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Critical Care: Trauma and Injuries (UPPER LIMB (FRACTURES (WRIST AND HAND,…

- - - - Medial Epicondylitis (Golfer's Elbow)
        
        Pain and Tenderness @ medial epicondyle
        
        Wrist flexion and pronation
        
        Ulnar nerve entapment: 4th/5th finger numbness and tingling
      - Olecronon bursitis
        
        Swelling on posterior elbow
        
        Warmth, Pain, Erythema
      - Lateral Epicondylitis (Tennis Elbow)
        
        Pain and Tenderness over lateral epicondyle
        
        Worse on wrist extension or supination with elbow extension
        
        Episodes last 6/12 -2yrs
        
        Acute pain 6-12 weeks
    - - Carpel Tunnel Syndrome
        
        Compression of median
        nerve in the carpel tunnel
        
        RF: >30yrs, Female, ↑BMI, Repetitive hand movements, Diabetes
        
        Numbness/tingling median nerve distribution, palmar sparing
        
        Worse at night
        
        Tinel's and Phalen's Tests
        
        Mx: Splint, surgery
        
        Ix: EMG( electromyography)
    - - Rotator Cuff Disease
        
        4 Muscles that Stabilise humeral head within the glenoid fossa
        
        Spectrum of disease: Impingement → tendonitis → Micro/Macro Tears
        
        Aet: Outlet/subacrominal Impingement: RC tendons and subacromial bursa stuck between head of humerus and Acromion, AC joint and CA Ligament tears
        
        PRESENTATION
        
        Insidious onset, Night Pain, Worse with active movement
        
        Feel: Tenderness over greater tuberosity
        
        Move: weakness, ↓ ROM (90-130 deg Overhead)
        
        ST: Hawkins- Kennedy: 90deg flexion and passive internal rotation (+ pain)
        Painful Arc: Active abduct shoulder (+ >90 tendinopathy)
        Lift off test Internally rotate arm to rest on the back, actively life hand away from back against examinaer resistance (+ if inability to lift → Subscapularis
        
        INVESTIGATIONS
        
        XRAY- Trauma Series( high riding Humerus)
        
        MRI
        
        Arthogram
        
        MANAGEMENT
        
        PAPLIOS
        
        Surgery: Repair if still pain in 2-3 months of physio and 1-2 steriod injections
        
        Arthroscopic/ open surgical repair
  - - - TYPES
        95% AnteriorInferior → force to extended, abducted, externally rotated humerous
        5% Posterior and Inferior → Direct blow to flexed abducted arm
      - PRESENTATION
        
        Symptom: Painful, Reduced mobility, feeling of instability
        
        Signs: Contralateral Asymmetry, loss of shoulder contour, Anterior bulge of humeral head
        
        A/S: Glenoid bone fractures, Rotator Cuff Injuries
        
        INVESTIGATION
        
        XRAY: Trauma series (Anterior-Posterior, Y-Scapular and Axial Views)
        
        Light Bulb Sign -Posterior Dislocation
      - MANAGEMENT
        
        PAPLIOS
        
        Reduction, Immobilisation, Rehabilitation
        
        Closed Reduction
        
        Assess Neurovascular Status: Pre and Post Reduction
        
        Broad Arm sling, 2 weeks
        
        Prognosis
        
        Possible Chronic Pain, Limited Stability, Stiffness and recurrence, Adhesive encapsulitis, nerve Damage Rotator Cuff injuries, Arthritis
    - - Perilunate Dislocation
        
        Capitate not vertically aligned with ulnar and radius
      - Scapholunate Dislocation
        
        Gap B/w Scaphoid and Lunate
  - - - Distal Humerus
        
        Supracondylar, trancondylar, Intercondylar, Condylar, Articular Surface, Epicondylar
      - Radial Head
        
        Nondisplaced, Displaced, Comminuted
        
        20-30yrs, ↑ Females
        
        Mech: Indirect trauma in extension, pronation, FOOSH
        
        Mason Classifiation
        
        CF:
        
