Management of Upper Extremity Trauma PDF Print E-mail
Written by Dr. Niru Prasad   


MANAGEMENT OF UPPER EXTREMITY TRAUMA

by

                                                               

NIRU PRASAD, M.D., F.A.A.P., F.A.C.E.P.

                                

                                

DEPARTMENT OF EMERGENCY MEDICINE

HENRY FORD HOSPITAL

WEST BLOOMFIELD CENTER

                             

                                

DEPARTMENT OF AMBULATORY PEDIATRICS

ST. JOSEPH MERCY HOSPITAL

PONTIAC, MICHIGAN
INTRODUCTION





General Principles



  Anatomy and Physiologic differences between Musculoskeletal System of Children and

  Adult



     Physeal Injuries

     Terminology and Classification

     Soft Tissue Injuries

        Muscle Strain

        Tendinitis

        Bursitis

     Emergency Splinting and Bandage

     Injuries of Upper Extremity

        Fractures of the Clavicle

        Fractures of the Proximal Humerus

        Fractures of Humeral Shaft

        Supracondylar Fracture

        Elbow Injuries

        Fractures of Forearm and Wrist

        Hand Injuries

INTRODUCTION



The musculoskeletal injuries account for 10 to 15% of childhood injuries.  In younger children

injuries are related to fall or intentional physical abuse, however in older children and

adolescent sports injuries and motor vehicle accidents predominate.  Due to the anatomic and

physiologic differences between skeletal structures of children and adults, it is very important

for the Emergency Room physician to realize that a serious growth plate injury can occur in a

child without any radiological changes.





GENERAL PRINCIPLES



The basic principles that should be kept in mind while treating any orthopedic injuries are:



A.   A careful history and physical examination will predict the x-ray findings with great

     accuracy.



B.   If x-ray findings are normal but patient clinically has sustained major trauma, treat as a

     fracture.



C.   The neurovascular competence should be checked before and after reductions.



D.   Most orthopedic injuries can be predicted by knowing the chief complaint, age of the

     patient and mechanism of injury.



E.   Be familiar with proper x-ray views and never accept inadequate x-rays.



F.   Always get x-rays before reductions unless it is limb threatening.



G.   Remember RISE

  R - Rest to the injured extremity

  I - Apply ice for the swelling to subside

  S - Splint and immobilize

  E - Elevate the injured extremity



H.   Circumferential casting should never be done by Emergency Physician due to malpractice

     reasons.



I.   Patient should be checked for their ability to ambulate safely before being discharged from

     the Emergency Department.  If in doubt admit the patient.



J.   All patients should receive after care instructions typed if possible before discharge.



K.   In a Multiple Trauma Victim the life threatening injuries should be treated before the non-

     critical orthopedic injuries.



L.   While contacting the orthopedic surgeon all injuries and fractures should be precisely

     described.



M.   While obtaining x-rays of Fractured Extremity always include joints above and below the

     site of injury and get comparison view of other extremity if indicated.



The Anatomic and Physiologic Differences between Musculoskeletal System of Children and

Adult.





The infants and young children have less ossified tissue, wider epiphyseal plates and thicken

periosteum than older children and adolescents.  Furthermore the children's bones are more

porous and bendable.  In utero the bone develops from mesenchymal tissue subsequently

they develop more cartilagineous and bony structure.  The physis or cartilagineous plate

contains the germinal chondrocytes which by reproducing themselves cause the bone to

increase in length.  While enchondral ossification with germinal layer proliferation of the physis

causes the bone to lengthen, the membranous ossification in the periosteum enlarges the

bone circumferentially causing an increase in diameter.  The periosteum in children is thicker

than in adults.  Due to the anatomic and physiologic differences, children's bones are more

susceptible to stress, buckle, greenstick fractures and growth plate injuries.





The Salter Harris Classification of Growth Plate Injury



The growth plate fractures involving Epiphysis and Metaphysis account for 15 - 20% of

childhood fractures and is described by Salter-Harris.  The Salter-Harris Type I Fractures

extend through the physis, not displaced, not visible radiologically and clinical diagnosis is

generally based on swelling and tenderness over the physis.



Type II Fracture involves Epiphysis and fragments of Metaphysis, the most common childhood

physeal injury, and is generally treated by reduction and immobilization for 3 - 4 weeks.



