BCCH Emergency Department UPPER LIMB INJURIES Resource pack Developed by: RENA HEATHCOTE RN

Transcription

1 - 1 - BCCH Emergency Department UPPER LIMB INJURIES Resource pack Developed by: RENA HEATHCOTE RN

2 - 2 - FRACTURES The shoulder Dislocation +/_ fracture of humeral head A dislocated shoulder generally follows a fall onto their arm, or directly onto their shoulder, causing the humeral head to dislocate from the joint capsule and out of the socket. This usually results in an anterior (towards the front) dislocation of the humeral head, where it is positioned in front of the joint socket. More rarely the humeral head dislocates posteriorly (behind) or inferiorly (underneath). The patient usually walks in holding their arm, and in obvious pain There is obvious deformity to the shoulder joint, noted as flattening to the top of the arm at the shoulder joint (the deltoid muscle region), and more obvious bony prominence. Obvious deformity of the shoulder, In this case, the humeral head has dislocated inferiorly

3 - 3 - The humeral head can at times be felt in the axilla Caution: The axillary nerve can become damaged causing paralysis over the deltoid region, and the absence of sensation over a patch below the shoulder. Sensation and radial pulse must always be checked Place the patients arm in a broad arm sling, according to the patients comfort These patients should have an immediate shoulder x ray to exclude any underlying accompanying fracture, followed by reduction of the dislocation under sedation ASAP to minimise pain and risk of neuro vascular injury Ensure the patient has received adequate analgesia Post reduction apply a broad arm sling, and advise patients to minimise movement to prevent the risk of the shoulder re dislocating Patients should be followed up in the orthopaedic clinic, as they tend to sustain significant damage to the surrounding capsule and ligaments, and may have an accompanying underlying fracture

4 - 4 - Fractured humeral neck/ shaft This injury is generally caused by a fall on out stretched hand (FOOSH), although can also be caused by direct impact, and occasionally other mechanisms This results in a fracture through the neck or shaft of the humerus, with varying degrees of displacement There tends to be a significant deformity present to the upper arm, often with bruising and swelling They will usually walk in holding their arm flexed at the elbow The patient will complain of pain at the fracture site Caution; The radial nerve runs behind the humerus, and injury may cause damage to the radial nerve, which can cause wrist drop Sensation, radial pulse, and wrist movement must always be checked Place the patients arm in a broad arm sling, according to the patients comfort Ensure the patient has received adequate analgesia X ray reveals the degree of angulation and site of fracture is dependant upon the site/degree of angulation/pain of the patient: These injuries are followed up in the orthopaedic clinic, and are sometimes surgically plated

5 - 5 - PULLED ELBOW A pulled elbow is a common minor injury which usually affects children under the age of five. Normally happens because children s joints are not completely developed & the ligaments around the elbow are still loose. It occurs when the radius, partially slips out of the ring shaped ligament which secures the radius to the ulna causing a radial head subluxation. A ssessment Care giver may describe hearing a crack or popping sound at the time of the injury Typically child is reluctant to use arm which hangs loosely at their side, the injured elbow is pronated and partially flexed. Anterolateral tenderness over radial head The story of how it occurred and an examination of the child s arm will normally be enough to diagnose a pulled elbow. An X ray is not usually necessary as the injury will not be visible.

6 - 6 - Give the child simple painkillers such as Tylenol or ibuprofen. Once the examination has shown no other injury the child s arm will need to be reduced. This is a quick and simple manoeuvre, and involves manipulating the head of the radius back into the correct position. Often a click is felt as the bone slips back 1. Cup affected elbow with opposite hand 2. Apply pressure over radial head 3. Thumb in antecubital fossa 4. Apply slight longitudunal traction by grasping wrist 5. Supiante, (palm up) and flex (90 degrees) forearm 6. Palpable click felt with reduction Shortly after this a child should be able to start using their arm, especially if distracted by playing with a toy, but sometimes this can take a few hours or more. The longer the arm has been subluxed the longer this is likely to take, but every child is different. We usually keep the children s in ER until the child has started to use their arm, The arm seems may appear a little sore or swollen after it has been treated, advise regular simple painkillers such as Tylenol or ibuprofen until they are using it normally.

