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Slide 1-

Upper Extremity Injuries: Shoulder, Elbow and Wrist Patrick M. Carter, MD Instructor Department of Emergency Medicine University of Michigan School of Medicine April 4, 2012 1 Quibik, Wikimedia Commons
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Objectives Review key orthopedic injuries of the shoulder, upper arm, elbow, forearm and wrist Fractures Dislocations Ligamentous Injuries Identify key x-ray findings Review treatment options for orthopedic disorders of upper extremity Review key complications of upper extremity disorders Not a complete review of all upper extremity injuries 2
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Shoulder Anatomy 3 Gray’s Anatomy, Wikimedia Commons
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Sternoclavicular Joint Injuries Sternoclavicular Ligament Costoclavicular Ligament Less than ½ of the medial end of the clavicle usually articulates with the sternum Joint Stability is dependent on the integrity of the surrounding ligaments 4 Gray’s Anatomy, Wikimedia Commons
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Sternoclavicular Joint Injuries Classification 1st Degree = Sprain Partial tear of SC and CC ligaments with mild subluxation 2nd Degree = Subluxation Complete tear of SC ligament with partial tear of CC ligament Clavicle subluxates from the manubrium on x-ray 3rd Degree = Dislocation Complete tear of SC and CC ligaments Complete dislocation of clavicle from the manubrium Anterior > Posterior Posterior = True Emergency – 25% will have concurrent life-threatening injuries to adjacent mediastinal structures 5
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Sternoclavicular Joint Injuries Mechanism of Injury Direct force applied to the medial end of the clavicle Indirect force to the shoulder with the shoulder rolled either forward or backward that tears medial ligaments Symptoms/Signs Pain and swelling over the SC joint Pain with movement of shoulder Anterior Dislocation = Prominent medial clavicle anterior to sternum Posterior Dislocation = Clavicle may not be palpable, may be subtle Diagnosis X-ray CT scan (Diagnostic Study of Choice if concern for underlying structures) 6
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Sternoclavicular Joint Injuries Treatment 1st Degree = Sling, Analgesia, Ice 2nd Degree Sling or Figure of Eight Clavicular Strap, Orthopedic Follow-up 3rd Degree Anterior Dislocation Uncomplicated anterior dislocations often don’t require reduction Sling or Figure of Eight, Analgesia and outpatient follow-up Posterior Dislocation Reduction often necessary due to underlying injury Closed reduction in OR Reduction Towel roll between scapula Traction applied to arm Towel clip on clavicle with traction to reduce 7
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Acromioclavicular Joint Injuries AC Joint Anatomy Mechanism of Injury Fall on outstretched arm with transmission to AC joint Fall on shoulder with arm adducted (most common) Scapula and Shoulder girdle driven inferiorly with clavicle in normal position Signs/Symptoms Joint Tenderness Swelling over the joint Pain with movement of affected extremity Displacement of clavicle Coracoclavicular Ligaments - Coracoacromial ligament - Trapezoid Coracoclavicular ligament - Conoid Coracoclavicular ligament Acromioclavicular Ligament 8 Gray’s Anatomy, Wikimedia Commons
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Acromioclavicular Joint Injuries AC Joint Injury Classification Tossy and Allman Classification (Types 1-3) Rockwood Classification (Types 4-6) Classification Type 1 = Sprain = Partial tear of AC ligament, No CC ligament injury Type 2 = Subluxation = Complete tear of AC ligament, CC ligament stretched or incompletely torn Type 3 = Dislocation = Complete tears of AC and CC ligaments with displacement of clavicle Direction of displacement defines types 4-6 Type IV = Posterior displacement in or through trapezius Type V = Superior displacement (more serious type 3 injury) Type VI = Inferior displacement of clavicle behind biceps tendon 9
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Acromioclavicular Joint Injuries 10 Source: Steve Oh, 2004
