Term
| Sternoclavicular Joint Injuries |
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Definition
• Less than 1⁄2 of the medial end of the clavicle usually articulates with the sternum
• Joint Stability is dependent on the integrity of the
surrounding ligaments
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Term
| Sternoclavicular Joint Injuries types |
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Definition
– 1st Degree = Sprain
• Partial tear of SC and CC ligaments with mild subluxation
– 2nd Degree = Subluxation
• Complete tear of SC ligament with partial tear of CC ligament
• Clavicle subluxates from the manubrium on x-ray – 3rd Degree = Dislocation
• Complete tear of SC and CC ligaments
• Complete dislocation of clavicle from the manubrium
• Anterior > Posterior
• Posterior = True Emergency – 25% will have concurrent life- threatening injuries to adjacent mediastinal structures |
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Term
| Sternoclavicular Joint Injuries MOA, S+S, diagnosis |
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Definition
• Mechanism of Injury
– Direct force applied to the medial end of the clavicle
– Indirect force to the shoulder with the shoulder rolled either forward or backward that tears medial ligaments
• Symptoms/Signs
– Pain and swelling over the SC joint
– Pain with movement of shoulder
– Anterior Dislocation
• Prominent medial clavicle anterior to sternum
– Posterior Dislocation
• Clavicle may not be palpable, may be subtle
• Diagnosis
– X-ray
– CT scan (Diagnostic Study of Choice if concern for underlying structures) |
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Term
| Sternoclavicular Joint Injuries treatment |
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Definition
– 1st Degree
• Sling,Analgesia,Ice
– 2nd Degree
• Sling or Figure of Eight Clavicular Strap, Orthopedic Follow-up
– 3rd Degree
• Anterior Dislocation
– Uncomplicated anterior dislocations often don’t require reduction – Sling or Figure of Eight, Analgesia and outpatient follow-up
• Posterior Dislocation
– Reduction often necessary due to underlying injury – Closed reduction in OR
– Reduction
» Towel roll between scapula
» Traction applied to arm
» Towel clip on clavicle with traction to reduce |
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Term
| Acromioclavicular Joint Injuries MOA, S+S, |
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Definition
• Mechanism of Injury
– Fall on outstretched arm with transmission to joint
– Fall on shoulder with arm adducted (most common)
– Scapula and Shoulder girdle driven inferiorly with clavicle in normal position
• Signs/Symptoms
– JointTenderness
– Swelling over the joint
– Pain with movement of affected extremity
– Displacement of clavicle
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Term
| Acromioclavicular Joint Injuries classifications |
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Definition
• AC Joint Injury Classification
– Tossy and Allman Classification (Types 1-3) – Rockwood Classification (Types 4-6)
• Classification
– Type 1 = Sprain = Partial tear of AC ligament, No CC ligament injury
– Type 2 = Subluxation = Complete tear of AC ligament, CC ligament stretched or incompletely torn
– Type 3 = Dislocation = Complete tears of AC and CC ligaments with displacement of clavicle
– Direction of displacement defines types 4-6
• TypeIV=Posterior displacement in or through trapezius
• Type V = Superior displacement (more serious type 3 injury)
• TypeVI=Inferior displacement of clavicle behind biceps tendon
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Term
| Acromioclavicular Joint Injuries findings and treatment |
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Definition
• X-rays
– AP views of clavicle usually sufficient
– Stress views not commonly used anymore and do not alter course of treatment
– Axillary views necessary for posterior dislocation identification (Type4)
– Findings
• Type 1 = Radiographically normal
• Type 2 = Increased distance between clavicle and acromion (< 1 cm)
• Type 3 = Increased distance between the clavicle and acromion (> 1 cm)
• Type 4-6 = Defined by displacement
• Treatment
– Type1-2= sling x1-2weeks,Rest,Ice,Analgesia,Early ROM 7-14 days
– Type3=Immobilize in sling, Prompt orthopedic referral
• Controversy regarding operative vs. conservative treatment options
• Shift towards conservative treatment
– Type4-6=Sling, Prompt orthopedic referral, Likely will require surgical management |
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Term
| Clavicle Fractures, use, MOA, S+S, testing |
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Definition
– Provides support and mobility for upper extremity
functions
– Protects adjacent structures
• Mechanism of Injury
– Direct blow to clavicle
– Fall on outstretched shoulder
• Symptoms/Signs
– Pain, Swelling and Deformity
– Arm is held inward and downward and supported by
other extremity
– Open fractures result from severe tenting and
piercing of overlying skin
• Imaging
– CXR or Clavicle films
– Children may have a greenstick fracture without
definite fracture on x-ray imaging |
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Term
| Clavicle fracture classification |
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Definition
• Allman Classification
– Middle 1/3 (80%)
• Most common area to fracture
• Especially in children
– Distal 1/3 (15%)
• Often associated with ruptured
CC joint with medial elevation
• May require operative
intervention to avoid non-union
– Medial 1/3 (5%)
• Uncommon
• Requires strong injury forces
• Higher association with
intrathoracic injury
– (e.g Subclavian Artery/Vein
injury)
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Term
| Clavicle fractures treatment |
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Definition
• Emergency Orthopedic Consultation
– Open Fractures
– Fractures with neurovascular injuries
– Fractures with significant tenting at high risk for converting to open
• Indications for Surgical Repair
– Displaced distal third
– Open
– Bilateral
– Neurovascular injury
• Treatment = Sling, Orthopedic Follow-up