Type III Fractures are transverse along Physeal-Metaphyseal junction and extends through

epiphyseal ossification, center, and articular certilage.  This is an unstable fracture requiring

good alignment.



Type IV Fractures involves Epiphysis, Metaphysis growth plates and Diaphysis and needs

surgical intervention.



Type V Fractures are generally the crush injuries involving growth plates and the bone.





Terminology and Classification



The fractures can be described, categorized and presented according to:  1) Anatomic

Location; and 2) Direction of Fracture Line.



A.   The Anatomic Location



  Fractures are usually described as involving the Proximal, Middle, or Distal thirds of a long

  bone.  The other anatomic terms frequently used are head, shaft or base of Metacarpals or

  Metatarsals.



B.   Direction of Fracture Lines



  Transverse - Fracture line running perpendicular to the bone.



  Oblique - Oblique fractures run across the bone at an angle of 45 to 60 degrees.



  Spiral - A spiral fracture has a torsional component.



  Comminuted - A comminuted fracture involves more than two fragments.



  Impacted - The ends of impacted fractures are compressed together.  These are generally

  stable fractures.



C.   Relationship of the Fracture Fragments to Each Other



  Alignment - This is the relationship of the axis of fragments of long bones to one another. 

  Alignment is described in degree of angulation of the distal fragment in relation to the

  proximal fragment.





Apposition



This describes the contact of the fracture surfaces which may be partial.  If the fragments are

not only displaced but also overlapping the term is called Bayonette opposition frequently

seen in femoral shaft fracture.





Stability



A stable fracture does not have a tendency to displace after reduction.



Unstable Fracture - A fracture that displaces after reduction.





Associated Soft Tissue Injuries



Closed Fracture - A fracture in which the overlying skin remains intact.



Compound or open fracture where overlying skin is broken.



Complicated Fracture - A fracture that is associated with either Neurovascular, Visceral,

Ligamentous or Muscular damage.  Intra articular fractures are usually complicated.



Uncomplicated Fractures are usually associated with minimal soft tissue injury.





Mechanism of Injury



It is very important to know the impact of injury such as:



Direct Force - Usually causes transverse, oblique or comminuted fractures.



Indirect Forces - Traction on a ligament attached to a bone can result in an avulsion fracture.  A

valgus stress at knee can result in compression or depression fracture of tibial condyles.





Dislocation, Subluxation and Diastasis



Joint injuries frequently associated with fractures are generally described as:



Dislocation - Where there is total disruption of the joint surfaces with loss of normal contact

between the two bony ends.



Subluxation - Partial disruption of a joint with partial contact between the two bones that make

up the joint.



Diastasis - A disruption of the intra osseous membrane connecting the two joints.





Clinical Features of Fractures



The swelling, pain, tenderness, are the frequent clinical findings at the site of fracture.  A gross

deformity or crepitus indicates unstable fractures and should be splinted immediately to

prevent neurovascular damage.  Bleeding is a common problem with most fractures.



              The Average Blood Loss with a Closed Fracture



             Fracture Site                         Amount



             Radius and Ulna                     150 - 250 cc

             Humerus                                250 cc

             Pelvis                             1500 - 3000 cc

             Femur                                 1000 cc

             Tibia and Fibula                       500 cc





                  Musculoskeletal Pain Following Trauma





                           Physical Examination

                           Localized Tenderness

                        Swelling Impaired Function









            Yes                                          No









         X-rays Exam                                 Symptomatic

                                                     Treatment







Positive           Negative                          Reevaluate in

                                                     5 - 10 Days

                                                     Improved?





Orthopedic         Immobilize with

Consultation       Splint or Cast               Yes                No

Treat as Fracture                                              X-rays and

                                                               Orthopedic

                                                               Evaluation





Follow up as       Reevaluate in

Needed             5 - 10 days





              Yes                No

                             Repeat X-rays

                             Consult

                             Orthopedic





A guideline approach to management of Orthopedic trauma.

Emergency Splinting and Bandage



The purpose of Emergency Splinting are:



1.   To prevent further soft tissue injury by the fracture fragments.



2.   Pain relief.



3.   Lower the incidence of fat embolism.





Any unstable fracture must be stabilized by external splinting before patient is transported to x-

rays.  In the Emergency Department, casting is usually delayed 24 - 48 hours until swelling

subsides.  All dislocations should be splinted using the bone above and bone below the joint. 

