniques may be required to confirm the diagnosis.18  

 

Initial treatment of carpal tunnel syndrome involves placing a volar splint to maintain the wrist in neutral position and giving the patient anti-inflammatory agents. Infiltration of the carpal tunnel with a mixture of 1 mL of 0.5% bupivacaine and 40 mg (1 mL) of triamcinolone may be beneficial, if the physician is experienced in the procedure. Unfortunately, this technique often provides only temporary relief. If this does not improve the condition, or if symptoms recur, surgical intervention is necessary to release the entrapment.

 

This condition may have a relapsing course, and permanent deficits of the median nerve occasionally are seen. Carpal tunnel syndrome should be diagnosed early, and the patient should be referred to a hand surgeon in a timely fashion.

Anonymous tint 1890

a.  Definition  a peripheral mononeuropathy that involves entrapment of the median nerve in the carpal canal or tunnel, which is covered by the tense transverse carpal ligament.  Whenever a condition causes swelling in the carpal tunnel, the median nerve is compressed, causing parasthesias that extend into the index and long fingers and the radial aspect of the ring finger and along the palmar aspect of the thumb.

b.  Presentation  The patient often complains of awakening at night with pain in the hand.  Patients often complain of numbness when driving a car or maintaining the hand in an extended position for a prolonged period of time. Direct trauma may exacerbate the symptoms, but the most common scenario is overuse syndromes with repeated flexion and extension of the wrist resulting in edema in the carpal tunnel.

c.  Risk factors  edematous conditions such as pregnancy and CHF and is more common in diabetes and rheumatoid arthritis.

Tinel’s and Phalen’s signs  

Tinel’s sign may support the diagnosis, Tap the volar aspect of the wrist over the median nerve.  A + sign produces paresthesias that extend into the index and long finger.

Phalen’s sign is more sensitive and specific, flex the wrist maximally and holding it in this position for at least a min.  The patient complains of tingling and numbness along the median nerve distribution.  Both signs are subject to false-positive and false-negative results and electrodiagnostic techniques may be required to confirm the diagnosis.

e.  Initial treatment  This involves placing a volar splint to maintain the wrist in neutral position and giving the patient anti-inflammatory agents.  Infiltration with a mixture of 1 ml of .5% bupivicaine and 40 mg of trimcinolonemay be beneficial, if it does not improve surgical intervention is necessary to release entrapment.   

Anonymous Tintinalli 1891

Pam    Tintinalli, p. 1474, 1891

Definition:  Carpal tunnel syndrome (CTS) is a peripheral mononeuropathy that involves entrapment of the median nerve in the carpal canal or tunnel, which is covered by the tense transverse carpal ligament.  

Presentation:  Whenever a condition causes swelling in the carpal tunnel, the median nerve is compressed, causing parasthesias that extend into the index and long fingers and the radial aspect of the ring finger and along the palmar aspect of the thumb.  The pt often complains of awakening at night with pain in the hand.  Pts also often complain of numbness when driving a car or maintaining the hand in an extended position for a prolonged period of time.

Risk factors:  Direct trauma to the wrist may exacerbate sx’s; however, a more common scenario involves overuse syndromes where the pt relays a hx of repeated flexion and extension of the wrist that results in edema in the carpal tunnel.  Other edematous conditions such as pregnancy and CHF may acutely exacerbate sx’x in pts with a predisposition for CTS.  It is also more common in diabetes and rheumatoid arthritis.

Tinel’s and Phalen’s signs:  Tinel’s sign---involves tapping the volar aspect of the wrist over the median nerve.  A positive sign produces paresthesias that extend into the index and long finger.     Phalen’s sign---is more sensitive (50%) and more specific (75%) and involves flexing the wrist maximally and holding it in this position for at least 1 min.  The pt complains of tingling and numbness along the median nerve distribution.  Both signs are subject to false positives and false negatives and electrodiagnositic techniques may be required to confirm the diagnosis.

Initial treatment:  involves placing a volar splint to maintain the wrist in neutral position and giving the pt anti-inflammatory agents.  Infiltration of the carpal tunnel with a mixture of 1mL of 0.5% bupivacaine and 40 mg of triamcinolone may be beneficial, if the physician is experienced with the procedure.  