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Acromioclavicular Joint Injuries X-rays AP views of clavicle usually sufficient Stress views not commonly used anymore and do not alter course of treatment Axillary views necessary for posterior dislocation identification (Type 4) Findings Type 1 = Radiographically normal Type 2 = Increased distance between clavicle and acromion (< 1 cm) Type 3 = Increased distance between the clavicle and acromion (> 1 cm) Type 4-6 = Defined by displacement Treatment Type 1-2 = Sling x 1-2 weeks, Rest, Ice, Analgesia, Early ROM 7-14 days Type 3 = Immobilize in sling, Prompt orthopedic referral Controversy regarding operative vs. conservative treatment options Shift towards conservative treatment Type 4-6 = Sling, Prompt orthopedic referral, Likely will require surgical management 11
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Acromioclavicular Separation – Type III 12 Root4(one), Wikimedia Commons Source Undetermined
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Clavicle Fractures Clavicle Provides support and mobility for upper extremity functions Protects adjacent structures Mechanism of Injury Direct blow to clavicle Fall on outstretched shoulder Symptoms/Signs Pain, Swelling and Deformity Arm is held inward and downward and supported by other extremity Open fractures result from severe tenting and piercing of overlying skin Imaging CXR or Clavicle films Children may have a greenstick fracture without definite fracture on x-ray imaging 13 Magnus Manske, Wikimedia Commons Source Undetermined
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Clavicle Fractures Allman Classification Middle 1/3 (80%) Most common area to fracture Especially in children Distal 1/3 (15%) Often associated with ruptured CC joint with medial elevation May require operative intervention to avoid non-union Medial 1/3 (5%) Uncommon Requires strong injury forces Higher association with intrathoracic injury (e.g Subclavian Artery/Vein injury) 14 Image adapted from Anatomagraphy, Wikimedia Commons Group III ~Medial 1/3 ~3%-6% Group I ~Middle 1/3 ~69%-85% Group II ~Distal 1/3 ~12%-28% Allman Classification
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Clavicle Fractures 15 Source Undetermined
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Clavicle Fractures Emergency Orthopedic Consultation Open Fractures Fractures with neurovascular injuries Fractures with significant tenting at high risk for converting to open Indications for Surgical Repair Displaced distal third Open Bilateral Neurovascular injury Treatment = Sling, Orthopedic Follow-up Non-operative management is successful in 90% Middle 1/3 Clavicle Non-union risk factors Shortening > 2 cm Comminuted fracture Elderly female Displaced fracture Significant associated trauma 16
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Scapular Injuries Scapula Links the axial skeleton to the upper extremity Stabilizing platform for the motion of the arm 1% cases of blunt trauma have scapular fracture 3-5% of shoulder injuries Mechanism of Injury Direct blow to the scapula Trauma to the shoulder Fall on an outstretched arm Clinical Presentation Localized pain over the scapula Ipsilateral arm held in adduction Any movement of arm exacerbates pain High association with other intrathoracic injuries (>75%) Due to high degree of energy required for fracture Pulmonary contusion > 50% of cases Pneumothorax, Rib fractures commonly associated Glenoid Body Neck 17 Gray’s Anatomy, Wikimedia Commons
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Scapular Injuries Classification Anatomic Location Body = 50-60% Neck = 25% Imaging Shoulder/Dedicated Scapular Series AP/Lateral/Axillary Axillary views help identify fractures: Glenoid fossa Acromion Coracoid Process Consider CXR/Chest CT to rule out associated injuries 18 Gray’s Anatomy, Wikimedia Commons
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Scapular Injuries Treatment Sling, Ice, Analgesia Immobilization Early ROM exercises Orthopedic Referral for ORIF Glenoid articular surface fractures with displacement Scapular neck fractures with angulation Acromial fractures associated with rotator cuff injuries 19 Source Undetermined
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Glenohumeral Joint Dislocation Shoulder dislocation = Most common dislocation in the ED Classification Anterior (95-97%) Subcoricoid, Subglenoid, Subclavicular, Intrathroracic Posterior (2-3%) Most commonly missed dislocation in the ED Association with Seizure, Electric Shock/lightening injuries Inferior (Luxatio Erecta) Superior (Very Rare) Mechanism of Injury Anterior = Abduction, Extension and External Rotation with force applied to shoulder Posterior = Indirect force with forceful internal rotation and adduction 20
