ORTHOPEDICS FOR THE PRACTICING EMERGENCY MEDICINE PHYSICIAN
I. The Arm
Yosef Leibman, MD
Director of Emergency Medicine
Bikur Holim Hospital
Address for correspondence:
Department of Emergency Medicine
Bikur Holim Hospital
5 Neeivim St.
Emergency Management of Arm Injuries
Elbow dislocation, Elbow Fracture. Humerus fracture, Galezzi’s Fracture, Monteggia’s Fracture, Barton Fracture, Colle’s Fracture
Group authorship and acknowledgments
Competing interests: None
This is the second of a series of articles on Orthopedics for the Practicing Emergency Medicine Physician. The series is intended to dispel the fear of the emergency medicine physician when encountering orthopedic injuries and to show that they can be appropriately managed in the emergency setting.
This article describes the main types of arm injuries seen in the emergency department and outlines the treatment of those that can be managed appropriately in this setting. Figures illustrating this review were taken from free internet sources.
ANATOMY OF THE ARM
Last issue we spoke about the shoulder, this issue we will speak about the arm- which for our purposes includes the upper arm, the elbow, the forearm, and the wrist. In the next article, we will deal with the carpal area- even though it is part of the wrist joint, as part of our series on the hand. The main bones of the arm are the humerus – the upper arm, which widens at its base to form the elbow joint. That area is called the olecranon and the wide knobs are called condyles. The other part of the elbow is the radius which terminates as a flat wheel and the ulna itself. As these bones continue down to the wrist, the ulna becomes thinner and the radius larger, and the radius forms most but not all of the wrist joint with the carpal bones. Here are some pictures
Fig. 1. Anatomy of the elbow
Let’s look more closely at the humerus and the ulna/ radius (forearm) (Fig. 2).
Fig. 2. Anatomy of the humerus
The head of the proximal humerus lies in the glenoid fossa. The anatomical neck is found at the base of the head, and the surgical neck, at the thinner part of the humerus. (In the figure, the surgical neck is at the level of the bicipital groove.) The two protrusions on the head are the greater and lesser tuberosities. We discussed this in the previous article on the shoulder. Pay attention to the condyles and the olecranon fossa, which will be important for our discussion of the elbow.
Now a look at the ulna and radius. I would like you to direct your attention to the coracoid process and the radial head in the distal bones, and the styloid processes in the proximal bones
Fig 3 the ulna and radius make up the forearm and the elbow and wrist joints
Just for review, remember that wrists can flex and extend, but rotation occurs from the elbow. Elbows themselves can extend and flex.
TYPES OF ARM INJURIES
Upper arms and forearms are generally fractured or contused. Elbows and wrists are at risk of fractures, dislocations, and soft tissue injuries. Wrist dislocations are usually very complicated and need operations. Like all joints, these can become infected as well.
We dealt with fractures of the surgical neck of the humerus in the previous article. Humeral mid shaft fractures are fairly common and are usually non-displaced and closed. They usually occur from the arm being fixed and weight falling upon it, as in the case of a pile up of football or rugby players, where one can not move his arm and an additional player falls on top, snapping the arm in two. Fractures in the absence of trauma bring to mind the possibility of a pathological fracture. The radial nerve travels very close to the humeral shaft so radial nerve function should be noted- especially signs of a wrist drop. Treatment is with a u splint (in the USA they call this a sugar tong splint) and it is just making a u shaped bandage out of plaster of Paris, and extending it from under the axilla, around the elbow and up to the axilla on the other side. It is then secured with an elastic bandage.
Here is a picture of the splint.
Fig 3 Sugar Tong or U splint pf the shoulder
The most common complication is radial nerve palsy; vascular complications can occur but are uncommon. It therefore behooves the examining physician to check neurovascular status and to document it as well.
Physiotherapy and hand /wrist motion exercises should start soon after the injury.
Special Considerations in Children
Humeral shaft fractures are not uncommon in kids, but fortunately heal well with the above therapy.
Leave It to the Orthopedist
Despite how bad radial nerve injuries look, most do well with conservative treatment, as the injury is due to tethering of the nerve. However, it is still a good idea to involve the orthopedist in cases of prolonged wrist drop. Other cases that need an orthopedist include, gunshot wounds, vascular injuries, comminuted fractures, and shaft fractures associated with elbow injuries..
