ski injuries to the upper extremities eugene bailey, md department of family medicine suny upstate...
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Ski injuries to the upper extremities
Eugene Bailey, MDDepartment of Family
MedicineSUNY Upstate Medical
University
Toggenburg Ski Patrol2008
Objectives General Comments Humerus fractures
Head Shaft Suprachondylar
Elbow Anterior/Posterio
dislocation Olecrenon fracture Radial head fracture Chorocoid fracture
Wrist Scaphoid fracture Colles fracture
Hand/Fingers Skier’s thumb
(Gamekeeper’s thumb)
Not going to cover Bicipital tendonitis Medial and Lateral epichondylitis Nursemaid’s elbow Carpel tunnel syndrome Bursitis Finger fractures
General CommentsZone of Injury
General CommentsIn the field
ABCs Airway Breathing Circulation
Always assess neurovascular status (CMS = circulation, motor and sensory)
Control any bleeding Do not move victim until stabilized
General Comments If possible, always ask the patient
to “point with one finger to the area that hurts the most.”
Remove jewelry, etc before splinting
Patient will self-splint the upper extremity (internal rotation, elbow flexed and adducted to body)
Self-splinting
“ARMS” Appearance and alignment Radial pulse Motor function and mechanism of
injury Sensation
Prevention
Ski Injuries - Statistics
Upper extremity injuriesSnowboarding
www.ski-injury.com
Upper extremity injuriesSnowboarding – Val, Colorado (10 year survey)
7430 injuries Most 30 yrs or younger 74% men, 26% women 39% beginners, 61% intermediate or experts Men rode more advanced levels than women Results
Injured were more likely to be beginners than non-injured 49.06% upper extremities (56.43% fractures, 26.78%
sprains and 9.66% dislocations) Wrist fx (x scaphoid) more common in beginners, women
and younger age groups Intermediate and expert were more likely to sustain hand,
elbow and shoulder injuries as well as more severe injuries Snowboarders who wear protective wrist guards are ½ as Snowboarders who wear protective wrist guards are ½ as
likely to sustain wrist injurylikely to sustain wrist injury
Idzikowski, et al. AJSM 2000;28:825-832.
Upper extremity injurySkiing
www.ski-injury.com
Upper extremity injurySkiboard
www.ski-injury.com
Humerus Injuries
Bony Anatomy: Humerus Distally – 2
condyles forming articular surfaces of trochlea and capitellum
Proximally – neck and head articulate with glenoid fossa of scapula
Humeral FracturesMOI
Head - Direct trauma to the humerus from collision with an object or fall directly onto the bone
Shaft – bent forces like breaking a stick (shear or torsion)
Supraconylar – upper transmission of force on outstretched hand
Humeral Head fractureDiagnosis
Upper humeral fractures usually involve the surgical neck of the bone
extracapsular low incidence of
avascular necrosis (AVN)
Anatomical Neck intracapsular higher incidence of
AVN
Humeral Head FracturesNEER Classification
*Velpeau view if cannot abduct arm
*
Humeral Head FracturesTreatment
One part fractures (no fracture fragments displaced < 1cm or 45 deg)
Non-operative immobilization in sling1-2 weeks
Early motion started immediately
75% good to excellent results; 10% poor
Any other fracture Closed reduction with
percutaneous pinning ORIF 2-6 weeks to allow pain free
movement
Humeral FracturesComplications
Avascular Necrosis of Humeral Head Especially at risk with 4 part fractures
Non-union 3-6 mos after injury
Shoulder stiffness with prolonged immobilization
Humeral Shaft FractureDiagnosis
Fractures of the shaft of the humerus
1-3% of all fracturesUp to 18% have radial nn palsey
Humeral Shaft Fracture
Humeral FracturesTreatment
Non-operative Acceptable alignment
AP anglulation - 20 deg Varus – 30 deg <30mm shortening
70-80% with 90-100% union rates
Time-consuming and requires cooperative patient
Collar and cuff; coaptation splint; hanging cast; functional bracing
Weight of forearm provides traction
Humeral FracturesTreatment
Operative Absolute Indications
Failure of closed treatment Associated articular involvement Vascular injuries Ipsilateral forearm fractures Pathological fractures Open fractures Polytrauma
Relative Indications Short oblique or transverse fracture in an active
individual Body habitus Patient compliance Staff considerations
Humeral FracturesComplications
Radial nerve palsy Most at risk – distal
1/3 fractures Occurs up to 18% of
fractures 90% neurapraxias
and heal in 3-4 mos Exploration indicated
No recovery in 3-4 mos (clinical or EMG)
Loss of function with closed reduction
Open fractures Holstein-Lewis distal
1/3 spiral fractures
Supracondylar fractureDiagnosis
Supracondylar fractures Most common
pediatric elbow fracture (65% of fractures and dislocations of the elbow)
Commonly associated with neurovascular injury
Supracondylar fracturesDiagnosis
Classification Type I - non-displaced Type II - angulated but not translated
in the sagittal plane with hinging of the posterior cortex of the humerus
Type III - posteriorly displaced with IIIA being posteromedial and type IIIB being posterolateral
Supracondylar FracturesDiagnosis
Radiology AP view
Baumann’s angle Medial
epichondylar epiphyseal angle (MEE)
Lateral view Humero-trochlear angle
Oblique
Supracondylar FractureTreatment
Non-displaced fxs – cast immobilization
Displaced fxs – close reduction with percutaneous pinning