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Anterior Shoulder Dislocations Clinical Presentation “Squared off” Shoulder Patient resists abduction and internal rotation Humeral head palpable anteriorly Must test axillary nerve function/sensation Quebec Decision Rule Radiographs needed for: Age > 40 and humeral ecchymosis Age > 40 and 1st dislocation Age < 40 and mechanism other than fall from standing height or lower Failed to be validated due to low sensitivity (CJEM 2011) Recurrent Shoulder dislocations Radiographs AP/Lateral/Y-view 21 Source Undetermined Source Undetermined
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Posterior Shoulder Dislocations Clinical Presentation Prominence of posterior shoulder Anterior flatness Unable to externally rotate or abduct the affected arm Radiography AP Radiograph “Light Bulb Sign” Internal rotation of the humerus Y view Diagnostic for posterior dislocation 22 Source Undetermined Source Undetermined
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Luxatio Erecta Inferior Shoulder Dislocation Hyperabduction force Levers humerus against the acromion tearing inferior capsule Forces humeral head out inferiorly Clinical Presentation Humerus is fully abducted, elbow flexed, hand behind the head Humeral head palpated on lateral chest wall Frequently associated with: Soft tissue injuries/rotator cuff tears Fractures of humeral head Neurovascular compression injury is common 23 Source Undetermined
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Glenohumeral Joint Dislocation Treatment Reduction using a variety of techniques Success rate = 70-96% regardless of technique Shoulder dislocation with associated humeral head fracture typically require orthopedic consultation and may require operative repair Neurovascular exam pre- and post reduction Procedural Sedation if initial attempts unsuccessful Intra-articular injection of 10-20 cc lidocaine alternative to procedural sedation After reduction, patient should be placed in shoulder immobilizer and orthopedic follow-up arranged 24 Nevit Dilman, Wikimedia Commons
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Shoulder Reduction Techniques External Rotation Hennepin Technique Gentle external rotation Followed by slow abduction of arm Reduction typically complete prior to reaching coronal plane 78% success rate Procedural sedation rarely needed 25 Source: University of Hawaii School of Medicine
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Shoulder Reduction Techniques Modified Hippocratic or Traction-Countertraction Technique 26 Source: University of Hawaii School of Medicine
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Shoulder Reduction Techniques Scapular Manipulation Technique Seated Position Steady forward traction on wrist parallel to floor Rotate inferior tip of scapula medially and superior aspect laterally 96% Success rate Requires two people Borders of scapula can be difficult to identify in obese patients Rarely requires sedation 27 Source: University of Hawaii School of Medicine Source: University of Hawaii School of Medicine
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Shoulder Reduction Techniques Stimpson or Hanging Weight Technique 28 Source: University of Hawaii School of Medicine
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Glenohumeral Joint Dislocations Complications Recurrent dislocation (Most Common) < 20 years old: > 90% > 40 years old: 10-15% Bony Injuries Hill-Sachs Deformity Compression fracture or groove of posterolateral aspect of humeral head Results from impact of humeral head on the anterior glenoid rim as it dislocates or reduces Avulsion of greater tuberosity (Higher incidence > 45 years old) Bankart’s Fracture = Fracture of the anterior glenoid lip Nerve Injuries (10-25% dislocations) Most often are traction related neuropraxias and resolve spontaneously Axillary nerve (most common) or Musculocutaneous nerve Rotator Cuff Tears 86% of patients > 40 years will have associated rotator cuff tear Axillary Artery Injury (rare) Elderly patients with weak pulse Rapidly expanding hematoma 29
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Complications Hill Sachs Deformity Bankart’s Lesion/Fracture http://www.mypacs.net/repos/mpv3_repo/viz/full/18712/935613.jpg 30 Hellerhoff, Wikimedia Commons RSatUSZ, Wikimedia Commons
