Orthopedics: Upper Extremity Annette Dorfman, MD 4/7/10

Objectives Review the need for emergent (in the ED) versus semi-urgent (outpt) consultation Practice intelligently describing fractures to consultants Discuss comprehensive examination techniques Review practical techniques for splinting and reduction Remember, even an orthopod can do this!

Recurring themes… Do you need an ortho/hand consult in the ED? How do you splint the injury?* Not a substitute for self-study

Case 1

Case 2

Case 3:

Case 4*

Flexor Tenosynovitis 4 Cardinal (Kanavel) signs: TTP along course of flexor tendon Symmetric fusiform swelling Pain on passive extension Flexed posture of the finger

Case 5

Metacarpal Neck Fx: Increasing mobility from digits 25 Increasing angulation from 25 Increasing likelihood of fx from 25 All rotational deformities need correction

Phalangeal and Metacarpal Fx Splints:

Metacarpal Shaft Fx

Case 6

Thumb Fx’s Bennett’s Fx: Intra-articular fx @ base + dislocation of CMC joint Axial load Reduction required Rolando’s Fx: Comminuted fx @ base of thumb Axial load Worse prognosis

Valgus Stress Test

Case 7: 28 yo M, s/p FOOSH*

45 degree pronation view Ulnar deviation view

Scaphoid Fx Second most common wrist fx Challenging dx CT scan superior to bone scan Poor healing Rx: Thumb spica ALL DISPLACED Fx’s require ED ortho c/s

Another FOOSH…(case 8)*

Perilunate dislocation Lunate dislocation

Wrist Arcs: Normal

Carpal Instability Progressive pattern of ligamentous injury: Stage I: Scapholunate Stage II: Perilunate dislocation Stage III: Perilunate + triquetrum dislocation Stage IV: Lunate dislocation Rx: Ortho c/s in ED required

Case 9 *

Colles’ Fracture Most common wrist fracture Median nerve injury Needs emergent closed reduction

Colles’ Fracture

Case 10

Salter Harris Classification

Case 11*

Supracondylar Fx Highest incidence in 10-15 yo Type I - nondisplaced Type II – minimally displaced Type III – complete cortical disruption *need ortho c/s in ED

Radial Head Fx Indirect injury Nondisplaced rx = sling Consider intra-articular injection for pain relief Any displaced fractures/dislocations need ortho c/s

Radial Head Subluxation AKA “nursemaid’s elbow” Usually no x-ray necessary Cause: stretching of annular ligament Reduction technique: supinate and flex

Case 11*

Posterior Dislocation

Shoulder Dislocation Axillary nerve testing Anterior most common Subcoracoid and subglenoid most common Techniques for muscle relaxation and analgesia

Prior to Reduction:

Reduction Techniques

Reduction Techniques

Reduction Techniques

Reduction Techniques

Conclusions Maintain a high index of suspicion Emphasis on proper splinting, reduction techniques Comprehensive examination skills necessary

References Browner: Skeletal Trauma, 4th ed. Copyright © 2008 W. B. Saunders Company DeLee: DeLee and Drez's Orthopaedic Sports Medicine, 3rd ed. Copyright © 2009 Saunders, An Imprint of Elsevier Marx: Rosen's Emergency Medicine, 7th ed. Copyright © 2009 Mosby, An Imprint of Elsevier Roberts: Clinical Procedures in Emergency Medicine, 5th ed. Copyright © 2009 Saunders, An Imprint of Elsevier