Ski injuries to the upper extremities

Eugene Bailey, MDDepartment of Family

MedicineSUNY Upstate Medical

University

Toggenberg MA PresentationJanuary 03, 2010

Objectives General Comments Shoulder Injurties

ShoulderDislocation Clavicular fracture Scapular fracture Acromioclavicular joint (ACJ)

injury Humerus fractures

Head Shaft Suprachondylar

Elbow Anterior/Posterior

dislocation Olecrenon fracture Radial head 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)

Remember "Ability and experience are

probably the most important factors in determining an individual's likelihood of injury when pursuing an outdoor sport."

“ARMS” Appearance and alignment Radial pulse Motor function and mechanism of

injury Sensation

Self-splinting

Prevention

Case Scenario A call comes to

you over your radio that a skier is down and appears to have an injury.

You grab a toboggan and respond to the scene quickly

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

Shoulder Injuries

Shoulder dislocation

MOI: Fall onto an

outstretched hand c the momentum of the fall twisting the body around wretching the shoulder out of joint

Posterior blow to shoulder

Majority are anterior dislocation (97%)

Shoulder dislocation The diagnosis of a

dislocated shoulder is usually clinical

Walk slowly holding affected arm, careful not to move it. Usually arm is away from body.

Loss of smooth contour of the shoulder anatomy

Radiograph of Anterior shoulder dislocation

Shoulder dislocation X-rays do not

have to be obtained before treatment

There are numerous techniques for reduction Traction Leverage

Kocher’s technique

Shoulder dislocation Immobilize the

injured joint Blanket roll Sling Sling and swath Ice

Clavicular fracture

Most commonly fractured bone in the entire body!

MOI: Transmission of

force up the arm Fall onto shoulder Direct blow to the

clavicle

Clavicular fracture presents with:

pain to direct palpation over the clavicle or with movement of the arm or neck

may be deformity of the bone with swelling and ecchymosis. (“tenting” over fracture site)

Arm held to the side Palpate for crepitus

Clavicular Fracture

•Middle third - 80%•Proximal third - 5%•Distal third - 15%

Distal third classification

Clavicular Fracture Simple sling Figure-of-eight

Do not apply if causes patient discomfort

Do not apply for distal fractures

IceAnderson, et.al., Acta Orthop Scand 1987;58:71-74

Stanley, et. al., Injury 1988;19:162-164

Scapular Fracture MOI: Forceful,

direct blow to the back

Very rare because well protected by muscles

Always assess for spinal injury or breathing difficulty

Sling and swathe

Acromio-clavicular joint (ACJ) injury

ACJ Injury MOI:

Falling directly onto the adducted shoulder

Injury to the ligament causes Tear (subluxation) Dislocation

ACJ Injury

Grade 1 Grade 2 Grade 3………

ACJ Injury

Presentation: Type 1/Grade 1 –

local tenderness without deformity

Type 2,3,4,5,6/ Grade 2,3 – local tenderness with deformity

ACJ Injury Simple sling! Collar and cuff Ice

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 (FOOSH) 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