        Pain,Briosing swelling, Tenderness on lower aspect of elbow at radil head
        
        Pain and Crepitus on supination and pronation
        
        Ix: XRAY and MRI
        
        Look out for "Saill Sign" - elbow effusion which can mask a fracture
        
        Mx: PAPLIO, in ED: Sling dont plaster Surgey if displaced
      - Humerus Shaft
        
        Mech: Direct blow to arm, FOOSH, Twisting of arm
        Presentation: Localised pain, Swollen, ↓ROM, Shortening/Rotated, Neuro involvement (radial nerve
        Investigation
        
        XRAY ( also think about: Primary Bone tumours/ Mets)
        
        MANAGEMENT
        
        Reduction, Immobilisation, Rehab
        
        PAPLIO
        *Refer to Ortho
      - Ulnar
        
        Olecronon or Coronoid
    - - XRAY Description
        
        PA, Oblique, Lateral View
        PA: DR RUCAS
        
        Distal Radius
        
        Junction B/W radius and Ulnar
        
        Carpal Arches
        
        Carpal Spaces
        Oblique
        Lateral
        
        Alignment of 3C's
        
        DRUJ Articulation > 50%
      - Scaphoid Fracture
        
        FOOSH → Impaction of scaphoid on dital radius leading to tranverse Fracture
        
        CF: Tenderness
        
        Anatomical snuffbox
        
        Over scaphoid tubercle
        
        Pain with long axis compression into scaphoid
        
        swelling and pain
        
        Watson's Test:
        
        Mx: XRAY and Wrsit Backslab Test even in not seen on xray - want to preserve radial nerve function
      - distal radius fracture
        
        types: 90% Colles fracture
        
        Extra-articulare tranverse fracture
        
        Dorsal angulation within 2cm of radiocarpel jpint +/- Ulnar styloid fracture
        
        Mech: FOOSH (usually low impact)
        
        "Dinner Fork" Deformity
        
        RF: ↑AGe, Female, Early menopause, SMoking and ETOH, Prolonged steroid use, Osteoporosis
        
        CF: Pain, Swelling, defromiting, Parasthesia,
        *Mx: Closed reduction, Below elbow backslab, Xray after 1 week. If sig. displaced: ORIF, K-Wire, PAPLIOS
        
        Complications: Malunion, median nerve compression, Osteoarthritis
      - Thumb fracture
        
        All need Surgery → Refer to Ortho
      - Other Hand Fractures → All Hand injuries refer to plastics
        Boxer's Fracture: 4 ad 5th metacarpal #
        
        Mx: RICE, XRAY, "Ulnar Gutter Splint" -
    - - clavicle
        
        Most common Shoulder #
        
        Mech: Fall onto shoulder, Direct Trauma, FOOSH
        
        Types
        
        Proximal (A): Uncommon, good ligament support
        
        Midshaft Clavical (B): 80%
        
        Distal Clavicle: distal to coracoclavicular ligamenets
        
        Non-displaced, Displaced, Articular
        
        Displace need ORIF
        
        Hx And Exam
        
        Pain, Swelling, gross deformity Hx of fall/trauma
        
        Pt hold affected arm (flexed abduction/internal rotation)
        
        Pain worse on movement
        
        Skin tenting, Bruising
        
        Tenderness, oedema, crepitis, deformity, decreased pulse and perfusion distal from the injury
        
        XRAY +/- CXR ( Pneumo)
        
        Complications
        
        Pneumothroax
        
        Subclavian artery or vein injury
        
        Internal Jugular Vein Injury
        
        Axillary Artery Injury
        
        Rib, Scapula trauma
        
        Brachial Plexxus injury
        
        Delayed Union/ non-union
        Poor Cosmetic appearance
        
        Arthritis
        
        Mx
        
        PAPLIOS
        
        Non-displaced → Immobilisation and support with sling 6-10 weeks
        
        Analgesia
        
        Refer to Fracture Clinic for F/U
        
        Displaced/Comminuted with >15-20mm clavicle shortening - ortho referal for ORIF