Chapter 19 – Upper Extremity Trauma




Abstract




Upper extremity (UE) trauma is a common finding in patients presenting to the Emergency Department (ED), found in 31.6% of patients reported to the National Trauma Data Base,1 and occurring with an estimated incidence of 1,130 upper extremity injuries per 100,000 persons per year.2





Chapter 19 Upper Extremity Trauma



Kristen Kann



Introduction


Upper extremity (UE) trauma is a common finding in patients presenting to the Emergency Department (ED), found in 31.6% of patients reported to the National Trauma Data Base,1 and occurring with an estimated incidence of 1,130 upper extremity injuries per 100,000 persons per year.2


General rules of wound management should be followed, including cleaning of the wound, complete neurovascular examination, tetanus administration as indicated, and pain control as needed. In addition, any wound with neurovascular compromise requires immediate intervention and/or emergent orthopedic consultation (Table 19.1).




Table 19.1 Hand surgery consultation


































Immediate Hand Surgery Consultation Delayed Hand Surgery Consultation
Amputation Tendon lacerations
Severe crush injury Tendon ruptures (Jersey finger, mallet finger)
Open fracture Closed fracture
Severe soft tissue loss Ligamentous injuries/laxity or instability
Irreducible dislocations Dislocations reduced in ER
Vascular injury Nerve injury
Compartment syndrome
High-pressure injection injury


Hand and Finger Injuries



Bone



Distal Phalanges



  • Tuft fracture: Distal, comminuted fracture. May be associated with nail bed injuries (Figure 19.1).3



  • Shaft fractures: Reduce those with gross deformity or severe pain and immobilize with malleable splint.



  • Dorsal intra-articular fractures: “Bony mallet finger,” see section below on soft tissue injuries (Figure 19.2).



  • Volar intra-articular fracture: “Bony jersey finger,” uncommon, presents with tenderness over the volar aspect of the distal phalanx – if patient also has palmar pain, assume rupture of the flexor digitorum profundus tendon. Treatment is volar splint and orthopedic follow up for likely surgical fixation.3





Figure 19.1 Tufts fracture





Figure 19.2 Mallet finger



Proximal and Middle Phalanges



  • Most fractures can be buddy taped or placed in a gutter splint (radial gutter for 2nd and 3rd phalanges, ulnar gutter for 4th and 5th) and followed up with primary care.3



  • Intra-articular and unstable (displaced, spiral, oblique, comminuted) fractures should be reduced to anatomic position, placed in a gutter splint, and referred for orthopedic follow up.4



Metacarpal Head

Place in gutter splint with metacarpophalangeal (MCP) joint flexed >70° and follow up with a hand surgeon (many require fixation).3, 4



Metacarpal Neck



  • Boxer’s fracture: Fracture of neck of the 4th or 5th metacarpal (MC) (Figure 19.3).3



  • Acceptable angulation: <10° for 2nd and 3rd MCs, <30–40° in 4th and 5th MCs.3, 4



  • Reduce as needed, then place in gutter splint with wrist at 20° extension and MCP >70° flexion.4





Figure 19.3 4th MC neck fracture



Metacarpal Shaft



  • Acceptable deformities:




    • Rotational: <10°.5



    • Dorsal angulation: <10° for 2nd and 3rd MCs, <10–20° for 4th and 5th MCs.3



    • Anything beyond these should be further reduced, and, if this is not possible, refer for likely operative fixation.




  • Place in gutter splint with wrist extended about 30° and MCP joint in 90° flexion, IP joints in extension.3



Thumb Metacarpal



  • Extra-articular:




    • Acceptable angulation <30°.3



    • Oblique and rotational fractures, often require pinning.3, 5




  • Intra-articular:




    • Bennett’s: Fracture dislocation at the metacarpal joint, ulnar portion in anatomic position with displaced radial/distal portion (Figure 19.4). Place in thumb spica splint and refer to orthopedics.5




    • Rolando’s: Comminuted intra-articular fracture. Place in thumb spica splint and refer to orthopedics.5






Figure 19.4 Bennett’s fracture



Joint Dislocations



  • Distal interphalangeal (DIP) joint: Usually dorsal. Digital block and reduce with exaggeration/traction/re-approximation technique.