All fractures should be splinted in position of function.





The guidelines for splinting traumatized extremity:



1.   Use splint of appropriate size and shape.



2.   Avoid applying circular rigid splint or cast which increases the chance of compartment

     syndrome.



3.   Pad all the bony prominences to avoid pressure necrosis.



4.   Wrap the splint loosely not too tight with Ace wrap.



5.   Give adequate after care instruction.





The fractures with obvious deformity are limb threatening injuries and look for signs of Pallor,

Paresthesia, Pulseless, Palsy, Pain in distal end, if these are present then immediate reduction

and traction are done before splinting.



There are different types of splints available to stabilize the injured limbs.



Inflatable splints are particularly useful in pre-hospital setting.



Soft splints such as Jone's dressing, pillow splints, figure of eight, clavicular strap.



Rigid splints made of Webril Pade and plaster.



Mast trousers especially used to stabilize femoral fracture.



Long arm or short arm splints.



Posterior arm splints for elbow and forearm fractures.



Special types of hand and wrist splints such as ulnar gutter splint for fractures 4th - 5th

metacarpal.



Dorsal extension splints for non-rotated finger injuries involving phalanges, IP joint.



Thumb spica splint or cast for fracture scaphoid.



Immediate orthopedic referral should be made for any significant injuries, obvious deformities

dislocations or open fractures.  The child should also be treated for any other injuries

sustained.





Long Term Sequelies



Fractures in children frequently lead to growth arrest and growth failure if not treated

adequately.  Other problems include non-unions usually with Salter III and open fractures. 

Avascular necrosis may complicate an injury that disrupts blood supply.  Angulation

deformities might result from improperly managed greenstick fractures, bowing fractures and

Salter II, III, IV injuries.  A longitudinal growth deformity might result from inadequately treated

Salter III, IV fractures.  Open fractures often leads to bone infections, joint stiffness and post

traumatic arthritis.





               MANAGEMENT OF FRACTURES OF UPPER EXTREMITIES





Fracture Clavicle



The clavicle is the most common bone fractured in children and can be treated easily by figure

of eight clavicle strap.



Fracture Proximal 3rd clavicle results from blow to anterior chest area.



Fracture Middle clavicle is the most common type of fracture seen in almost 80% of clavicle

fracture and results from fall.



A direct blow to top of shoulder leads to fracture distal third clavicle.



The child presents to Emergency Room with pain aggravated with upper arm movement,

swelling, tenderness, crepitus at the site, the arm is usually kept downward close to the body.



After performing a complete physical and neurovascular examination, a shoulder sling should

be applied before patient is sent to X-ray Department, and pain medication should be given. 

The uncomplicated fractures of clavicle are treated with figure of eight bandage for 3 - 4 weeks

which helps in keeping the shoulder in abduction.  The complicated fractures, sterno clavicular

dislocations, acromio clavicular separation should be referred to Orthopedic Surgery.





Shoulder Injuries



Shoulder injuries are common during vigorous athletic activities in adolescents and older

children and patients generally present to Emergency Room with:



1.   Shoulder contusions.



2.   Fracture humeral heads.



3.   Acromio clavicular separations.



4.   Anterior and posterior shoulder dislocations.





Shoulder Dislocations



The dislocation of humeral head from glenoid cavity is more frequent in adolescent resulting

from serious, vigorous trauma to shoulder generally during sports activities.  95% of

dislocations are anterior and results from indirect trauma to the arm causing abduction and

extension of the shoulder disrupting the joint capsule.  The posterior shoulder dislocations are

injuries seen in Newborns with birth trauma and shoulder dystocia, and in epileptic patients

secondary to fall on adducted arm.



Physical examination of patients with anterior dislocation reveals obvious deformity of the

shoulder with flattened deltoid muscle, prominent acromion and palpable humeral head

anterior, medial or inferior to glenoid.  There is limited range of abduction and external rotation

of arm.  Hyposthesia over deltoid muscles result from axillary nerve injury.  Recurrent shoulder

dislocation associated with glenoid Labrum tear and compression fracture of posterior humeral

head is condition called Hill-Sachs Lesion.