Suprachondylar fractureComplications
Vascular injury – brachial aa
Neurologic deficits – median nerve; possible radial nerve
Volkmann’s contracture
Cubitus varus
Humerus InjuriesEmergency Care
Sling Ladder splint
Elbow Injuries
Radial Anatomy
Radial head articulates with capitellum
Radial neck tapers to radial tuberosity which is insertion for biceps brachii tendon
Ulnar Anatomy Sigmoid/semilunar/ trochlear notch
Anteriorly composed of coronoid process
Posteriorly composed of olecranon process
Articulates with trochlea of humerus
Elbow Joint Articulation- Elbow consists of
articulations: Ulnohumeral (elbow
flexion/extension) Radiohumeral
(forearm pronation/supination)
Radioulnar (forearm pronation/supination)
Elbow InjuriesMOI
Fall onto outstretched hand with elbow extended or direct trauma
Elbow dislocationDiagnosis
Second to shoulder dislocations
Posterior dislocation account for 80-90%
Most occur without fracture
Elbow dislocationTreatment
Immediate reduction vs splint and refer
Children should be splinted; increase incidence of fractures
Need for radiographs
After relocation Assess neurovascular
status Assess joint stability Rehab early
Elbow fracture
Radial head – 30%
Olecrenon – 20% Coronoid
fractures – 10 to 15% of elbow dislocations
Elbow fat pads
Elbow Fat Pads
Elbow FracturesTreatment
Radial Head Non-displaced (type I)
sling and or splint until no pain
Displaced (type II) Longer immobilization (1-2
weeks) removal of bone fragments
if necessary Comminuted (Type III)
Surgery to remove bone fragments
Repair ligament damage
Elbow FracturesTreatment
Olecrenon Fracture Non-displaced (type I)
Sling, splint and or cast for 3-4 weeks
Follow by x-ray for dislocation of fracture
Displaced (type II) ORIF
Comminuted (Type III) ORIF
Elbow FracturesTreatment
Coronoid Fracture Type 1
Immobilization for 2 weeks Type 2
Immobilization for 2 weeks Displaced or humeroulnar
joint instability may consider ORIF
Type 3 ORIF
Elbow dislocation or fractureEmergency Care
Immobilize Sling Posterior elbow
splint using ladder splint or SAM splint
ice
Wrist Injuries
Anatomy of the wrist
Wrist fracture Incidence of
fracture is 2x for snowboarding vs. skiing
With loss of balance, the natural tendency is to break fall with outstretched hand (FOOSH)
Wrist fracture (distal radial)
Most common - Distal radius or Colles fracture
Silver fork deformity
Wrist Fracture (distal radial)Median nerve assessment (ant interosseous)
normal abnormal
Wrist fracture
Colles FractureTreatment
Colles FractureTreatment
Colles FractureTreatment
Colles FractureTreatment
Closed reduction and immobilization in cast Stable fractures Examine for carpal tunnel syndrome before and
after application Avoid palmar flexion and ulnar deviation
(Cotton-Loder position) Percutaneous pinning External Fixators ORIF
Scaphoid fractureDiagnosis
Scaphoid fracture
Scaphoid Fracture Acute non-
displaced, distal and horizontal Thumb spica cast
Displaced or prox, vertical fractures ORIF Increased
incidence of avascular necrosis
Prevention of Wrist Injury
www.ski-injury.com
Wrist fractureEmergency Care
Padded splint Including the elbow is
not essential in distal injuries
Splint in the “position of function”, ie., fingers cupped around a gauze roll held in the palm
Sling can be used to steady extremity to aid in patient comfort
Hand/Finger Injuries
Gamekeeper’s or skier’s thumb
thumb forced away like from a ski pole
Disruption or sprain to the ulnar collateral ligament (MCP joint)
Splint including thumb (thumb spica)
Gamekeeper’s thumbwith fracture
Gamekeeper’s thumbTreatment
Short arm immobilizer with thumb splica
Main complication is inability to heal
Surgery (<2-3 weeks old)
Gross radiologic instability
Palpable torn ligament ends (Stener lesion)
Reassessment reveal unstable joint
Conclusion Falls, collisions and direct blows cause
injury to the upper extremities Humerus Elbow Wrist Hand/fingers
Remember general comments “Zone of injury” Life-threatening injuries first (ABCs)
Conclusion Patients will self-splint the extremity
Internal rotation, elbow flexed, adducted to body
Injuries close to joints can involve neurovascular bundle Assess CMS
ARMS Appearance and alignment, radial pulse,
motor and MOI, sensation
Conclusion Accurate assessment and rapid
transport critical (60” rule) Immobilize in the position found
Sling and swathe is good immobilizer for upper extremity injuries
Every patient should be advised to seek the care of a physician regardless of injury, especially if symptoms persist > 24 hrs.
Thank -You
Distal Humerus Anatomy Medial epicondyle
proximal to trochlea – attachment site for UCL and flexor/pronator ms.
Lateral epicondyle proximal to capitellum – attachment site for RCL, extensor/supinator ms.
Radial fossa – accommodates margin of radial head during flexion
Coronoid fossa – accepts coronoid process of ulna during flexion
Distal Humerus – Posterior
Olecranon fossa accepts olecranon process of ulna during extension
Bony Alignment With elbow
extended, straight line between medial/lateral epicondyles and tip of olecranon process’
With elbow flexed, isosceles triangle connects these points
Carrying Angle/Cubitus Valgus Formed by long
axis of humerus and midline of forearm
Male norms – 11-14 degrees
Female norms – 13-16 degrees
Larger angles are considered abnormal