FOOSH It sounded like a fun thing at the time!

Transcription

1 FOOSH It sounded like a fun thing at the time! Evaluating acute hand and wrist injuries Larry Collins, MPAS, PA-C, ATC, DFAAPA Assistant Professor, Physician Assistant Program Assistant Professor, Department of Orthopaedics & Sports Medicine USF Health, Morsani College of Medicine

2 Disclosures I have no real or apparent conflicts of interest to report

3 History What was the cause? What were the symptoms at the time of injury, did they occur later, were they localized or diffuse? Was there swelling and discoloration? What treatment was given and how does it feel now?

4 Observation Deformity Swelling Skin defect Range of motion Pain w/motion

5 Palpation Point of injury Proximal and distal Tenderness Deformity Edema Crepitus Changes in skin temperature false joint

6 Neurovascular Status Motor and sensory function Median, radial, and ulnar nerves Circulation Radial pulse Capillary refill

7 Distal Radius Fractures Common fracture in upper extremity Majority occur as isolated injuries Youths sports high-energy falls Seniors low-energy falls

8 Presentation Audible pop or crack followed by moderate to severe pain, swelling, and disability Proximal third radius fracture may result in abduction deformity due pull of pronator teres Edema, ecchymosis w/ possible crepitus Forward displacement of radius causing visible deformity (dinner fork deformity) When no deformity is present, injury can be passed off as bad sprain Tendons may be torn/avulsed and there may be median nerve damage

9 Radiographs Loss of normal anatomy Displacement Angulation radial height Involvement of radiocarpal or distal radioulnar joint Articular surface Step-off Separation Significant comminution

10 Management Adult RICE Splint Emergent orthopedic referral Open fractures Compression neuropathy Compartment syndrome Vascular compromise

11 Surgical vs. Non-Surgical Patient needs Bone quality Comorbidities Functional demand

12 Management Peds Urgent Referral Open fractures Neurovascular compromise Displaced radius with intact ulna Associated wrist or elbow dislocation Supracondylar fracture Radius fracture with dislocation of distal ulna (Galeazzi )

13 Non-displaced Extra-articular Fractures Stable Well-molded sugar-tong, or double sugar-tong splint Transition to cast 1-2 weeks Elevation Range of motion for shoulder and fingers Opioids as needed

14 Sugar-tong Splints

15 Referral Articular step-off Intraarticular displacement Displacement > 2/3 of radial shaft Comminution with radial shortening

16 Management Peds Refer displaced I or II and all III, IV, V

17 Management Peds Torus (buckle) fracture Stable Immobilization with splint or short-arm cast Non-displaced Salter-Harris I or II fractures Stable Immobilization with short arm splint x 3-4 weeks Volar splint for I; sugar-tong for II Sling for support Greenstick fracture Immobilization with cast x 6-8 weeks Distal short arm cast Proximal long arm cast x 3 then short arm

18 Wrist Sprains Etiology Most common wrist injury Arises from any abnormal, forced movement Falling on hyperextended wrist, violent flexion or torsion Signs and Symptoms Pain, swelling and difficulty w/ movement

19 Wrist Sprains Management RICE Splint NSAIDs ROM Begin strengthening soon

20 Triangular Fibrocartilage Complex (TFCC) Injury Etiology Occurs through forced hyperextension, falling on outstretched hand Violent twist or torque of the wrist Signs and Symptoms Pain along ulnar side of wrist, difficulty w/ wrist extension, possible clicking Swelling is possible, not much initially Pain increases with rotation and ulnar deviation of the wrist

21 Triangular Fibrocartilage Complex (TFCC) Injury

22 Examination Recreate symptoms with ulnar deviation and extension Axial loading with ulnar deviation Push-off test Getting out of chair with armrests

23 Management NSIADs Thumb spica splint or short arm cast x 4-6 weeks Surgical referral may be indicated

24 Scaphoid Fracture Common Often initially missed May fail to heal 2 poor blood supply Non-union Accessed 12/08/2018.

25 Scaphoid Fracture Signs and Symptoms Swelling Pain in anatomic snuff box Presents like wrist sprain Pain w/ radial flexion

26 Scaphoid Fracture Management High index of suspicion Consider MRI Splint Thumb spica Immobilization lasts 6 weeks Wrist requires protection against impact loading for 3 additional months

27 Indications For Surgical Referral Open Neurovascular compromise Proximal pole Displaced Patient preference Delayed presentation Scapholunate disruption Evidence of non-union or osteonecrosis

28 Scaphoid Fractures

29 Usefulness of MRI

30 Metacarpal Shaft Fractures Direct axial or compressive force 5th metacarpal fractures punch Boxer s fracture Signs and Symptoms Pain Swelling Crepitus Angular or rotational deformity

31 Rotational Deformity Accessed 12/11/2017.

32 Indications For Referral Open Intra-articular Rotational malalignment Significant displacement Multiple

33 Metacarpal Fracture Management Splint (include digits) MCP in flexion Cast after 1-2 weeks (leave PIP free) 6 weeks in cast? Transition to splint

34 5 th Metacarpal Fracture Management Stable Splint for pain Consider cast or splint

35 1st Metacarpal Fracture Bennett Fracture Base of 1 st metacarpal Result of an axial and abduction force to the thumb Signs and Symptoms Pain Swelling Inability to grip/pinch

36 Radiographs Intra-articular

37 1st Metacarpal Fracture High incidence OA Unstable Surgical referral Displacement Casting is option for non-displaced

38 Phalangeal Fractures Occurs from direct trauma or twist Spiral or angulated Signs and Symptoms Pain and swelling Possible deformity

39 Indications for Referral Open Neurovascular injury Intra-articular Rotated Shortened Comminuted

40 Management RICE and analgesics Non-displaced Transverse, oblique, or avulsion Buddy tape Consider gutter splint for function

41 Questions? Evaluating acute hand and wrist injuries Larry Collins, MPAS, PA-C, ATC, DFAAPA Assistant Professor, Physician Assistant Program Assistant Professor, Department of Orthopaedics & Sports Medicine USF Health, Morsani College of Medicine