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Rotator Cuff Injuries Rotator cuff = 4 muscles that insert tendons into the greater and lesser tuberosity SITS MUSCLES = Subscapularis, Supraspinatous, Infraspinatous, Teres minor Mechanisms of Injury Acute tear = Forceful abduction of the arm against resistance (e.g. fall on outstretched arm) Chronic teat = 90% = Results from subacromial impingement and decreased blood supply to the tendons (worsens as patient ages) Clinical Picture Typically affects males at 40 y/o or later Pain over anterior aspect of shoulder, tearing quality to pain, typically worse at night PE with weak and painful abduction or inability to initiate abduction (if complete tear) Tenderness on palpation of supraspinatous over greater tuberosity Imaging In ED, plain film x-rays indicated to exclude fracture and may show degenerative changes and superior displacement of humeral head MRI is diagnostic (not typically done in ED setting) Treatment Sling Immobilization, Analgesia, Ortho Referral Complete tears require early surgical repair (< 3 weeks) Chronic tears are managed with immobilization, analgesia and orthopedic follow-up for rehabilitation exercises and possible steroid injection 31
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Humerus Fractures Proximal Humerus Fractures Common in elderly patients with osteoporosis Mechanism of Injury = Fall on outstretched hand with elbow extended Clinical Presentation Pain, swelling and tenderness around the shoulder Brachial plexus and axillary arteries injuries Higher incidence (>50%) in displaced fractures Neer Classification guides treatment Fractures separate humerus into 4 fragments by epiphyseal lines Displacement > 1 cm or angulation > 45 degrees defines a fragment as a “separate part” when fractures occur If none of fragments are displaced > 1cm, fracture is termed 1 part Treatment One part fractures (85%) = immobilization in sling/swathe, ice, analgesics, orthopedic referral Two/Three/Four part fractures = Orthopedic Consultation 32
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Proximal Humerus Fractures Fragments of Humerus Head Articular surface of humeral head Greater tubercle Lesser tubercle Shaft of humerus 33 3 1 2 James Heilman, MD, Wikimedia Commons Gray’s Anatomy, Wikimedia Commons
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Mid-shaft Humerus Fractures Typically involve middle 1/3 of the humeral shaft Mechanism of Injury Direct Blow (Most common) Fall on outstretched arm or elbow Pathologic Fracture (e.g. breast cancer) Clinical Presentation Pain and deformity over affected region Associated Injuries Radial Nerve injury = Wrist Drop (10-20%) Neuropraxia will often resolve spontaneously Nerve palsy after manipulation or splinting is due to nerve entrapment and must be immediately explored by orthopedic surgery Ulnar and Median nerve injury (less common) Brachial Artery Injury 34
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Mid-shaft Humerus Fractures Imaging = Standard x-ray imaging Treatment Non-operative Management (most common) Simple Sling and Swath adequate for ED patients Closed treatment options Coaptation splint (sugar tong) Hanging cast External fixation Operative management Neurovascular compromise, pathologic fractures Complications Neurovascular injury Delayed union Adhesive capsulitis 35 Bill Rhodes, Wikimedia Commons
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Biceps Rupture Proximal or distal biceps tendon rupture Mechanism of Injury = Sudden or prolonged contraction against resistance in middle aged or elderly patients Clinical Presentation “Snap” or “Pop” typically described Pain, swelling, tenderness over site of tendon rupture Flexion of elbow = Mid-arm ball Loss of strength sometimes minimal X-rays to exclude avulsion fracture ED Treatment Sling, Ice, Analgesia, Orthopedic referral Surgical repair for young, active patients 36 Patenthalse, Wikimedia Commons Gray’s Anatomy, Wikimedia Commons
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Radiographic Evaluation of the Elbow 37 Source Undetermined
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Anterior Fat Pad “Sail Sign” Posterior Fat Pad (Never normal) Anterior Humeral Line Normal = Middle of capitellum Abnormal = Anterior 1/3 of capitellum or completely anterior Radial-Capitellar Line Normal = Transects middle of capitellum Radiographic Evaluation of the Elbow 38 Hellerhoff, Wikimedia Commons Source Undetermined Source Undetermined
