Transcript Assessment and Management of Shoulder and Elbow Fractures

Assessment and Management of
Shoulder and Elbow Fractures and
Dislocations
Yingda Li
HMO Surgery
May 2010
Objectives
1.
Develop a general approach to assessment and
management of orthopaedic injuries
2.
Apply this approach to shoulder and elbow injuries
highlighting important injury-specific issues
3.
Consolidate these issues through exam-type questions
Assessing orthopaedic injuries
Approach I was taught as a medical student
1. History
2. Examination
3. Investigations
Approach I use as a junior doctor
1. Is there a life-threatening injury
2. Is there a limb-threatening injury
3. Is there an indication for surgery
4. Is there anything precluding me from having coffee
Is there a life-threatening injury
1.
Airway
2.
Breathing
3.
Circulation
4.
Disability
5.
Exposure
Is there a limb-threatening injury
1.
Vascular compromise
2.
Compartment syndrome
3.
Open fracture
4.
Overlying skin integrity
5.
Neurological compromise
Is there an indication for surgery
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Threat to limb not abated by non-operative measures
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Significant fracture displacement
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Significant intra-articular component
History
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Mechanism of injury
Age
Allergies
Medications
Previous medical history
Influence of drugs, alcohol
Immunisation status
Handedness
Occupation
Premorbid function
Last meal
Collateral history
Examination
1.
Look
2.
Feel
3.
Move
Investigations
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Plain film
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Computed tomography
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Magnetic resonance
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Angiography
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Blood tests
Management
1.
Short-term
Operative, non-operative, communication
2.
Medium-term
Follow-up, rehabilitation, delayed surgery
3.
Long-term
Secondary prevention, vigilance for complications
Shoulder
Fractures of the clavicle
Mechanism of injury
 Patterns of injury
 Clinical findings
 Potential life-threatening or limb-threatening injuries
 Indications for surgery
 Long-term complications
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Fractures of the scapula
Mechanism of injury
 Patterns of injury
 Clinical findings
 Potential life-threatening or limb-threatening injuries
 Indications for surgery
 Long-term complications
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Dislocations of the shoulder
Mechanisms of injury
 Patterns of injury
 Clinical findings
 Potential life-threatening or limb-threatening injuries
 Indications for surgery
 Long-term complications
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Elbow
Supracondylar fractures
Mechanisms of injury
 Patterns of injury
 Clinical findings
 Potential life-threatening or limb-threatening injuries
 Indications for surgery
 Long-term consequences
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Fractures of radial head
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Mechanisms of injury
Patterns of injury
Clinical findings
Potential life-threatening or limb-threatening injuries
Indications for surgery
Long-term complications
Fractures of the olecranon
Mechanisms of injury
 Patterns of injury
 Clinical findings
 Potential life-threatening or limb-threatening injuries
 Indications for surgery
 Long-term complications
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Elbow dislocations
Mechanisms of injury
 Patterns of injury
 Clinical findings
 Potential life-threatening or limb-threatening injuries
 Indications for surgery
 Long-term complications
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Topics not covered today
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Fractures of proximal humerus
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Acromioclavicular joint disruption
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Pulled elbow
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Epiphyseal injuries
Which of the following fractures is most commonly associated with a
significant vascular complication:
A.
B.
C.
D.
E.
Fracture of mid-shaft of femur
Fracture of distal radius
Fracture of lower end of tibia
Supracondylar fracture of the humerus
Subcapital fracture of humerus
26-year-old netball player collides with her arms outstretched with another
player and dislocates her left shoulder. She is rushed to emergency at a nearby
hospital and has an X-ray which confirms her humeral head is located
anteroinferior to the glenoid. There is no fracture. She is sedated and has her
shoulder reduced. Post-reduction X-rays again show no fracture and the joint is
normally aligned. She has her arm placed in a shoulder immobiliser sling and is
reviewed by the visiting Orthopaedic surgeon the following week.
At this review, she is found to be unable to abduct the arm above 10o and has
reduced sensation over the insertion of the deltoid muscle. Elbow and wrist
movements are intact. The radial pulse is not diminished.
The likely diagnosis is:
A.
B.
C.
D.
E.
Frozen shoulder (adhesive capsulitis)
C5 nerve root injury
Axillary nerve injury
Musculocutaneous nerve injury
Upper brachial plexus (C5-6) injury
A 65-year-old woman presents to the Emergency Department after a
fall complaining of a painful left shoulder. X-ray reveals a subcapital
fracture of the humerus. She should be treated by:
A.
B.
C.
D.
E.
Full length arm plaster for 8 weeks.
Insertion of a nail into the shaft of the humerus.
Excision of the head of the humerus.
Collar and cuff for pain relief followed by early mobilisation
Open reduction and stabilisation by plate and pins
Take home messages
1.
Assess and treat life-threatening injuries first
Treat like you would a trauma patient i.e. airway, breathing,
circulation
2.
Assess and treat limb-threatening injuries second
Vascular, compartment syndrome, open fracture, skin necrosis,
neurological
3.
Assess indication for surgery
Risk to limb, displaced fracture, intra-articular fracture
Stabilise to safely mobilise without causing unnecessary
complication, treat the patient you’ve got
4.
Management
Holistic, multidisciplinary, communicate, follow-up, prevention
Questions