Management of Upper Extremity Trauma

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 noncritical 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