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Supracondylar Fractures Supracondylar Extension Fractures Most Common Type Mechanism of injury Fall on outstretched arm with elbow in extension Imaging Distal humerus fractures and humeral fragment displaced posteriorly Sharp fracture fragments displaced anteriorly with potential for injury of brachial artery and median nerve Treatment Non-displaced fracture (Rare) = Immobilization in posterior splint May be discharged home with close follow-up Displaced fracture Orthopedic Consultation and reduction Patients with displaced fractures or significant soft tissue swelling require admission for observation 39
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Supracondylar Fractures Supracondylar Flexion Fractures (rare) Mechanism of Injury Direct blow to posterior aspect of flexed elbow Fractures are frequently open Imaging = Distal humerus fracture displaced anteriorly Treatment Non-displaced fractures Splint immobilization and early orthopedic follow-up Displaced fractures Orthopedic consultation for reduction Patients with displacement and soft tissue swelling require admission 40
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Supracondylar Fractures Extension Type Fracture Flexion Type Fracture 41 Source Undetermined Source Undetermined Source Undetermined
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Supracondylar fractures Early Complications Neurologic (7%) Results from traction, direct trauma or nerve ischemia Radial Nerve (Posterior-medial displacement) Median Nerve (Posterior-lateral displacement) Ulnar Nerve (Uncommon) Anterior Interosseous Nerve Injuries High incidence with supracondylar fractures No sensory component, Motor component must be tested (“OK sign”) Vascular Entrapment (Brachial Artery) Late Complications Non-union/Mal-union Loss of mobility 42
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Volkmann’s Ischemic Contracture Compartment syndrome of the forearm Complication of elbow/forearm fractures Increased compartment pressure results in ischemia of muscles of forearm, typically flexor compartment Patient complains of pain out of proportion of injury, digit swelling and paresthesias Also consider in any patient presenting with pain and numbness in hand after casting has been performed Irreversible damage in 6 hours (see image) Treatment Removal of cast Surgical decompression with fasciotomy 43 Source Undetermined
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Radial Head Fracture Most common fractures of the elbow Mechanism of Injury = Fall on outstretched hand Clinical Finding = Tenderness and swelling over the radial head Imaging May not be seen on initial x-ray or may be subtle on x-ray Evaluate for anterior or posterior fat pad which suggests diagnosis Associated Injuries Essex-Lopresti Lesion Disruption of fibrocartilage of the wrist and interosseus membrane Distal radial-ulnar dissociation Articular surface of capitellum frequently also injured Treatment Non-displaced = Sling, Ortho follow-up Comminuted/Displaced Fractures require urgent orthopedic referral within 24 hours 44 Source Undetermined
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Radial Head Subluxation Nursemaid’s elbow = Subluxation of radial head beneath the annular ligament Mechanism of injury = Longitudinal traction on hand or forearm with arm in pronation X-rays not necessary Treatment = Reduction Thumb over radial head with concurrent supination of forearm and flexion of elbow Extension and pronation (another option for reduction) 45 David Tan, Flickr
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Radial Head Subluxation 46 Therese Clutario, Wikimedia Commons hyperpronation supination flexion
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Elbow Dislocations Third most common joint dislocation Posterolateral (90%) Mechanism of Injury = Fall on outstretched hand Clinical Findings Marked swelling with loss of landmarks Posterior prominence of olecranon Immediate consideration must be given to neurovascular status Ulnar or Median Nerve injury common (8-21%) Brachial artery injury (5-13%) Associated fractures (30-60%) of coronoid process and radial head Terrible triad injury = elbow dislocation + radial head and coronoid fracture (unstable) Anterior (Uncommon) Mechanism of Injury = Blow to Olecranon with elbow in flexion Associated Injuries = Much higher incidence of vascular impingement 47
