Upper Extremity Fractures

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Bones susceptible to avascular necrosis: scaphoid, lunate, capitate, talus, navicular, 5th metatarsal, femoral neck.

Ring structures, such as the pelvis, mandible, and C1 vertebrae, tend to disrupt in more than one location.

HAND

*Ring removal is the first priority for any injury with potential for digit swelling

Boxer’s Fracture:
-look for fight bite
-degree of rotation should be assessed by having the patient make a fist – all of the fingers should point to the scaphoid without overlap or “scissoring” of fingers.
-reduce if degree of angulation >45′
—hand is held in a clenched fist, while simultaneous dorsal force is applied on the flexed PIP joint and volar force applied to the proximal metacarpal shaft
hematoma block, a needle is inserted into the fracture and blood aspirated to confirm appropriate placement, then 5cc of lidocaine (without epinephrine) or bupivacaine is injected
ulnar nerve block, 5cc of anesthetic is injected proximal to the ulnar styloid between the ulnar artery (medial) and the tendon of the flexor carpi ulnaris (lateral).

Distal tuft fracture:
-Irrigation, debridement, and IV antibiotics are indicated for open tuft fractures
-prompt referral to a hand surgeon

  1. If the nail plate is intact, leave it in place. Drain the subungual hematoma (via trephination of the nail) to relieve pain and prevent pressure necrosis
  2. Damage or loss of the nail plate requires nail removal, nail bed repair with 6-0 chromic suture, and protection.

-Surgery if the dorsal surface of the phalanx that supports the nail matrix has significant step-off – requires reduction of the nail bed to a flat surface and surgical repair

Mallet Finger: = PIP extensor tendon injury
= either an avulsion of the extensor tendon (without fracture) or an avulsion fracture at the tendon’s attachment at base of the distal phalanx
-clinically: unable to extend the DIP joint actively (passive extension intact)
-pts may present late as pain often is minimal and deformity may be subtle
-splint in slight hyperextension with rapid follow-up with the hand specialist
-splint can be placed on the dorsal or volar surface of the DIP joint with the other joints left mobile
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Bennett’s Fracture:
= fracture at the base of first metacarpal with subluxation of the first metacarpal from the carpo-metacarpal joint
-usu due to axial load injury (ex punching)
-pain and swelling at the thumb base
-exam: limited ROM, CMC instability is frequently noted with gentle stress of the first metacarpal
-this injury may severely affect function bc the carpometacarpal (CMC) joint is critical for pinch and opposition
-can attempt to reduce (thumb traction combined + metacarpal extension) and immobilize in thumb spica however usu strength of APL subluxes the metacarpal again. Often require ORIF – prompt follow-up with a hand specialist
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Rolando’s fracture is a communicated Bennett’s fracture
–need true lateral of the 1st CMC joint xray – for accurate evaluation, determine whether surgery is needed
-thumb spica splint – from just distal to 1st IP joint to mid-forearm with 25 degrees extension at the CMC joint and 0 degrees at the MCP and IP joints.
-early hand follow up

Gamekeeper’s thumb
= injury of the ulnar collateral ligament of the first digit with or without concomitant avulsion fracture of first proximal phalanx
-UCL helps stabilize the thumb MCP joint. It inserts on the ulnar side of the proximal phalanx (next to the webspace). UCL disruption causes significant instability and morbidity
-mechanism: abduction and hyperextension of thumb
-exam: ttp over ulnar aspect of base of proximal phalanx of thumb. Stress the UCL by applying valgus pressure, compare with unaffected side. May need local anesthesia prior
-if suspected, immobilize in thumb spica and f/u with hand 
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Proximal phalanx fracture:
-usu angulated due to forces exerted by the extensors and interosseous muscles
check for rotational deformities, which may be more easily diagnosed by physical exam than radiographically. Have the patient flex all the digits simultaneously. Each finger should point toward the scaphoid. If the injured finger points in a different direction than the others when flexed, a rotational deformity is present. Also assess for nerve and tendon injuries.
-stable, nondisplaced, and nonrotated fractures can be buddy taped
-Reduction (difficult) and immobilization in a gutter splint if unstable: rotational deformity, displaced >5mm, angulated >15mm, or intraarticular
-Surgical fixation if reduction fails, comminution, or in athletes
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PIP dislocation (uncommon in DIP joint which is very stable)
-clinically: unable to extend finger at PIP joint
-reduce (mild exaggeration in the direction of the dislocation to disengage from the articular plate. Then the clinician applies longitudinal traction and firm pressure on the proximal aspect of the middle phalanx to reduce the fracture) and immobilize
-obtain post-reduction films to assess for bony fragments not visualized on prior films
-the articular cartilage may be entrapped, and a hand specialist should be immediately consulted
-If there is evidence of complete ligamentous disruption in all directions on postreduction ROM testing, refer to a hand surgeon for possible operative repair
Screen Shot 2018-01-26 at 1.59.46 PM<– dorsal displacement/dislocations is more common
-Volar dislocations (pic below) are more difficult and often result in hand consultation
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Digit amputations
-obtain information to determine if pt is candidate for reimplantation: time of injury, mechanism of injury, hand dominance, tetanus status, past medical history, and occupation
-exam: note amount of soft tissue soiling and damage. Look for any devitalized tissue which may require debridement and inspect closely for exposed bone (this may be easier after obtaining hemostasis). Observe the amount of remaining nail matrix – remove if <5mm (unlikely to grow)
-amputated digits should immediately be covered in saline-soaked gauze and placed in watertight bag. This bag should then be immersed in a 50/50 mix of ice and water
-use pressure dressings, elevation, and tourniquets to control bleeding (no clamps!)
-treat as open fx and give abx