7 - 7 - Dislocated elbow H istory Dislocation of the elbow joint results from fall on outstretched hand. It requires a fairly significant force This typically causes posterio lateral dislocation of the olecranon and radial head Obvious deformity Posterior dislocation There is obvious marked deformity and pain The patient will not want to move their arm, and will be holding it against their body This can be mistaken for a supracondylar fracture (see below),especially in children Caution: Dislocation can cause damage to the ulna or medial nerve or brachial artery, but is uncommon (McRae, 2003) Distal sensation and radial pulse/ capillary refill must always be checked Place the patients arm in a broad arm sling, according to the patients comfort These patients should have an immediate elbow x ray to confirm the dislocation and exclude any underlying accompanying fracture, followed by urgent reduction of the dislocation under sedation Ensure the patient has received adequate analgesia

8 - 8 - Supracondylar Fracture This is an extremely common elbow fracture in children, although can occur in adults as well The injury generally occurs from a FOOSH, which may displace the elbow backwards, incurring the fracture The term applies to fractures of the humerus in the distal third, lying just above the trochlea and capitellum (McRae, 2003) The patient will be reluctant to move their arm, and a child will not be using it / reluctant to let it be examined The patient will complain of tenderness / pain around the distal region of the humerus Caution: In significantly displaced fractures, there is high risk of damage to the brachial artery causing limb threatening arterial obstruction The medial nerve can also be compromised Distal sensation and radial pulse/ capillary refill, and wrist movement must always be checked Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered X ray reveals the severity and angulation of the fracture is dependant on the severity of the fracture, any neurovascular compromise, and the age of the patient Generally, non complicated / displaced fractures are placed in an above elbow backslab and collar and cuff, and are followed up in forthopaedic clinic Complicated / displaced fractures, or fractures with evidence of arterial obstruction/ nerve compromise, are referred urgently to the orthopaedic team for manipulation and reduction

9 - 9 - Caused by the mechanism of FOOSH, leading to a fracture through the head of the radius sessment The patient will be reluctant to straighten and move elbow/forearm, as this will reproduce pain The may be some degree of swelling The patient will complain of tenderness over the radial head on palpation of the region Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered An elbow x ray may show a fracture through the radial head, or and effusion within the joint that indicates significant injury If the fracture is minimally displaced or impacted, the arm is placed in a collar and cuff, and the patient is referred to orthopaedic clinic

10 Forearm fractures These injuries are often sustained from falling onto forearm, direct impact, or FOOSH There are varying types of fracture varying from simple mid shaft fractures of the radius or ulna, or more complicated fractures involving both bones and/or associated dislocations at the elbow or wrist joint The patient will complain of pain at the site of the injury in their forearm There may be swelling or deformity They will be reluctant to move their arm, and may be supporting the injured area They may complain of pain at a further site e.g. the elbow/wrist or shoulder Damage to the arterial supply and nerves must always be considered, and a radial pulse and sensation should always be checked Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered An x ray needs to be requested dependant upon the site of bony tenderness / suspected injuries is dependant upon the site / severity of the fracture and/or dislocation Simple mid shaft isolated fractures are treated in an above elbow POP backslab, with a broad arm sling and orthopaedic clinic follow up Complicated fractures and/or associated joint dislocations are referred immediately to the orthopaedic team for reduction and plating under G.A

11 Children with greenstick fracture. Children's bone has the ability to bend before it breaks. It therefore doesn't crack like a dry twig but rather buckles like a green stick. These are stable fractures and heal quickly in a plaster cast. If the fracture is right at the wrist end of the bone a simple below elbow cast is sufficient. If the fracture is more than 3 cm from the wrist a plaster which extends above the elbow is preferred. Bone always grows straight. Therefore children have the ability to 'remodel' their bone as they grow. In children under 8, the ability to do this is amazing and significant deformity can be accepted. Sometimes the bone is too bent and needs to be straightened; this can be done with manipulation under anaesthetic (MUA).