Jenn Emerg Med Study Guide,pg 1891 & Taber’s

a.       Definition:  (Entrapment neuropathy) Peripheral mononeuropathy that involves entrapment of the median nerve in the carpal canal or tunnel, which is covered by the tense transverse carpal ligament.

b.      Presentation:  Swelling in the carpal tunnel compresses the median nerve causing parasthesias that extend into the index and long fingers and the radial aspect of the ring finger and along the palmar aspect of the thumb.

c.       Risk factors:  Direct trauma to the wrist may exacerbate symptoms; however, a more common scenario involves overuse syndromes where the patient relays a history of repeated flexion and extension of the wrist that results in edema in the carpal tunnel.  Other edematous conditions such as pregnancy and CHF may acutely exacerbate symptoms in pts w/a predisposition for carpal tunnel syndrome.

d.      Tinel’s and Phalen’s signs:

i.                     Tinel’s sign is a cutaneous tingling sensation produced by pressing on or tapping the nerve trunk that has been damaged or is regenerating following trauma.

ii.                   Phalen’s sign is a physical test involving flexion of the fully extended hand at the wrist to aid in the diagnosis of carpal tunnel syndrome.

e.       Initial treatment:  Involves placing a volar splint to maintain the wrist in neutral position and giving the pt anti-inflammatory agts.  Infiltration of the carpal tunnel w/a mixture of 1mL of 0.5% bupivacaine and 40mg of triamcinolone may be beneficial, if the physician is experienced in the procedure (temporary relief).  Patients should be referred to a hand surgeon as an outpatient for further diagnostics and mgt.

 

32.    Describe Dupuytren’s contracture, how the diagnosis is made, and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

Dupuytren´s Contracture

Dupuytren´s contracture is a poorly understood disorder resulting in fibroplastic changes of the subcutaneous tissues of the palm and volar aspect of the fingers. There appears to be a genetic component, and the condition is found most commonly in men of northern European descent.19 This process eventually may lead to tethering and joint contracture. Firm longitudinal thickening and nodularity of the superficial tissues usually are readily appreciated. The diagnosis is made by identifying a nodule in the palm, usually at the distal palmar crease of the ring or small finger, which is held in the classic flexion contracture.20 This condition should be referred to a skilled hand specialist because surgical excision of the fibrotic bands is usually palliative.

Anonymous

A poorly understood disorder resulting in fibroplastic changes of the subcutaneous tissues of the palm and volar aspect of the fingers.  There appears to be a genetic component, and the condition is found most commonly in men of Northern European descent.  It may eventually lead to tethering and joint contracture.  Firm longitudinally thickening and nodularity of the superficial tissues usually are readily appreciated.

Diagnosis: is made by identifying a nodule in the palm, usually at the distal palmar crease of the ring or small finger, which is held in the classic flexion contracture.

Treatment: This condition should be referred to a skilled hand specialist because surgical excision of the fibrotic bands is usually palliative.

Anonymous  Tintinalli 1891

Fibroplastic changes of the subcutaneous tissue of the palm and volar aspect of the fingers.  Diagnosis is made by identifying a nodule in the palm, usually at the distal palmar crease of the ring or small finger, which is held in the classic flexion contracture.  This patient is referred to a hand specialist.

Pam    Tintinalli, p. 1891

            Dupuytren’s contracture is a poorly understood disorder resulting in fibroplastic changes of the subcutaneous tissues of the palm and volar aspect of the fingers.   There appears to be a genetic component, and the condition is found most commonly in men of northern European descent.  This process eventually may lead to tethering and jt contracture.  Firm longitudinal thickening and nodularity of the superficial tissues usually are readily appreciated.  The dx is made by identifying a nodule in the palm, usually at the distal palmar crease of the ring or small finger, which is held in the classic flexion contracture.  This condition should be referred to a skilled hand specialist because surgical excision of the fibrotic bands is usually palliative.