Proximal PIP avulsion fracture
-injury to volar plate (fibrocartilaginous) which stabilizes PIP joint
-hyperextension injury. Seen on lateral xray
-isolated avulsion fractures –> dorsal finger splint
-if concomitant dislocation (middle phalanx subluxes dorsally) –> reduce in the ED (disengage the middle phalanx, apply traction, and then flex the PIP joint). Place in dorsal extension block splint with the PIP joint in 30° of flexion
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FOREARM

Colles’ fracture:
= distal radius fx with dorsal displacement
-eval for median nerve injury

Smith’s (or reverse Colles’) fracture:
= distal radius fx with volar displacement
-also eval for median nerve injury

Galeazzi Fracture:  RG 
= Fracture of the shaft of Radius + dislocation of distal radioulnar joint (widened DRUJ space)
-Mechanism: direct wrist trauma, FOOSH with forearm in pronation
-tx – OR acutely
-complications:
—Compartment syndrome: increased risk with high energy crush injuries
—anterior interosseous nerve palsy: pure motor deficit – inability to pinch between the thumb and index finger
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Monteggia Fracture: UM 
= Fracture of the proximal portion of the Ulna combined with dislocation of the radial head.
-FOOSH with the forearm in excessive pronation (hyper-pronation injury)
-Complications: radial nerve injury (common) or posterior interosseus nerve injury (pure motor deficit of finger extension)
-consult ortho for OR in adults (Reduction of the radial head and splinting in 90 degrees of flexion with the hand supinated may be done in the ED prior to surgery) or casting in children
-make sure that line drawn through middle of radius intersects capitellum in all views
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ELBOW

Olecranon fracture:
-direct blow to elbow
-olecranon is essential for triceps strength and normal extension of the elbow
-exam: palpable bony fragment, inability to extend elbow against force
-eval for ulnar nerve injury: motor weakness of the interossei muscles of the hand and loss of sensation on the palmar surface of the fifth digit and hypothenar eminence
-displacement >2 mm –> surgery. A fracture line that displaces with flexion of the elbow is considered a displaced fracture
-nondisplaced fractures can be treated by immobilization in 45 to 90 degrees
-fractures that are displaced, involve articular surface, or with nerve injury  –> consult ortho in ED

Occult radial head fracture
-FOOSH mechanism (radial head driven against capitellum)
-look for posterior fat pad, displaced anterior fat pad (“sail sign”)
-exam: ttp of the lateral elbow, may have limited elbow ROM depending on the size of the effusion. Pain on passive forearm pronation, which rotates the radial head
-eval for AIN injury: have pt show OK sign
-sling for comfort with ortho follow up; if comminuted or displaced, immobilize with posterior mold

Supracondylar fracture
-FOOSH with elbow extension, adults and peds
-high risk of vascular injury: brachial artery injury or compartment syndrome – if missed, Volkmann’s ischemic contracture
-also assess ulnar, radial, and median nerve function
-obtain true lateral film: line along the anterior border of the humerus should bisect the capitellum. If not –> posteriorly displaced
-consult ortho for all of these to determine management; pt will likely need admission at the minimum to monitor for compartment syndrome, if not surgery

Elbow dislocation
-can occur in any direction; often assoc with fracture
-for posterior dislocations (most common), brachial artery and median nerve should be assessed before and after reduction attempts
-anterior dislocations are rare and severe. Eval for neurovascular injury
-Reduce by stabilizing the humerus while an assistant applies steady longitudinal traction is applied at the wrist. A “clunk” should be appreciated as the elbow reduces; the elbow then should be flexed to 90° and a posterior mold applied to the elbow in 90 degrees of flexion with the hand in neutral position, and the patient given a sling.
—also the Parvin method: Place the patient prone with the forearm hanging down off the bed with 5-10 lbs of weight hanging off the wrist. Reduction should occur within 15-20 minutes
-consult ortho for open dislocations or those associated with fractures

HUMERUS

Humeral neck fractures:
-occur at surgical neck, anatomic neck, greater &/or lesser tuberosity
-use Neer classification system to guide management:

  • 1-part fractures: nondisplaced, nonangulated –> sling, ortho f/u as outpt
  • 2, 3, 4-part fracture: require ortho consult in ED for surgical planning & management

-obtain axillary or scapular (Y) views (give pain meds prior) to classify accurately and r/u glenohumeral dislocation
-Fractures of the anatomic neck are at risk for avascular necrosis due to the distal-to-proximal vascular supply of the proximal humerus –> close orthopedic f/u regardless of the Neer classification
-isolated greater tuberosity fractures with >5mm of displacement need prompt orthopedic follow-up
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Humeral shaft fracture:
-in peds, think of child abuse esp if spiral (rotational force)
-eval for radial nerve injury and associated shoulder and elbow injuries
-consult ortho if: a neurovascular deficit, an open fracture, or a distal spiral shaft fracture
Transverse fractures: can be managed with a sugar-tong splint and a sling
Spiral or oblique fractures: reduction with traction, immobilized in a coaptation splint or a hanging arm splint. Do NOT use a sling in these cases because it worsens displacement
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SHOULDER

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Anterior dislocation:
-severe pain, held in slight abduction and external rotation and often supported by the opposite extremity, “squared off” appearance (prominence of acromion)
-Assess for neurovascular injury, particularly axillary and radial nerves. Axillary nerve function can be assessed by testing for sensation over the lateral aspect of the shoulder and with motor function of shoulder abduction. The radial nerve can be assessed by asking the patient to extend the wrist and elbow and abducting the thumb
-if neurovascularly intact, obtain films before reduction (and after)
-postreduction films can detect bony defects caused by dislocation that are associated with an increased risk of recurrent shoulder dislocation:

  • Hill-Sach’s deformity -cortical depression (compression fracture) in the head of the humerus (blue arrow)
  • Bankart lesion – avulsion of the anteroinferior glenoid labrum (red arrow)Screen Shot 2018-01-26 at 6.40.08 PM

-complications from most to least frequent: axillary nerve injury (anesthesia of deltoid), humeral head fracture (Hill-Sach’s), and glenoid rim disruption (Bankart)
-can use intra-articular anesthesia or conscious sedation (to decrease muscle tone) for reduction
-reduction techniques:

  • The Stimson technique of hanging weights from the forearm of the prone patient.
  • The two person technique of traction-countertraction with bedsheets.
  • External rotation of Leidelmeyer performed on the supine patient.
  • Elevation maneuver of Cooper and Milch.
  • Scapular manipulation.

-Shoulder immobilization for 3-6 weeks in younger patients, 1-2 weeks in patients over 40. Primary dislocations or cases with associated fracture, rotator cuff injury, axillary nerve injury require orthopedic follow-up
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Posterior dislocation:
-severe pain with the arm held across the trunk in adduction and internal rotation
-usu there is no obvious deformity. The patient will not be able to range the shoulder.
-Neurovascular injuries are uncommon; associated fractures are common
-the normal overlap of the humeral head and the glenoid may be absent in posterior shoulder dislocations
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-on scapular Y or axillary views, the humeral appears lateral to the Y (actually posterior to the glenoid) rather than in-line with the Y
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-blue line: the “trough line sign”, which represents an impaction fracture, or “reverse Hill-Sach’s” lesion (compression fracture of the anteromedial portion of the humeral head produced by the posterior cortical rim of the glenoid)
-reduce by applying axial traction. Anterior pressure from behind the humeral head may help coax the humeral head over the glenoid rim. Place in a sling or shoulder immobilizer and obtain postreduction films to better visualize fractures

Clavicular fracture:
-pts hold the arm adducted; shoulder ROM is limited due to pain. Point ttp, swelling and crepitance. Look for skin tenting and step-offs. Assess for neurovascular injury: brachial plexus and subclavian artery
-conservative mgmt with sling for nondisplaced fractures
-ortho referral for pts at risk of nonunion: distal clavicle fractures, displacement greater than one bone width, shortening >1.5cm, and elderly pts

AC separation:
-fall onto lateral shoulder while adducted. The AC ligaments rupture first, then the coracoclavicular (CC) ligaments
-exam: pain on the superior aspect of the shoulder, shoulder may sag and the clavicle appear prominent. +ttp over the AC joint. Shoulder ROM is often painful. +pain with cross arm adduction testing
-normal AC joint space is 3mm and the normal coracoclavicular distance is 13 mm
—an AC sprain (type 1) is ttp over AC joint without joint separation on films
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Screen Shot 2018-01-27 at 2.11.32 PM–> AC joint widened, CC intact
Screen Shot 2018-01-27 at 2.06.10 PM–> both AC & CC joints widened (clavicle elevates)
-type 1 & 2 (just AC joint affected) –> sling and early ROM
-types 3 & up –> ortho consult to arrange for outpt surgical repair

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