Management



After having stabilized the patient with shoulder sling, pain control, x-rays should be obtained

including anteroposterior, lateral and axillary views and orthopedic consultation should be

made.  The reductions are generally done under sedation with traction, countertraction

technique.





Fractures of Humerus



Patients with proximal humeral fractures present to Emergency Room with pain, swelling,

deformity of upper arm usually after having fallen backward with arm extended.  Children and

adolescent with shoulder injuries generally have Salter II epiphyseal separation of proximal

humerus.



Most fractures of proximal humerus are treated with sling and swathe until union occurs. 

More severely displaced fractures need surgical correction.





Fractures of Humeral Shaft



These fractures result from direct blow or indirect trauma from falling on outstretched hand. 

Spiral fractures of the humerus in newborn suggest birth trauma, in older babies suggest

physical abuse.  Radial nerve injury frequently results from fracture humerus resulting in wrist

drop.  These fractures in children heal very fast and external support with plaster splints for

several weeks usually hold upper arm stable enough for union to occur.





Supra Condylar Fractures of the Humerus



Children with supra condylar fracture humerus present to Emergency Room with severe pain,

swelling deformity around elbow with impaired distal circulation to the forearm and wrist.  The

distal fragments of humerus is pushed posteriorly leading to damage of brachial artery and

median nerves leading to compartment syndrome and Volkmann's Contracture to the limb. 

Clinically the most significant sign of ischemic myositis is pain in forearm, aggravated by

fingers extension, numbness and paresthesia, pallor and cyanosis of the fingers.  An

immediate orthopedic consultation should be made and these patients are generally admitted

for observation and surgical treatment of the fracture.





Elbow Injuries in Children



These injuries are very common in children due to direct or indirect forces and if not

recognized or treated early might lead to growth disturbance, deformity, neurologic

impairment and joint stiffness.



The common elbow injuries are:



A.   Fracture of the capitellum.



B.   Epiphyseal separation of medial humeral epicondyle.



C.   Fracture of medial humeral condyle.



D.   Fracture of olecranon.



E.   Fracture of neck of radius.



F.   Posterior elbow dislocation.



Children with fractures of the capitellum generally have Salter IV epiphyseal injuries which

needs surgical correction in order to avoid severe cubitus valgus deformity and joint

contractures.



Fractures of medial humeral condyle though rare in children, have the potential for producing

cubitus varus deformity if not treated adequately.  These fractures need open reduction and

internal fixation if there is impingement on ulnar nerve.



Radial neck fractures need open reduction if there is angulation more than 30 .  Most of the

elbow injuries are treated with rest, sling, ice, pain control, elbow aspiration to relieve

hemarthrosis and orthopedic referral.





Subluxation of Radial Head or Nurse Maid's Elbow



This is a common injury seen in children 6 months to 5 years of age and results from tear of

periosteal attachment of the annular ligament that holds the radial head with proximal ulna and

capitellum.  Typically the parent or baby sitter has pulled the child by arm with arm extended

and pronated.  The child presents to Emergency Room with pain, arms pronated, slightly

flexed and close to the body and unable to move the arm.



One can reduce the subluxation by supinating the forearm while extending the elbow and then

flexing.  A reduction clip heard can be felt if thumb is placed over radius head during

reduction.  The child can usually move the arm freely after the procedure.





Fractures of Forearm and Wrist



These are most common fractures seen in pediatric age group.  The diagnosis is made easily

by history, swelling, pain, tenderness over the extremity and confirmed by x-rays.  Simple

undisplaced fractures like minor buckle fracture of radius or torus fractures can be treated by

applying well molded short arm cast and discharged home.



Displaced fractures of radius and ulna with over 30  angulations usually require reduction by

orthopedic surgeon.  More severely displaced fractures usually need aggressive treatment. 

Child with severely displaced fractures of radius and ulna needs hospitalization, reduction and

stabilization under general anesthesia.  A green stick fracture involving one cortex area only

might need manipulation to break through both cortices to prevent re-angulation.  Fractures of

distal radial physis with dorsal displacement of the epiphysis are common injuries seen in

adolescent and children and are treated by reduction and casting.





