1/19/2018. Winter injuries to the shoulder and elbow. Highgate Private Hospital (Whittington Health NHS Trust)

Transcription

1 Winter injuries to the shoulder and elbow Omar Haddo Consultant Orthopaedic Surgeon, Shoulder, Elbow, Hand & Wrist Specialist MBBS, BmedSci, FRCS(Orth) Highgate Private Hospital (Whittington Health NHS Trust) E: Objectives Introduction Clavicle fracture/dislocation Humerus Head fracture/dislocation Shaft fracture Suprachondylar fracture Elbow Anterior/Posterio dislocation Olecrenon fracture Radial head fracture Chorocoid fracture General Comments Zone of Injury 1

2 General Comments In 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 where it hurts the most. Remove jewellery, etc before splinting Patient will self-splint the upper extremity (internal rotation, elbow flexed and adducted to body) Self-splinting 2

3 ARMS Appearance and alignment Pulse Motor function and mechanism of injury Sensation Prevention Upper extremity injuries Snowboarding 3

4 Upper extremity injury Skiing Clavicle injuries 4

5 5

6 Humerus Injuries 6

7 Humeral Fractures MOI 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 fracture Diagnosis 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 Fractures NEER Classification 7

8 Humeral Head Fractures Treatment 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 Fractures Complications Avascular Necrosis of Humeral Head Especially at risk with 4 part fractures Non-union 3-6 mos after injury Shoulder stiffness with prolonged immobilization Shoulder Dislocation Most commonly anterior Examine for associated injuries (vascular or neurological) Rule out associated fracture Reduce asap 8

9 Shoulder Dislocation Younger patient Bankart lesion Older patient RC tear Shoulder Dislocation Younger patient: 1st time Reduce Mobilise after 2-3 weeks Reassess at 6 weeks if still apprehensive then consider surgery Recurrent Reduce Surgery Shoulder Dislocation Older patient: Reduce Reassess after 6 weeks Repair of RC if unable to elevate arm 9

10 Humeral Shaft Fracture Diagnosis Fractures of the shaft of the humerus 1 3% of all fractures Up to 20% have radial n palsy Humeral Shaft Fracture Humeral Fractures Treatment Non-operative Acceptable alignment AP anglulation 20 deg Varus 30 deg <30mm shortening 70 80% with % union rates Time consuming and requires cooperative patient Collar and cuff; coaptation splint; hanging cast; functional bracing Weight of forearm provides traction 10

11 Humeral Fractures Treatment 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 Radial nerve palsy Most at risk distal 1/3 fractures Occurs up to 20% 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 fracture Diagnosis Supracondylar fractures Most common pediatric elbow fracture (65% of fractures and dislocations of the elbow) Commonly associated with neurovascular injury 11

12 Supracondylar fractures Diagnosis 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 Fractures Diagnosis Radiology AP view Baumann s angle Medial epichondylar epiphyseal angle (MEE) Lateral view Humerotrochlear angle Oblique Supracondylar Fracture Treatment Non-displaced fxs cast immobilization Displaced fxs close reduction with percutaneous pinning 12

13 Suprachondylar fracture Complications Vascular injury brachial aa Neurologic deficits median nerve; possible radial nerve Volkmann s contracture Cubitus varus Humerus Injuries Emergency Care Sling Ladder splint Elbow Injuries 13

14 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) 14

15 Elbow Injuries MOI Fall onto outstretched hand with elbow extended or direct trauma Elbow dislocation Diagnosis Second to shoulder dislocations Posterior dislocation account for 80-90% Most occur without fracture Elbow dislocation Treatment 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 15

16 Elbow fracture Radial head 30% Olecrenon 20% Coronoid fractures 10 to 15% of elbow dislocations Elbow fat pads Elbow Fat Pads 16

17 Elbow Fractures Treatment 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 Fractures Treatment 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 Fractures Treatment 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 17

18 Elbow dislocation or fracture Emergency Care Immobilize Sling Posterior elbow splint or brace ice Conclusion Accurate assessment and rapid transport critical (60 rule) Immobilize in the position found Sling 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 18