  • Proximal interphalangeal (PIP) joint: Usually dorsal or lateral; reduce as with DIPs.



  • MCP subluxations and dislocations: Usually dorsal. To reduce, flex the wrist and apply volar pressure over the proximal phalanx. Splint in MCP flexion, such as with a gutter splint.5



  • Carpometacarpal joint dislocations: Usually dorsal. Reduce with traction, flexion, and pressure on the MC base. Volar dislocations should be referred.5



Nerve


Table 19.2 provides specific innervation of the hand.




Table 19.2 Innervation of the hand
























Nerve Motor Exam Sensory Exam
Radial nerve Wrist and finger extension, thumb extension against resistance Sensation at web space between thumb and index finger
Median nerve Thumb–pinky opposition Sensation at pad of index finger
Ulnar nerve Resisted abduction of fingers Sensation at pad of pinky finger


Soft Tissue




  • Up to 90% of a tendon can be lacerated with preserved ROM without resistance – always test with resistance and compare to uninjured side.5



  • Tendon laceration – May be able to fix extensors in consultation with hand surgeon, but operative repair is becoming more common. For flexor tendon injury, consult hand surgeon, with loose closure and splint until follow up.5



  • Specific injuries:




    • Mallet finger:6




      1. Most common tendon injury in athletes.5



      2. Complete laceration/rupture of extensor tendon resulting in inability to extend DIP joint.



      3. Splint in extension, as no flexion is allowed for 6–10 weeks. Any flexion requires resplinting and restarting the immobilization period.35



      4. Poor healing leads to Swan neck deformity, in which lateral bands slip dorsally and increase extension at the PIP.5




    • Jersey finger:6




      1. Laceration/rupture of flexor tendon at insertion into distal phalanx.



      2. Presents with pain/tenderness at volar DIP/distal phalanx, with digit held in relative extension.



      3. Splint in flexion and refer to a hand surgeon, as operative repair is almost always necessary.




    • Boutonniere deformity:




      1. PIP flexion and DIP extension caused by laceration/rupture of central slip over the PIP and volar displacement of lateral bands.7



      2. Splint with PIP in full extension and follow up with orthopedics/hand surgeon.




    • Gamekeeper’s/Skier’s thumb:




      1. Rupture or strain of ulnar collateral ligament (UCL).




        1. Presents with pain and ecchymosis at thumb MCP, as well as pincer weakness.




      2. >35° radial angulation, or >10° difference from uninjured thumb, indicates complete rupture and should be treated in consultation with a hand surgeon.



      3. Place in thumb spica splint and obtain urgent orthopedics/hand surgery follow up for likely surgical repair.8




    • High-pressure injection injury:




      1. Orthopedic emergency: Benign early appearance progresses to edema, pallor, and exquisite tenderness to palpation.



      2. Treatment: Early orthopedic consult for surgical debridement.



      3. While pending bedside consult, splint and elevate the extremity, update tetanus, and provide broad spectrum antibiotics and analgesia.5





Wrist and Distal Forearm Injuries



Bone



Distal Radius



  • Colles’ fracture:




    • Usually from a fall onto an outstretched hand (FOOSH) type injury, with distal fracture fragment of the radius dorsally angulated and displaced (Figure 19.5).5




    • Classic “dinner fork” deformity with gross dorsiflexion of the wrist.



    • >20° angulation, intra-articular involvement, marked comminution, or >1 cm of shortening meets criteria for an unstable fracture.5



    • Closed reduction with restoration of volar tilt (minimum of 0° angulation) and proper radial length and application of a sugar tong splint.5




  • Smith’s fracture is equivalent to reverse Colles’ fracture:




    • Volar angulation of the distal radius after a fracture, known as “garden spade” deformity.5



    • Closed reduction and sugar tong splint application.




  • Barton’s fracture:




    • Rim fractures of the distal radius, frequently with carpal subluxation.



    • Sugar tong splint application and orthopedic follow up.5




  • Radial styloid fracture:




    • Radial styloid is the insertion site of multiple major carpal ligaments.



    • Often accompanied by lunate dislocation.



    • Place in short arm splint with wrist in mild flexion and ulnar deviation and orthopedic referral.5






Figure 19.5 Colle’s fracture



Distal Ulna



  • Ulnar styloid fracture:




    • Rarely significant, unless extensive and involving the triangular fibrocartilage complex/distal radioulnar joint.