Let us start with the most important elbow fracture and that is the supracondylar fracture. This is one of the few orthopedic emergencies. It occurs from falling on an outstretched arm with the elbow extended. The result in adults is generally a dislocation, and in children, fractures as the ligaments in a child are stronger than the bone. There is a danger of compromise of the brachial artery and the median nerve. Therefore a thorough neurovascular exam and immediate reduction is essential.
Fig 4 Supracondylar fracture of the elbow
Note that the fracture in this case is best seen on lateral. And sometimes, especially in undisplaced fractures, you may miss it. Sometimes it may be a greenstick fracture. If you are in doubt and especially because of the amount of ossification areas in the elbow- it may be worthwhile ordering a comparison view of the healthy side.
Reduction if you have to do it, is by traction (please never attempt this without sedation and adequate pain control) and pushing the broken fragments into place- whether it be pushing the fragment that is pointed anteriorly backwards in the case above, or moving laterally or medially for other displacements. Most of these kids at least need admission, and many need surgery. You never lose by splinting the elbow until you can make a definitive decision as to disposition.
Fractures of other areas in the elbow occur, but a lot less frequently. Medial, and lateral epicondylar fractures capitellum fractures, trochelar fractures, epicondylar fractures (seen more in kids) and olecrannon fractures are all treated with the same principles. Minimally displaced- immobilization; displaced- orthopedics consultation often leading to surgery.
One other fracture is very common and can be occult- but fear not, there are tips that will help you and if it is missed.it is usually benign.
Recall from the anatomy pictures above that the radius terminates in a head which abuts the ulna and the humerus. Falling on an outstretched arm can cause the head to ram into the capitellum and fracture. The x ray is the interesting part- the only indication of fracture may be the presence of a fat pad sign. The anterior fat pad sign is always present and can be seen as a black stripe anterior to the humerus. When there is a fracture or effusion, it is pushed outward. The posterior fat sign is a stripe that is seen on the back side of the humerus and should not be sign under normal circumstances- it’s presence indicates an effusion or fracture.
Fig 5 Radial Head Fracture with anterior and posterior fat pad signs
Note that the fracture is not clearly seen. The treatments for non displaced or minimally displaced fractures is a sling and begin physiotherapy within 48 hours. Some people dispute the need for any immobilization at all, and there are those who inject the elbow with lidocaine to aid in mobilization and minimizing pain.
However, very displaced fractures may need screws and totally comminuted fractures may need surgery to remove the head completely. When the radial head is that fractured make sure you check the wrist for an Essex Lopresti lesion-a tear of the radioulnar ligaments that may require surgery as well. Remember this lesson for the ankle, where a Maissoneuve’s fracture can also cause a distant orthopedic injury.
These are the major fractures. We now proceed to the dislocations, of which are fairly common
. Up to ninety percent of elbow fractures are posterior, and truthfully, I have never seen an anterior one. Again the mechanism is an outstretched arm with the elbow flexed. The patient will not be able to move the arm, and you usually can discern a recess above the elbow. Note that neuro deficits in the ulnar and medial distribution are common, so documentation again is very important. Circulatory comprise can occur. . As such, relocation, like with shoulders is easiest and healthiest when done promptly.
Unlike shoulders, there is really only one way of relocating elbow (with many variations on the same theme) and that is because the relocation is easier than with shoulders as the condyles just must clear the coranoid process which is not a major feat. I will diverge with an anecdote as to how I learned to do elbow relocations- I was working in Park Ridge Hospital just outside of Rochester NY when one of these came in. Never having relocated one, I called the on call orthopedist who told me he was at a party, and he would prefer not to come in, he would walk me through it by telephone. Sure enough, after a little “C’mon, you can do it “ encouragement from the likable orthopedist, that baby slid right in.
So how do you return them to their place? Again, adequate sedation is essential. You need to fix the upper arm; either by having an assistant pull on it in line, or by flexing the elbow, and supporting the upper arm with a towel being pulled by an assistant. You then pull the lower arm from the wrist, and flex the elbow, and the elbow should be in. I have seen a variation of this using a chair which support the upper arm, and pulling on the wrist which hangs down.