12 FRACTURE OF DISTAL RADIUS Generally a fall onto the outstretched hand (FOOSH) There is often a characteristic dinner fork deformity The patient complain of tenderness to the distal radius, and a step in the bone is often felt on palpation Radial pulse, sensation and capillary refill must always be checked to ensure no neuro vascular compromise

13 Distal Radius Fracture Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered An x ray will show the degree of angulation and/or impaction, and any other associated fractures Simple, minimally displaced fractures are treated conservatively in a cast and followed up in the orthopaedic clinic More severely angulated and/or impacted fractures require manipulation. This is often undertaken in the ER as a procedural sedation

14 SCAPHOID INJURIES (Caution scaphioid Injuries are rare in children below 12 years and highly unlikely in children under 6 years) Injuries to the scaphoid bone classically occur from FOOSH. They can sometimes also occur from forced hyperextension e.g.: hand being forced back by a ball, or putting hand up against a heavy closing door. This can cause a fracture through various areas of the scaphoid bone; a banana shaped carpal bone in the wrist, sitting between the base of the thumb and the radius The scaphoid has a blood supply coming from the distal (furthest) end, which supplies the proximal areas (a backwards blood supply). Hence, If there is a fracture through the waist (middle) of the bone, this can cut off the supply to the nearest fragment, causing avascular necrosis. As a result of this, serious disability, instability

15 and arthritis can occur, and it is an area of high litigation within the medical profession In view of above, this injury is taken extremely seriously, and any patient that exhibits signs of a potential scaphoid fracture, along with an appropriate mechanism of injury, is suspected of having a possible fracture and treated as such, regardless of initial x ray findings The patient will describe the classic FOOSH mechanism, or similar mechanism They will complain of pain in the region of the scaphoid, and there may well be swelling/bruising to the same region The patient will have tenderness when pressed in the anatomical snuff box of the wrist The anatomical snuff box where The scaphoid bone is underlying Patients with scaphoid fractures have the potential for accompanying injuries e.g. distal radius and radial head fractures Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered X rays including scaphoid views may be requested dependant on clinical suspicion, time since injury, and main point of bony tenderness If the clinical suspicion / examination means that a scaphoid fracture is suspected, regardless of whether the x rays show a fracture at the time of the injury, the wrist is put into a scaphoid plaster The injury is then followed up days post injury, and if still clinically suspected, is re xrayed to look for any evidence of fracture or periosteal reaction to the bone that could indicate an underlying fracture. The orthopaedic doctors then treat the injury accordingly

16 Bennetts fracture / fracture to base of thumb metacarpal These fractures often arise from a punch injury, or from forced abduction They can be classified as 1) a simple fracture across the base of the thumb metacarpal OR 2) a Bennetts fracture which consists of an oblique, intra articular (extends into the joint) fragment to the base of the thumb metacarpal, with subluxation (displacement) of the thumb metacarpal Deformity may be obvious There will be tenderness to the base of the thumb metacarpal, and possibly a palpable deformity The patient will be reluctant to move the thumb, and may be unable due to swelling / bruising Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered An x ray will show the type of fracture and degree of joint involvement / displacement Simple, non displaced fractures are placed in a Bennetts POP, broad arm sling, and are reviewed in the next ortho clinic Complicated fractures are discussed urgently with the hand surgeons, as they require urgent reduction and sometimes fixation

17 Ulna collateral ligament injury (gamekeepers/ skiers thumb) This injury is sustained from forced abduction (the thumb being forced outwards to the side or upward) It involves a rupture or partial tear of the ulna collateral ligament, which stabilises the thumb metacarpophalyngeal joint, on the ulna aspect It is considered a serious injury, as if left untreated there may be progressive subluxation (partial dislocation) of the joint, leading to instability and permanent disability (McRae, 2003) It is common to get an avulsion fracture from where the ligament attaches onto the bone This injury is suspected with the appropriate mechanism There may be swelling and bruising around the thumb web space, and the patient will complain of pain in this area

