wrist forearm elbow
DESCRIPTION
By Prapassorn Pattarananakul, MDTRANSCRIPT
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Tintinalli's Emergency MedicineSection 22. Injuries to Bones and Joints Chapter 266,267Rosen's Emergency Medicine: Concepts and Clinical Practice, Chapter 48,49
Prapassorn Pattarananakul ,MD
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Wrist Distal Radius and Ulna Fractures▪ Colles,Smith,Barton,Radial Styloid fractures▪ Distal Radioulnar Joint Disruption
Forearm Fractures of Both Radius and Ulna Ulna Fractures Radius Fractures
Elbow Soft Tissue Injuries Elbow Dislocation Fractures About the Elbow
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Most common injuries affecting the wrist
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Distal radial metaphysis fracture Dorsally angulated and displaced
proximally and dorsally"dinner-fork," deformity.Palmar paresthesias
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Dorsal angulation Distal radius fragment is displaced proximally and
dorsally Ulnar styloid may be fractured
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>20 degrees of dorsal angulation,
Intra-articular involvement,Marked comminution, orMore than a centimeter of
shortening.
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Closed reduction, using local anesthesia,
Cast immobilization
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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.
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"reverse Colles fracture“Volar angulated fracture of the distal
radius. "garden-spade deformity"
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Volar angulation Distal radius
fragment is displaced proximally and volarly
The fracture line extends obliquely from the dorsal surface to the volar surface 1–2 cm proximal to the articular surface
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Barton fractures are dorsal or volar rim fractures of the distal radius
Minimally displaced fractures can be treated acutely in a sugar tong splint
Unstable fractures involving >50% of the radial articular surface accompanying carpal subluxation
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comminuted fracture of the distal radial metaphysis.
intra-articular fracture of the volar or dorsal rim of the radius,
which may be accompanied by carpal subluxation in the same direction
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Hutchinson's fracture, or chauffeur's fracture,
Intra-articular fracture of the radial styloid
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Fall on the outstretched hand with either hyperpronation, hypersupination
Radiographs :reported as normal Immobilizing the wrist in
supination ( dorsal dislocations), pronation(volar dislocations)
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None displaced :long arm cast 8 wk
Displaced : ORIF compartment
syndrome Volkmann
contractures
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Isolated Ulna Fracture (Nightstick Fracture)
direct blowsNondisplace :immobilized
distal third > short arm cast Middle/proximal >long arm cast
Displace : R/O radial head dislocation(>10° ,> 50% diameter ulnar)
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Fx proximal third of the ulna with a radial head dislocation
! Posterior interosseus nerve
Type II Monteggia fracture-dislocation
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Fx radial head dislocation
Type I Prox. or middle ulnar anterior
Type II Prox.or middle ulnar posterior
Type III distal to coronoid process
lateral
Type IV Prox. or middle ulnaProx. radius
anterior
Consultation in the ED :- ORIF - children : closed reduction and long arm splinting supination
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Fx distal third of the radial shaft c DRUJ dislocation
reverse Monteggia fractureConsultation : ORIF
Radiographs : AP :increased DRUJ space Lateral : ulna dorsal displacement
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A. Radial nerve innervation.
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B. MEDIAN NERVE INNERVATION.
C. ULNAR NERVE INNERVATION.
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Proximal Biceps Rupture (long head) result of repetitive microtrauma,
overuse and Steroidsmiddle-aged and older individuals
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Distal biceps injuriesmiddle-aged men Pain : antecubital fossa "biceps squeeze test," ED Tx : sling, ice, analgesics, and refer for definitive care.
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Young men Fall on an outstretched hand causing a
forceful flexion of an extended elbow Direct blow to the olecranon Spontaneous ruptures from systemic
illnesses, ( hyperparathyroidism)The ability to extend the elbow is
lost. modified Thompson test
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"tennis elbow,“Repetitive movement Tenderness over the lateral
epicondylePain with forced extension and
supinationTx : rest, ice, medications,and
immobilization, counterforce brace
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"golfer's elbow“Tenderness over
the medial epicondyle
Pain with forced flexion and pronation
Ulnar neuropathy
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fall on an outstretched handElbow flexion in 45 °Olecranon is prominentFirst priority of care
neurovascular status brachial a., ulnar, radial, and median nerves
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Look for associated fractures coronoid process and radial head. In a child: Fx medial epicondyle
Tx : Reduction long arm posterior mold
90 ° of flexion
Consultation : irreducible dislocations, neurovascular compromise, joint capsule disruption, associated fractures, open dislocations
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Children age 1 to 3 years“nursemaid's elbow or pulled elbow” Sudden longitudinal pull on the
forearm while pronationX-rays are not requiredRecurrence rate of about 20%
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Supination of the forearm while slight pressure on the radial head
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RADIOGRAPHS
"sail sign" Posterior fat pad :
fat from the olecranon fossa
Anterior fat pad:hemarthrosis
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Most common fracture about the elbow in children
Gartland Classification of Pediatric Supracondylar Fractures
Extension type Flexion type
Nondisplaced Nondisplaced
Displaced, but posterior cortex intact
Displaced, but anterior cortex intact
Completely displaced Completely displaced
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Fall on an outstretched hand with the elbow in extension
Displaced fractures : emergent orthopedic consultation CRPP/ORIF
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Direct anterior force against a flexed elbow
Often open Displaced fractures : emergent orthopedic
consultation CRPP/ORIF
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Early complications Neurologic ▪ Radial nerve Median nerve (anterior interosseous
branch) Ulnar Vascular ▪ Volkmann ischemic contracture (compartment
syndrome of the forearm) Late complications
Nonunion Malunion Myositis ossificans Loss of motion
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Lateral condyle fractures (second most common fractures involving the elbow in children)
Medial Condyle Fractures
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Nondisplaced :long arm posterior immobilization
Displaced : immediate orthopedic consultation(CRPP/ORIF)
Milch Classification I/II>Salter Harris type IV/II
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Direct trauma to the elbow that drives the olecranon against the humeral articular surface
adults in 50-60 yTx :ORIF
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Little Leaguer's Elbow
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Tx : controversial simple immobilization
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associated with posterior elbow dislocations Classification of Coronoid Fractures Type I Anterior tip of coronoid Type II Up to 50% of the height of the coronoid Type III The base of the coronoid II/III > ORIF, poor outcome
Tx : Long arm posterior immobilization and refer 24hr(elbow flexion /forearm supination)
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Direct trauma / fall with forced hyperextension
MayoClassification of Olecranon Fractures Type I Nondisplaced, stable fracture Type II Displaced, stable joint Type III Displaced,
unstable ulnohumeral joint
Type I can be conservative long arm posterior immobilization
(elbow flexion and forearm neutral) Refer 24 hr
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Associated injuries are common
“Essex-Lopresti lesion” disruption of the triangular fibrocartilage
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Pain on pronation and supination forearm
Obliques and a radial head-capitellum view
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radiocapitellar line abnormal fat pad
Nondisplaced :sling immobilization with the elbow in flexion refer within 1 week
Displaced : Refer in 24 hours
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1. Colles fracture2. Smith fracture3. Barton fracture
A
B
C
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a) Galeazzi Fractureb) Nightstick Fracturec) Monteggia Fracture
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a) Supracondylar Fracturesb) Intercondylar Fracturesc) Lateral Epicondyle Fracturesd) Lateral condyle fractures
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a) Volkmann ischemic contractureb) Myositis ossificansc) anterior interosseous palsyd) Cubitus varuse) None of above