Fig 5 Posterior elbow dislocation
Here is an example of the variation of relocation, but in line traction works just as well
Fig 6 Relocation of the dilocted elbow
The patient should be splinted and sent on to the orthopedist for a physiotherapy program. Surgery is generally not needed.
Special Considerations in Children
See above. I will also point out that dislocations of the elbow in kids are usually accompanied by a fracture. One case which we have not discussed which is exclusively a problem in children is the pulled elbow, or nursemaid’s elbow This occurs from a pull on the arm, but often the mechanism is not remembered by the patient’s family. The pull on the arm causes the annular ligament to get caught in between the capitellum and the radial head. The child will have is pronated arm by his side, that will show no swelling or localized tenderness, he just refuses to use it. X rays are not recommended unless there is a doubt such as a suspicion of a non displaced supracondylar fracture. Reduction is easy and comes in two manners, both of which do not need sedation, but the principle of early reduction means easier reduction applies. The old technique is to have your non dominant hand clutching the elbow and using the other hand to supinate the arm while quickly flexing it. The new way is to simply hyperpronate the arm that is, rotate it even more. Both cases result with a click sensation that you feel, followed by a crying child who still refuses to use the arm. You then give him a bear or keys to distract him and soon he will use the arm. Usually by age seven they grow out of this problem
Fig 7 causing a nursemaid’s elbow
Leave It to the Orthopedist
We have dealt with this above. Most fracture dislocations in this area or major displacements need ORIF and an orthopedist needs to be involved
This area is an uncommon area for fractures. Some principles apply. If there is a fracture of one bone, check the second- usually neither the radius nor the ulna can adequately absorb the shock wave that breaks a least one bone. Second principal- if it is displaced- leave it for the orthopedist- most need ORIF. If it isn’t cast it in a long arm cast immobilizing the elbow and the wrist. Thirdly, check the elbow and the wrist for injuries that commonly accompany these fractures. I will deal with the three fractures you commonly see, although there is little you can do for two of them
Isolated fractures of the radius are not very common, and I do not think I have ever seen one. There is adequate padding from muscles that protect this bone. Isolated ulna fractures can happen and this is the nightstick fracture. In many communities especially in England and the USA, policemen on patrol carry heavy wooden nightsticks which they beat criminals into submission. Often the criminal will raise his arm to protect himself, and the result is a blow to the ulna with resulting fracture. If there is an accompanying dislocation of the radial head, you are looking at a Monteggia’s fracture and that needs ORIF. (Kids can be managed with closed reduction) Fractures of the proximal radius with ulna subluxation are called a Galeazzi’s fracture and aslope demand ORIF. So in summary, in forearm fractures, you can take care of non-displaced nightstick ones with a cast and the others look bad and really are bad. Here are some x rays to help you (fig 8a, 8b, 8c)
Fig 8a displaced nightstick fracture. In this view, a Monteggia’s fracture can not be ruled out
8b Monteggia’s Fracture
8c Galeazzi’s Fracture
Special Considerations in Children
Galeazzi and Monteggia fractures are rare in kids. More commonly seen are buckle (sometimes called torus) fractures and greenstick fractures- both unique to kids due to softer bone cortex. Both require you to look closely not to miss them, both heal very well. There are also controversies with both. Greenstick fractures (figure 9a) do well no matter what, but some people complete the fracture in order to make reduction easier if there is displacement. Many disagree as children do tend to correct for displacement better than adults and do not need further fracture. There are those that believe that it makes it harder to maintain reduction. Speak to your orthopedist so that you are all on the same line. . Buckle fracture are identified by a bulge on AP x ray (see fig 9b) or a sharp cut off of the bone as opposed to a smooth parabola on lateral film. See figure 9c below. There are many, especially in the UK who do not even cast them. They all seem to do well, so there is some justification to this idea. Others say that a cast protects the arm in case of another blow- so if you have a kid that falls often from his Korkinet (scooter) consider a cast.