18 Upon examination by an ENP / doctor, there will be laxity (looseness) when gently stressing (pulling upon) this ligament, with accompanying pain Place the patients arm in a broad arm sling, if the patient finds it more comfortable Ensure adequate analgesia is administered Examination by a medical practitioner will provide clinical suspicion / confirmation of this injury An x ray will be taken to rule out an accompanying avulsion fracture or any other fractures to the same region Minor sprains of the ligament without any fracture are treated conservatively in a thumb spica and review clinic Significant laxity / rupture or accompanying fracture is referred to plastics These injuries can be treated in a cast, or can require surgical repair Boxers Fracture / fractures to the fifth metacarpal As the name suggests, this injury is most commonly sustained from punching a hard surface or person A boxers fracture is a fracture through the neck of the 5 th metacarpal, with common angulation and impaction of the fracture Other fractures can occur of the 5 th metacarpal shaft or base The mechanism gives the diagnosis! There may well be swelling over the 5 th Metacarpal, most markedly around the site of the fracture Often there is obvious deformity to the knuckle joint, and the little finger

19 Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered An x ray will show the degree of angulation / severity of the fracture Simple, minimally displaced fractures are treated with buddy strapping and referred to the ortho clinic Complicated / displaced fractures are referred to the hand surgeons Fractures to 2 nd /3 rd /4 th metacarpals Metacarpals may fracture in three places: The neck The shaft (including spiral fractures) The base (often involving dislocation of the joint with the carpal bones)

20 As for boxers fracture As for boxers fracture dependant upon severity of the fracture Phalyngeal Fractures / Dislocations Occurs from varying mechanisms, often sports injury related, or crush injures Fractures are common injures, which if improperly treated lead to stiffness and bony deformity Finger fractures often have accompanying soft tissue injuries, which are often overlooked Dislocations need prompt reduction to reduce pain, avoid further tissue damage, and increase ease of reducing the dislocation There may be obvious deformity / swelling / bruising Place the patients arm in a broad arm sling, according to the patients comfort Ensure adequate analgesia is administered as required If there is a possibility of dislocation, seek help from an ENP / doctor for prompt x ray and reduction An x ray shows the severity / displacement of the fracture, and whether it extends into the joint surfaces Simple fractures are treated with neighbour strapping, and review clinic / fracture clinic follow up

21 Mallet Finger This is caused by forcible flexion of a straight finger (McRae, 2003) e.g: being hit end on by a cricket ball, stubbing finger against something, or from a laceration to the tendon The extensor tendon (the tendon running along the top of the finger) normally inserts at the base of the distal phalanx. This tendon can rupture, become lacerated, or can avulse from the base of the distal phalanx This causes an extensor lag to the distal phalanx, as there is no tendon to hold the phalanx up An obvious extensor lag (drooping to the end of the finger) will be apparent

22 There may or may not be swelling /bruising or tenderness The distal phalanx can be easily passively extended (the medical practitioner performs this for them), but the patient is unable to actively extend (lift it up themselves) Elevate limb as required Ensure adequate analgesia is administered as required An x ray is taken to look for an associated avulsion fracture The distal phalanx is re positioned in a straight position, with very slight hyperextension, and placed in a mallet splint, or a form of zimmer splint. This splint stays on at all times for the next 6 weeks, to maintain the extended position, so that the two ends of the tendon or bone can heal together The patient is taught how to self care with the splint, and wash the finger, whilst the finger maintains the straight position throughout If the splint is removed and the finger is allowed to droop, the tendon ends will split apart again and form scar tissue, and will most likely stay permanently deformed If there is a large avulsion fracture, the patient is referred to the hand surgeons for follow up, as possible fixation of the fragment References McRae, R (2003) Orthopaedics and Fractures, Churchill Livingstone, Oxford