Jenn Emerg Med Study Guide,pg 1891

Dupuytren’s contracture is a poorly understood disorder resulting in fibroplastic changes of the subcutaneous tissues of the palm and volar aspect of the fingers.  There appears to be a genetic component, and the conditions found most commonly in men of northern European descent.  Firm longitudinal thickening and nodularity of the superficial tissues usually are readily appreciated.

Diagnosis is made by identifying a nodule in the palm, usually at the distal palmar crease of the ring or small finger, which is held in the classic flexion contracture.

Treatment:  This condition should be referred to a skilled hand specialist because surgical excision of the fibrotic bands is usually palliative.

 

33.    Discuss the following fractures that can occur in pediatric patients:

         a.            clavicle

         b.            supracondylar fracture of the humerus

         c.            wrist

         d.            hand

Zen Seeker Tinitinalli EM Fifth Edition

CLAVICLE FRACTURE

The clavicle, extending from the scapular acromion process to the manubrium sterni, serves as the sole skeletal connection between the upper extremity and the trunk and absorbs all medial forces imposed upon the upper arm. The clavicle consists of a double curve in the horizontal plane. Viewed from the front, the medial two-thirds is convex, while the lateral one-third is concave. The junction between the two curves represents its structurally weakest area and most frequently fractured site. The clavicle is the most commonly fractured bone in children.

 

Clavicle fractures may occur in the newborn as a result of shoulder compression during a difficult delivery. In the older infant, toddler, or child, the usual mechanism of fracture is a fall onto an outstretched hand or elbow or onto the side of a shoulder. Often, in younger children, the fracture is of the incomplete, or greenstick, type. A direct blow to the clavicle may also cause a fracture.

 

Diagnosis of clavicular fracture is facilitated by its subcutaneous location and the ease of its palpation on examination. Newborns with clavicle fractures may not be symptomatic. When they are symptomatic, it may come in the form of “pseudoparalysis,” or nonuse of the ipsilateral upper extremity. Alternatively, parents or health care providers may notice the bone callus at 2 to 3 weeks of age, indicative of a fracture previously unappreciated.

 

Older infants and children with clavicular fractures have pain on attempted range-of-motion movement of the neck or upper extremity. Soft tissue swelling, point tenderness, and bone crepitance are indicative of the fracture site. In view of the close proximity of the clavicle to the subclavian vessels and lung, careful assessment of the circulation to the ipsilateral upper extremity and chest auscultation are important. Anteroposterior radiographs of the clavicle and shoulder are principally useful in excluding other associated skeletal injuries, particularly those involving the proximal humerus and scapular prominences. Dislocations of the sternoclavicular joint, particularly posterior dislocations of the proximal clavicle, are optimally visualized by lordotic views.

 

Care of the child with a clavicle fracture is principally directed toward comfort and analgesia for the child. The child´s future bone growth and the modeling potential confer great healing and restorative capability to the fractured clavicle. Even displaced fractures nearly always heal well, whether or not strict anatomic reduction is accomplished in the emergency department.

 

“Figure-of-eight” shoulder abduction restraints are available in various sizes and can be offered to children outside infancy. Application should ensure a snug, symmetrical fit without excessive tightness or pinching. As is the case with the application of any orthopedic appliance, subsequent assessment of the child´s neurovascular status in the upper extremities is mandatory. Some children, however, complain of greater discomfort with the figure-of-eight restraint than without. In such instances, the use of an upper extremity sling-and-swathe or shoulder immobilizer will offer adequate protection from the discomfort associated with shoulder and upper extremity movements.

 

Children with either type of immobilizing or restraint device are encouraged to wear the restraint day and night for 2 weeks, followed by daytime use for another 2 to 3 weeks. Oral analgesia sufficient to ensure the child´s comfort is of paramount importance. Follow-up care can be arranged through the child´s primary care physician or an orthopedic surgeon.

 

SUPRACONDYLAR FRACTURES

The most common elbow fracture in childhood is the supracondylar fracture of the distal humeral metaphysis. It is an important injury pattern not only by virtue of its frequency but also because of its associated potential neurovascular complications. Hyperextension forces during a fall against an outstretched arm displace the distal fragment posteriorly and proximally.  

