Upper Limb Injuries

13 yo boy falls off his bike and lands on his arm as he goes to break his fall. He comes into A+E and pain restricts movement in his L. arm. Hes complains the pain is over his L. upper shoulder

What do you think has happened?

✔ Clavicular fracture✗ Shoulder dislocation

- Remember to clarify what pt means by the words the use

Where is the most common location of a clavicle fracture to occur?

Between the proximal end of the lateral 3rd and distal end of middle 3rd / junction between lateral and middle 3rds of clavicle

On inspection you see an obvious deformity of the clavicle - what would it look like and why?

• Lateral fragment pulled downward – due to weight of shoulder

• Proximal fragment pulled upward – due to contraction of Sternocleidomastoid

Middle+++ Medial

+

Lateral++

Clavicle #• Presentation:

– FOOSH – horizontal blow– Most commonly between middle-lateral 3rd

– Sternal end of clavicle will stick out of chest, limb pulled down

• Complications:– Brachial plexus damage– Subclavian vein

• Management: – Not a lot…– ‘figure of 8’ brace– Sling

Pt comes into A+E after being rammed in the shoulder during a rugby game. You suspect she has a shoulder dislocation.

What specific test do you want to do on examination?

Test sensation over REGIMENTAL BADGE (RB) region

Loss of sensation over RB region would indicate damage to which structure? What other clinical features may occur??

AXILLAY NERVE• Paralysis of deltoid & teres minor• Limb to hang limp by side• Loss of shoulder contour• Sensory loss over lateral shoulder (regimental badge region)

Why is an ANTERIOR shoulder dislocation most common?

Lower part of the joint capsule is lax & folded to permit free movement. This makes it the weakest point in the capsule.- Downward force applied to an abducted arm can dislocate the shoulder

Shoulder Dislocation

• Presentation:– FOOSH– Externally rotated– Looks ‘square’

• X-ray appearance:– Head of humerus fallen down into space below glenoid

fossa– Usually ANTERIOR (95%)

• Complications:– Axillary artery and nerve damage

Elbow Injuries• Nursemaids elbow:

– Smooth head of radius and stretchy ligaments in children– Pulling their arm can easily pull the radius out!

• Tennis elbow:– Sideways blow to MEDIAL side– Damaged medial (ulnar) collateral ligament

• Golfers elbow:– Sideways blow to LATERAL side– Damaged lateral (radial) collateral ligament

• Need to do valgus and varus stress test– Hold humerus and pull forearm to either side

• Elbow is most likely to dislocate POSTERIORLY

Wrist #

• Colles:– Classically osteoporotic elderly women following a

fall – ‘fork shaped’– Carpel tunnel can be stretched and damaged as

well– Fix traction and pull down, put in plaster – Should follow up by investigating for osteoporosis

• Smith:– Fall on back of hand

35 yo gymnast falls from parallel bars onto R. outstretched arm. He complains of persistent pain on

exercise involving anatomical snuffbox in R. wrist.What are the borders of the anatomical snuff-box?

1. Extensor Pollicis Longus2. Extensor Pollicis Brevis3. Abductor Pollicis Longus

The FY1 X-rays this guy in A+E. Plain radiograph comes back normal, so the FY1 treats as sprain – Why is this management incorrect

Scaphoid fracture doesn’t usually show up on radiograph, therefore normal radiograph doesn’t rule out scaphoid fracture

What do you think has happened to this gymnast?

Scaphoid fracture

On examination palpation of the snuffbox elicits pain – what is this clinical sign called?

Snuffbox tenderness

Why is it important to identify and treat scaphoid fracture?

Risk of avascular necrosis if blood supply compromised – due to distal to proximal blood supply

Scaphoid # • Caused by FOOSH• Painful snuffbox • Check for avascular necrosis!! (poor blood

supply)

Bennets # • # of 1st proximal metacarpal (thumb)• Caused by punching or thumb caught

in steering wheel