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Elbow Dislocation http://tw.myblog.yahoo.com/doctor--anjenli/article?mid=776&prev=778&next=774&l=f&fid=79 Anterior Elbow Dislocation Posterior Elbow Dislocation 48 Source Undetermined Source Undetermined
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Elbow Dislocation Elbow Reduction Immobilize humerus Apply traction at wrist Slight flexion of the elbow Posterior pressure on olecranon Post-Reduction Long Term Complications Post-traumatic arthritis Joint instability 49
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Both Bone Forearm Fracture Fracture of both ulnar and radius Usually displaced fracture Mechanism of Injury Direct blow to forearm Associated Injury Peripheral Nerve Deficits Uncommon in most closed injuries More common with open fractures Development of compartment syndrome Treatment Displaced – ORIF Complications Compartment Syndrome Malunion 50 Source Undetermined
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Nightstick Fracture Isolated fracture of ulnar shaft Mechanism Direct blow to ulna Patient raising forearm to protect face Treatment Non-displaced Immobilization in splint Displaced >10 degrees angulation Displacement > 50% of ulna Orthopedic consultation - ORIF 51 Source Undetermined
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Galeazzi Fracture Distal Radius Fracture Distal radio-ulnar dislocation Reverse Monteggia’s fx Mechanism of Injury Direct blow to back of wrist Fall on outstretched hand Complication = Ulnar nerve injury Treatment = ORIF http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow157lg.jpg 52 Th. Zimmermann, Wikimedia Commons
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Monteggia’s Fracture Proximal 1/3 Ulnar Fracture Dislocation of radial head Mechanism of Injury = Direct blow to posterior aspect of ulna Fall on outstretched hand Imaging Elbow/Forearm x-rays Radial head dislocation missed in 25% of cases Carefully examine the alignment of radial head Associated Injury = Radial Nerve Injury Treatment ORIF Closed Reduction/Splinting 53 Jane Agnes, Wikimedia Commons
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Galeazzi vs. Monteggia Fractures Galeazzi Radial Fracture Ulnar Fracture Monteggia G M U R 54 Patrick Carter, University of Michigan Patrick Carter, University of Michigan
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Colles Fracture Transverse fracture of distal radius with dorsal displacement of distal fragment Mechanism = Fall on outstretched hand Most common fracture in adults > 50 years old Exam = Classic Dinner Fork Deformity Associated Injuries Ulnar styloid fracture Median Nerve Injury Unstable Fractures >20 degrees angulation, intra-articular involvement, comminuted fractures or > 1 cm of shortening Treatment Non-displaced Fracture Sugar Tong Splint, Referral to Orthopedic Surgery Displaced Fracture Reduction – Finger traps and manipulation under procedural sedation or with hematoma block Immobilization in Sugar tong splint Referral to Orthopedic Surgery 55
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Smith Fracture Transverse fracture of distal radius with volar displacement Mechanism = Fall on outstretched arm with forearm in supination Associated Injury = Median Nerve Injury Treatment Reduction with finger traps and manipulation Immobilization in sugar tong or long arm splint Orthopedic referral 56
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Colles vs. Smith Fracture Colles Fracture Smith Fracture Goals of Reduction: * Restore volar tilt * Radial Inclination * Proper radial length 57 Lucien Monfils, Wikimedia Commons Source Undetermined
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Carpal Fractures 58 Source Undetermined
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Scaphoid Fracture Scaphoid Fracture Most common carpal bone fracture Mechanism = fall on outstretched hand or axial load to thumb 2/3 of fracture in waist of scaphoid Imaging – Initial x-rays may fail to demonstrate fracture > 10% of cases Repeat Imaging in 2 weeks will often show fracture Clinical findings = tenderness in anatomical snuff box Treatment Non-displaced or clinically suspected fracture Thumb spica Splint Displaced fractures will require ORIF Complications Avascular necrosis of proximal fragment -> arthritis Delayed union or malunion 59