 

The close proximity of the brachial artery to the supracondylar fracture predisposes the artery to contusion, laceration, or entrapment by fractured fragments. Subsequent arterial spasm or compression by splints, casts, or other dressings may further embarrass the arterial blood supply to the muscles of the forearm and to the hand. A resultant forearm compartment syndrome may ensue, with the development within hours of permanent injury and disability to the function of the involved forearm and hand. This is called Volkmann ´s ischemic contracture and is presaged by (1) pain referred to the proximal forearm upon passive extension of the fingers, (2) “stocking- glove” anesthesia of the ischemic hand, and (3) rock hard forearm swelling. Skin perfusion is usually normal despite the severe ischemic insult to the entire forearm and hand, and pulses may remain palpable at the wrist despite serious vascular compromise. The clinical suspicion of a potential ischemic compartment syndrome involving the forearm necessitates an immediate consultation by an orthopedic surgeon who is prepared to offer a complete and radical forearm decompression if reduction of the fracture does not satisfactorily restore vascular integrity.

 

The diagnosis of a supracondylar fracture of the distal humerus is suspected when tenderness is elicited upon palpation of the distal humerus and the child complains of pain on passive flexion of the elbow. The child usually prefers to maintain the forearm in pronation. The degree of soft tissue swelling and ecchymosis of the elbow ranges from severe to subtle.

 

As mentioned above, neurovascular assessment of the hand and forearm is the most critical step in the evaluation of elbow injuries in children. In addition to assessments of vascular integrity, injuries to the ulnar, median, or radial nerves should be noted. Such associated injuries are common, occurring in 5 to 10 percent of children with supracondylar fractures.

 

Differential diagnostic considerations include fractures to the humeral condyles, intercondylar fractures, fractures of the radial head and the olecranon of the ulna, and subluxation of the radial head (“nursemaid´s elbow”). The physical examination of all these conditions may be undistinguishing except for that of nursemaid´s elbow.

 

Definitive diagnosis of supracondylar fractures rests with radiography, which usually delineates the injury. Occasionally the appearance of the fracture line is subtle. Observations of a loss of the usual anterior angulation of the capitellum or of a posterior fat pad sign, indicative of an intraarticular elbow effusion (usually of blood), may confer indirect evidence of a supracondylar fracture if the fracture line itself is inapparent. An anterior humeral line, an imaginary line drawn along the anterior margin of the distal humeral diaphysis, normally bisects the posterior two-thirds of the capitellum in the lateral view of the elbow. In subtle supracondylar fractures with loss of the normal anterior angulation of the capitellum, the anterior humeral line may bisect the anterior portion of the capitellum. In association with a posterior fat pad sign, such a loss of the normal anatomic relationships may well indicate a supracondylar fracture.

 

Management of a child´s supracondylar fracture is begun immediately upon arrival in the department. Splinting of the affected elbow in extension is recommended in order to safeguard against development of secondary injury to the vessels, nerves, and soft tissues surrounding the fracture. Frequent reassessments of neurovascular status of the forearm and hand are important. Consultation with an orthopedic surgeon is necessary in all cases of supracondylar fracture. In cases of neurovascular compromise, immediate fracture reduction is mandatory. Careful monitoring of neurovascular status following fracture reduction and maintenance of the elbow in extension are in order. If an ischemic volar forearm compartment is still suspected over the succeeding 6 h, surgical decompression and/or arterial exploration may be indicated.

 

In the absence of neurovascular compromise, therapy is influenced largely by the degree of displacement of the distal fragment, associated soft tissue swelling, and the reliability of the follow-up arrangements. Admission is indicated for all children whose supracondylar fracture is displaced, who manifest significant soft tissue swelling, or whose parents cannot ensure reliable outpatient follow-up. Open reduction is indicated if closed reduction techniques are unsuccessful, especially for oblique fractures. Outpatient management is considered for the child whose fracture is nondisplaced and has minimal swelling. The orthopedic surgeon should reexamine such children within 24 h of injury.

 

Lateral and medial condylar fractures, intercondylar fractures, and transcondylar fractures carry their own associated risks of neurovascular compromise. Children with such fractures typically present with moderate-to-severe soft tissue swelling and tenderness of the elbow, which is maintained in a moderate degree of flexion. Circulatory integrity of the forearm and hand should be assessed immediately. Peripheral nerve function, particularly ulnar nerve function, is at risk.