Monteggia Fracture



These injuries result from fall on outstretched hand.  The hyper pronation when truck and

humerus rotate externally after the hand is fixed on the ground can cause fracture of ulna with

radial head dislocation.  The child present to Emergency Room with pain, swelling, tenderness

of forearm with restricted range of motion elbow joint.  Radiological investigation should

always include x-rays forearm with wrist and elbow.





Management



Reduction of radial head dislocation and ulnar fracture should be done by orthopedic surgeon. 

Supination, traction and direct pressure on radial head with elbow flexed 90  generally reduce

the dislocation.  The elbow is splinted in flexion and repeat x-rays are made to document the

reduction.



Galeazzi Fracture involves break at the junction of middle and distal third radius with disruption

of distal radio ulnar ligament.



Colles' Fracture is a transverse fracture of distal radius with dorsal angulation and loss or

reversal of volar tilt to the distal radial articulating surface.  Patients might have accompanying

fracture of ulnar styloid or Salter II epiphyseal injury.



Smith's Fracture is reverse Colle's Fracture caused by blow to the dorsum of wrist or distal

radius with forearm in pronation.





Management



Treatment depends upon the type of fracture and alignment.  Angulated fractures greater than

15 degrees in children lead to decreased function.  Generally fractures are immobilized for 4 - 6

weeks.





Wrist and Hand Injuries



Since hand is the most frequently injured part of the body, physicians should be aware of

common wrist and hand injuries.  As mentioned before a good history and physical

examination of the injured site with adequate radiological investigation will lead to proper

management of the injury.



Fractures of Wrists



Since carpal bones are largely cartilaginous in growing years, carpal fractures are rare in

children and mostly result from extension injuries to wrist.



Navicular Fractures



The scaphoid is most frequently injured bone resulting from fall on outstretched hand.  Child

complains of pain along distal radius, swelling and tenderness are noted at anatomic snuff box

and x-rays of wrist including navicular view confirm diagnosis.



Treatment



Non displaced fractures require immobilization for 6 - 10 weeks with thumb spica cast.



Lunate and perilunate dislocations are injuries resulting from fall on outstretched hand. 

Diagnosis is confirmed by x-rays where the normal alignment formed by 3rd metacarpal,

capitate, lunate and radius is disrupted.  These injuries should be referred to orthopedics.



Game Keeper's Thumb



This injury results when skier falls on outstretched hand while grasping the ski pole.  The hyper

extended thumb with ulnar collateral injury often is associated with Salter III fracture of

proximal phalanx thumb which needs open reduction and pin fixation to avoid angular

deformity of thumb.



Bennett's Fracture is fracture at base of 1st metacarpal with dislocation of one of the fragment. 

An uncomplicated ulnar collateral injury at base of thumb is managed by thumb spica cast for

6 weeks.



Fracture of Phalanges



Finger fractures are common in children and may present to Emergency Room as crush

injuries, open fractures, subungual hematoma, mallet finger or boutonniere deformity.



Mallet's Finger also know as baseball finger is injury to extensor tendon at distal

interphalangeal joint often associated with fracture at distal phaleux.  The finger is bent at joint

and cannot be extended.  This is treated with splinting the distal phalanx in mild

hyperextension.



Boutonniere Deformity is injury to proximal phalanx due to direct blow leading to disruption of

central slip of extensor tendon at PIP joint with volar subluxation of lateral filmes of tendon. 

The finger should be splinted in extension.



Jersey Finger is avulsion of flexor digitorum profundus involving ring finger seen commonly in

athletes with football or rugby sports.  The patient is unable to flex the distal IP joint, has

swelling tenderness at volar plate.  Such injuries should be referred to hand surgeons.



For most of the hands and finger injuries the hand should be splinted at 90  flexion at MP joint,

and 15  flexion at interphalangeal joint.



In summary the author has discussed the Common Guidelines for Management of Upper

Extremity Trauma at Emergency Room with strong emphasis.  Put on thorough physical

examination, adequate x-rays and proper immobilization of the damaged extremity.

                               Bibliography





Pediatric Emergency Medicine, 1992, Barkin.



Textbook of Pediatric Emergency Medicine, 2nd Edition, Gary Fleisher and Stephen Ludwig.



Emergency Orthopedics, 2nd Edition, 1987, Robert R. Simon.



Physical Examination of Spines and Extremities, 1976, Stanley Hoppenfeld.