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Scaphoid Fracture 60 Gilo1969, Wikimedia Commons
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Carpal Fractures Triquetrum Fracture (2nd most common) Mechanism = Fall on outstretched hand Body fracture or avulsion chip fractures Exam = Tenderness on palpation distal to ulnar styloid on dorsal aspect of wrist, painful flexion Avulsion fracture best visualized on lateral or oblique view of wrist Treatment = Volar splint, Orthopedic referral Lunate Fracture Mechanism = Fall on outstretched hand Exam = Pain over mid-dorsum of wrist increased with axial loading of 3rd digit Vascular supply is through distal end of bone -> high risk for avascular necrosis of the proximal portion Plain x-rays are often normal Treatment = Immobilization in thumb spica splint, orthopedic referral Complications Kienbock’s disease = Avascular necrosis of proximal segment Chronic pain, decreased grip strength, osteoarthritis 61
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Carpal Fractures Triquetrum Fracture Lunate Fracture 62 Hellerhoff, Wikimedia Commons Source Undetermined
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Carpal Ligamentous Injuries Lunate is at the center of the carpal bones Majority of ligamentous injuries are centered on the lunate Injuries are from forceful dorsiflexion of wrist Degree of force determines severity of injury Spectrum from isolated tear to dislocations Spectrum of ligamentous injuries Scapholunate ligament instability Triquetrolunate ligament instability Perilunate and Lunate dislocations 63
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Scapholunate Ligament Instability Scapholunate ligament binds the scaphoid and lunate together Most common ligamentous injury of hand Commonly missed Pain with wrist hyperextension, snapping or clicking sensation with radial/ulnar deviation Radiographic signs Scaphoid is foreshortened and has a dense ring shaped image around its distal edge (signet or cortical ring sign) Widening of space between the lunate/scaphoid > 3 mm, Terry Thomas sign Treatment Thumb spica or radial gutter splint Orthopedic Referral 64
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Scapholunate Dislocation Terry Thomas and Signet Ring Sign 65 Source Undetermined
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Perilunate and Lunate Dislocations Perilunate and lunate dislocations are the result of the most severe carpal ligamentous injury Mechanism of Injury = Violent Hyperextension usually combined with a fall from height or motor vehicle crash Clinical examination Generalized swelling, pain and tenderness over wrist May be deceiving with no evidence of gross deformity Radiographic evaluation is key to diagnosis Treatment = Orthopedic Consultation Treatment is dependent on severity of injury Closed reduction and long-arm immobilization if possible Open, unstable and irreducible dislocations require OR Some orthopedists take all dislocations to OR Complications Degenerative Arthritis Delayed union/Malunion/Non-union Avascular necrosis 66
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Lunate vs. Peri-lunate Dislocation 4 C’s Need to line up on normal x-ray Lunate 67 Source Undetermined
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Lunate vs. Peri-lunate Dislocation Lunate Dislocation Capitate is centered over the radius and the lunate is tilted out Spilled Tea cup deformity Peri-lunate Dislocation Lunate is centered over the radius and capitate is tilted out Associated with scaphoid fx 68 Source: Radiology Assistant Source: Radiology Assistant
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Carpal Overuse Syndromes Carpal Tunnel Syndrome Entrapment of Median nerve Tinel’s sign = Tapping over volar wrist produces paresthesias Phalen’s sign = Hyperflexion of wrist = Paresthesias Risk Factors = Pregnancy, Hypothyroid, DM, RA Treatment = Splinting, Rest, Surgical Decompression DeQuervain’s Tenosynovitis Overuse syndrome with inflammation of extensor tendons of thumb Characterized by pain along radial aspect of wrist that is exacerbated with use of thumb Finkelstein’s test = Ulnar deviation of fisted hand produces pain Treatment = NSAIDS, Splint, Rest Guyon’s Canal Syndrome Ulnar nerve entrapment syndrome Numbness and tingling in ring and small finger Causes = repetitive trauma (handle bar neuropathy), cyst Treatment = Splint, Surgical Decompression 69
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Questions? 70 ?