 

Immediate orthopedic consultation is indicated, since such fractures often require open reduction and carry risks of long- term sequelae. Neurovascular insults usually resolve nicely with appropriate management of the fracture. Growth arrest is rare.

 

 

         c.            wrist

????

         d.            hand

????

Pam    Current Pediatric, p.804, 823,  824,  

clavicle:  Clavicular fx’s are very common in children and infants.  The pt can be immobilized in a sling for comfort.  The healing callus will be apparent when the fx has consolidated, but this unsightly lump will generally resolve over a period of months to a year.

supracondylar fracture of the humerus:  Supracondylar fx’s tend to occur in children aged 3-6 years and are potentially dangerous because of the proximity to the brachial artery in the distal arm.  They are usually associated with a significant amt of trauma, so that swelling may be severe.  Volkmann ischemic contracture of the forearm may occur as a result of vascular compromise.  When severe swelling is present, the safest course is to place the arm in traction and carefully observe nerve function and the vascular supply to the hand.  The child should be hospitalized and cared for by medical staff experienced with such injuries.  If the blood supply is compromised, exposure of the brachial artery may be necessary.  Most often, these fx’s are treated by closed reduction and percutaneous pinning.  Complications include a resultant cubitus varus (decreased carrying angle) secondary to poor reduction.  This so-called gun-stock deformity of the elbow may be somewhat unsightly but does not usually interfere with jt function.

wrist:  Most swollen wrists without evidence of instability can be splinted for several weeks.  Radial and ulnar fx’s must be ruled out because these are fairly common in children.  Scaphoid fx’s are caused by a force applied to a hyperextended wrist.  If evidence of snuff box tenderness and swelling is present, the wrist must be immobilized for 10 days and then reassessed, even if x-rays are normal.  

hand:  All hand and wrist injuries have the potential for long-term, often serious disability and deserve a thorough eval.  Distal Phalanx Injuries—Tuft injury requires splinting for 6 wks or until the pt is px free.  If there is significant displacement, then a K-wire can be used for reduction.  Nailbed injury often requires splinting and drainage of subungual hemotoma.   Distal Interphalangeal Injuries---Mallet finger or extensor tendon avulsion occurs in ball-handling sports.  The mechanism of injury is a force applied to an extended finger.  Tx is splinting for 6 wks for fx’s and 8 wks for tendon rupture.  Boxer’s fx---is a neck fx of the fifth digit.  These fx’s can be treated by closed reduction and casting for 3 wks.  A displaced fx requires open reduction and internal fixation.

Jenn Emerg Med Study Guide,pg 909

a.                   Clavicle:  This is the most common fracture of childhood, with almost half of these injuries occurring by the age of 7.  The clavicle, extending from the scapular acromion process to the manubrium sterni, serves as the sole skeletal connection between the upper-extremity and the trunk and absorbs all medial forces imposed upon the upper arm.  The clavicle consists of a double curve in the horizontal plane.

i.                                 Newborn:  Clavicle fractures may occur as a result of shoulder compression during a difficult delivery.  They tend to be asymptomatic and when they are symptomatic, it comes in the form of “pseudoparalysis” or nonuse of the ipsilateral upper extremity.

ii.                               Older Infant:  The usual mechanism of fracture is a fall onto an outstretched hand or elbow or onto the side of a shoulder.  They tend to have pain on attempted ROM movement of the neck or upper extremity.  Soft tissue swelling, point tenderness, and bone crepitance are indicative of the fracture site.

iii.                              Younger children:  The fracture is of the incomplete or greenstick type.  A direct blow to the clavicle may also cause a fracture.  Symptoms are the same as the older infant.

         Care of the child w/a clavicle fracture is principally directed toward comfort and analgesia for the child.  The child’s future bone growth and the modeling potential cofer great healing and restorative capability to the fractures clavicle.  Even displaced fractures nearly always heal well, whether or not strict anatomic reduction is accomplished in the ER dept.

b.                  Supracondylar fracture of the humerus:  The most common elbow fracture in childhood.  Hyperextension forces during a fall against an outstretched arm displace the distal fragment posteriorly and proximally.  The close proximity of the bdracial artery to the supracondylar fracture predisposes the artery to contusion, laceration, or entrapment by fractured fragments.