    • Treat with ulnar gutter splint with slight ulnar deviation and a neutral wrist.5




Carpal Fractures



  • Scaphoid:




    • Most commonly fractured carpal bone (Figure 19.6).5



    • Clinical exam: pain along radial aspect of the wrist, specifically tenderness in the anatomic snuffbox. Exam may also reveal pain in the snuffbox with resisted supination or pronation, as well as pain on axial load of the thumb’s MC joint.5



    • If x-rays are negative but there is concern for scaphoid fracture, consider MRI or CT of the scaphoid.9



    • Vascular supply to scaphoid enters distally, so fractures (especially proximal, oblique, or displaced fractures) can lead to proximal avascular necrosis.5



    • For non-displaced fractures or those with negative x-rays but concern for scaphoid fracture, place in short arm thumb spica splint with dorsiflexion and radial deviation.5




  • Triquetrum fractures:




    • Second most common carpal bone fracture:5



    • Tenderness dorsally, just distal to the ulnar styloid.



    • Dorsal avulsion fractures: “Flake” of bone over triquetrum on lateral x-rays, usually splinted for 1–2 weeks with excellent prognosis.5



    • Body fractures: Usually cast for 6 weeks. Displaced fractures may require fixation.5




  • Lunate fractures: Rare in isolation. Distal blood supply, similar to the scaphoid, increases risk of avascular necrosis.5




    • Fractures require orthopedic consult and short arm thumb spica splint.




  • Trapezium fracture: Painful thumb movement and weak pinch with tenderness at the snuffbox. Consult orthopedics and place in a short arm thumb spica splint.5



  • Pisiform fracture: Localized tenderness over the pisiform, which can be palpated in the hypothenar eminence with the wrist flexed.




    • Consider carpal tunnel view or supination films.



    • Treat with compression dressing or splint in 30° flexion with ulnar deviation.5




  • Hamate fracture: Usually involves the hook of the hamate, best visualized with carpal tunnel views, though consider a CT if negative x-rays and high index of suspicion.




    • Remember to examine for signs of injury to the ulnar nerve and artery, which pass through Guyon’s canal.5



    • Splint and refer to orthopedics.




  • Capitate fracture: Often occur in conjunction with a scaphoid fracture. Distal blood supply with danger of avascular necrosis, similar to the lunate and scaphoid.




    • Examination with tenderness and swelling just proximal to the 3rd MC.



    • Splint and consult orthopedics.5




  • Trapezoid fracture: Rare, examination reveals tenderness on axial load of the index finger. Consider CT or MRI if negative x-rays and place thumb spica splint.5





Figure 19.6 Scaphoid fracture



Subluxations and Dislocations



  • Distal radio-ulnar joint subluxation:




    • Rarely isolated, usually seen with intra-articular or distal radial shaft fractures (Galeazzi) or both-bone fractures of the forearm.5



    • True lateral X-ray will show displacement of the ulna (either volar or dorsal).



    • Examination with pain at radioulnar joint, prominent ulnar head, weak grip, and decreased ROM in pronation and supination.5




  • Peri-lunate and lunate dislocations:10




    • Parts of a continuous spectrum of high-energy injuries. Typically, there is little gross deformity on examination.



    • Lunate dislocation: “Spilled teacup” sign on lateral x-ray shows the lunate’s concavity oriented towards the palm (Figure 19.7).



    • Both perilunate and lunate dislocations necessitate immediate orthopedic consultation.5






Figure 19.7 Lunate dislocation



Soft Tissue




  • Scapholunate ligament: Most commonly injured ligament of the wrist, most often from FOOSH.5




    • Scapholunate dissociation: “Terry Thomas sign” results from widening of the scapholunate joint space of >3 mm.5



    • If high suspicion, obtain a grip compression view or consider comparison views of uninjured hand.10



    • Treatment includes radial gutter splint or short arm volar posterior mold and orthopedic referral.




  • Triquetrolunate ligament instability: The ulnar version of scapholunate injuries; usually a result of a FOOSH onto the hypothenar eminence. Treat with ulnar gutter splint and orthopedics referral.

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Jan 10, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 19 – Upper Extremity Trauma
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