9a Displaced Greenstick fracture Note the fracture does not extend all the way through the boney cortex
9b Torus fracture- note the bulge
9c torus fracture- note the sharp contour
A last subtle pediatric fracture is the plastic bowing fracture. I have tried to make this forum practical by omitting rare fractures, but you need to remember this one even though you may never see it ( or identify it at least) Generally you do not see a fracture, but due to the pliability of children’s bones, the bone bows or assumes a rounder presentation. If you miss this, you could have a child with problems with supination and pronation in the future. If you have a suspicion, you will need to arrange for closed reduction and as most of us are not skilled in this; leave it to the orthopedists.
Fig10 Plastic Bowing fracture (of the fibula)
Leave It to the Orthopedist
Basically, displaced fractures, and comminuted fractures should be left for the orthopedists. You should be able to take care of buckle and greenstick fractures yourself.
As mentioned above, we will only be looking at the half of the wrist joint this month, the half will be dealt with in the next installment on the hand.
As before let us start with anatomy.
Fig. 10 the radius and ulna.
Note that by the wrist the ulna has become thinner and the radius a thicker bone, making up most of the joint apposition. Note also the styloid process on both bones, they are often part of the axis of fractures in this area.
The most common fracture in this area is the Colle’s fracture. The presentation is with a grossly swollen wrist, sometimes with the “dinner fork abnormality” which is a bulge in the wrist that reminded someone of a dinner fork. These fractures usually happen in an older person who fell on an outstretched arm. As before, check neurovascular function and the elbow and shoulder as well. The shock wave will travel up to elbow and shoulder as well. An x-ray will show a fracture of the distal radius and a fracture of the ulna styloid.
Fig 11 Colles fracture, you can see the ulna styloid fracture too.
The treatments of these fractures can be done by the emergency physician if the fracture line does not extend into the joint space- if it does, ORIF is necessary. Note that while the reduction is easy, even in the best hands, these fractures do not hela well and there is almost always some limitation of motion, although it may be minimal Anesthesia is generally done via a hematoma block, where the skin is carefully cleaned with antiseptic, and 2% lidocaine is infused directly into the fracture itself. The distal fragment of radius is maneuvered back on to the proximal fragment of radius, and the hand is flexed, rotated to the ulnar side, and then casted. You may also use a u splint (sugar tong). You leave the ulna styloid alone.
Now for the other fractures of the wrist which are lot less common. The Smith fracture is actually the reverse of a Colle’s fracture; the person falls on a flexed hand. The treatment principles are the same except in reverse
Fig 11 Comparison of the Smith and Colle’s fractures
A Barton’s fracture looks disastrous, and it is. This is a fracture of the volar surface of the radius on the articular surface with some subluxation of the carpal bones. Most need ORIF.
Fig 12 Barton’s Fracture
The last fracture is not a serious one, but is of historic interest. The Chauffeur’s fracture is a throwback to the days when cars needed to be cranked up, sometimes the car would backfire, and the crank would throw the wrist back violently, creating a fracture of the radial styloid. Sometimes they need pinning, but you can leave them splinted and let the orthopedist see them in follow up
Special Considerations in Children
As the skeleton of a child is very pliable, these wrist fractures are uncommon.
Leave It to the Orthopedist
Intrarticular fractures. Most others you should be able to handle
Soft Tissue Injuries
The arm is often injured and soft tissue injuries abound.Although a number of diagnostic tests are available, I suggest simply a good physical and neurovascular examination. Treatment is usually symptomatic, with patients discharged with a sling and pain control. Tennis elbow and little league elbow can occur, and they are inflammatory condition, with similar treatment. Elastic bandages and NSAIDs usually suffice. You can inject an elbow with steroids and bupivicaine, I have not found it to be necessaryin most cases.
The emergency medicine physician needs to be able to diagnose a septic joint, but this will be reviewed in a future article. The wrist is not a common site of infection but gouty arthritis can occur there. Elbows often get bursitis, especially in the olecranon area, these can look infected, so if you have any doubt, your should aspirate and send the fluid for gram stain and cell count. Those who do not look infected can be treated with conservative treatment alone.
As with the shoulder, most arm injuries can be treated well by the emergency physician. Pediatric fractures and dislocations are more common here, but easily treated. Intraarticular fractures, and fracture dislocations need ORIF and your orthopedist should be involved
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