      Diagnosis is made when tenderness is elicited upon palpation of the distal humerus and the child complains of pain on passive flexion of the elbow.  The child usually prefers to maintain the forearm in pronation.

c.                   Wrist:  Scaphoid fractures are caused by a force applied to a hyperextended wrist.  If evidence of snuff box tenderness and swelling is present, the wrist must be immobilized for 10 days and then reassessed, even if x-rays are normal.  A nondisplaced fracture requires at least 6 wks of immobilization in a thumb spica cast. CPDT, pg 824

d.                  Hand:  CPDT, pg 824  All hand and wrist injuries have the potential for long term, often serious disability and deserve a thorough evaluation.

•                    Distal Phalanx Injuries:  Tuft injuries require splinting for 6 wks or until the pt is pain free.  If there is significant displacement, then a K-wire can be used for reduction.  Nail bed injury often requires splinting and drainage of subungual hematomas.

•                    Distal Interphalangeal Injuries:  Mallet finger or extensor tendon avulsion occurs in ball-handling sports.  The mechanism of injury is a force applied to an extended finger.  Treatment is splinting in extension for 6 wks for fractures and 8 wks for tendon rupture.

•                    Thumb Injuries:  Gamekeeper’s thumb is an injury to the ulnar collateral ligament from forced abduction of the metacarpalphalangeal joint.  It is a common skiing injury.

 

34.    Be able to identify the most appropriate imaging technique for soft tissue trauma to the upper extremity to include, the hand, wrist, elbow and shoulder.

Zen Seeker Tinitinalli EM Fifth Edition

Beer Lights

Pam    Tintinalli, p. 1763-1787    (I could not find anything specific for generalized  “soft tissue trauma” in any of my books, so went with the general info Tintinalli gives.  Otherwise, for foreign bodies a “soft tissue” radiograph can always be obtained of any affected extremity, and MRI is the gold standard for any soft tissue eval)

•  Hand:  Radiologic evaluation should include at a minimum a PA, lateral and oblique projection.  Actual or suspected injuries of tendons and nerves should be referred to a hand specialist.  

•  Wrist:  The clinical examination should determine which radiographs are necessary to support the diagnosis.  Standard vws of the wrist include PA, Lat, and Oblique vws.  Other projections may be necessary to profile specific carpal injuries.  Scapholunate ligament instability, triquetrolunate ligament instability, and dislocations of the perilunate and lunate can be demonstrated radiographically.  

•  Elbow:  PA, Lat, Oblique

•  Shoulder:  CT for soft tissue clavicular injuries (ie suspected but radiographically negative sternoclavicular dislocation); for scapular injuries get an AP shoulder view, scapular “Y” view, and axillary view;  for AC joint injuries get AP bilateral AC joint films—(both weightbearing and non-weightbearing).

 

35.    Be able to identify the imaging technique of choice, other than plain films for evaluating proximal humerus fractures.

Zen Seeker Tinitinalli EM Fifth Edition

Radiographs consisting of anteroposterior, lateral shoulder, and axillary views will correctly diagnose most proximal humerus fractures. Fractures of the articular surface may be suggested by a fat fluid level or by a superior joint hematoma that appears to push the humerus downward in the joint as a “pseudosubluxation.” A transthoracic lateral radiograph, tomograms, CT scan, and magnetic resonance imaging scan may also be of value.

Pam    Tintinalli, p. 1790  (Tintinalli did not specify which imaging modality would be the best, but from experience I’ve wagered a good guess.)

            A transthoracic lateral radiograph, tomograms (for those hospitals that still actually HAVE one of those units and don’t have a CT available), CT scan and MRI may also be of value.  Other than plain films, CT would be the imaging technique of choice due to it’s greater sensitivity to bone tissue and it’s cost effectiveness in comparison to MRI.

Jenn Emerg Med Study Guide,pg 1790

            A transthoracic lateral radiograph, tomograms, CT scan, and MRI scan may also be of value.