– Non-operative management is successful in 90%
• Middle 1/3 Clavicle Non-union risk factors
– Shortening > 2 cm
– Comminuted fracture
– Elderly female
– Displaced fracture
– Significant associated trauma |
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Term
| Scapular Injuries, use, MOA, findings |
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Definition
– Links the axial skeleton to the upper extremity
– Stabilizing platform for the motion of the arm
– 1% cases of blunt trauma have scapular fracture
– 3-5% of shoulder injuries
• Mechanism of Injury
– Direct blow to the scapula
– Trauma to the shoulder
– Fall on an outstretched arm
• Clinical Presentation
– Localized pain over the scapula
– Ipsilateral arm held in adduction
– Any movement of arm exacerbates pain
• High association with other intrathoracic
injuries (>75%)
– Due to high degree of energy required for fracture
– Pulmonary contusion > 50% of cases
– Pneumothorax, Rib fractures commonly associated
Glenoid
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Term
| Scapular injuries types and testing |
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Definition
• Classification
– Anatomic Location – Body = 50-60%
– Neck=25%
• Imaging
– Shoulder/Dedicated
Scapular Series
• AP/Lateral/Axillary
– Axillary views help identify
fractures:
• Glenoid fossa
• Acromion
• Coracoid Process
– Consider CXR/Chest CT to rule out associated injuries
[image] |
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Term
| Scapular injuries treatment |
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Definition
– Sling,Ice,Analgesia
– Immobilization
– Early ROM exercises
– Orthopedic Referral for ORIF
• Glenoid articular surface fractures with displacement
• Scapular neck fractures with angulation
• Acromial fractures associated with rotator cuff injuries
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Term
| Glenohumeral Joint Dislocation types MOA |
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Definition
• Shoulder dislocation = Most common dislocation in the ED • Classification
– Anterior (95-97%)
• Subcoricoid, Subglenoid, Subclavicular, Intrathroracic
– Posterior (2-3%)
• Most commonly missed dislocation in the ED
• Association with Seizure, Electric Shock/lightening injuries
– Inferior (Luxatio Erecta)
– Superior (Very Rare)
• Mechanism of Injury
– Anterior = Abduction, Extension and External Rotation with force applied to shoulder
– Posterior = Indirect force with forceful internal rotation and adduction |
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Term
| Anterior Shoulder Dislocations findings, testing |
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Definition
• Clinical Presentation
– “Squared off” Shoulder
– Patient resists abduction and internal
rotation
– Humeral head palpable anteriorly
– Must test axillary nerve
function/sensation
• Quebec Decision Rule
– Radiographs needed for: • Age > 40 and humeral ecchymosis • Age > 40 and 1st dislocation • Age < 40 and mechanism other than fall from standing height or lower
– Failed to be validated due to low
sensitivity (CJEM 2011)
• Recurrent Shoulder dislocations
• Radiographs
– AP/Lateral/Y-view
[image] |
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Term
| Posterior Shoulder Dislocations findings, testing |
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Definition
• ClinicalPresentation
– Prominence of posterior
shoulder
– Anterior flatness
– Unable to externally rotate
or abduct the affected arm
• Radiography
– AP Radiograph • “Light Bulb Sign” • Internal rotation of the
humerus
– Y view • Diagnostic for posterior
dislocation
[image] |
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Term
| Glenohumeral Joint Dislocation treatment |
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Definition
– Reduction using a variety of techniques
• Success rate = 70-96% regardless of technique
– Shoulder dislocation with associated humeral head fracture typically require orthopedic consultation and may require operative repair
– Neurovascular exam pre- and post reduction
– Procedural Sedation if initial attempts unsuccessful
– Intra-articular injection of 10-20 cc lidocaine alternative to procedural sedation
– After reduction, patient should be placed in shoulder immobilizer and orthopedic follow-up arranged
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Term
| External rotation shoulder reduction technique |
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Definition
– Hennepin Technique
– Gentle external rotation
– Followed by slow abduction of arm
– Reduction typically complete prior to reaching coronal plane
– 78% success rate
– Procedural sedation rarely needed
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Term
| Scapular manipulation shoulder reduction technique |
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Definition
– Technique
• Seated Position
• Steady forward traction on wrist parallel to floor
• Rotate inferior tip of scapula medially and superior aspect laterally
– 96% Success rate
– Requires two people
– Borders of scapula can be difficult to identify in obese patients
– Rarely requires sedation
[image] |
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Term
| Glenohumoral joint dislocations complications |
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Definition
– Recurrent dislocation (Most Common)
• < 20 years old: > 90%
• > 40 years old: 10-15%
– BonyInjuries
• Hill-Sachs Deformity
– Compression fracture or groove of posterolateral aspect of humeral head
– Results from impact of humeral head on the anterior glenoid rim as it dislocates or reduces
• Avulsion of greater tuberosity (Higher incidence > 45 years old)
• Bankart’s Fracture = Fracture of the anterior glenoid lip
– Nerve Injuries (10-25%dislocations)
• Most often are traction related neuropraxias and resolve spontaneously
• Axillary nerve (most common) or Musculocutaneous nerve
– Rotator Cuff Tears
• 86% of patients > 40 years will have associated rotator cuff tear
– Axillary Artery Injury (rare)
• Elderly patients with weak pulse
• Rapidly expanding hematoma
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Term
| Rotator cuff injuries, use, MOA, findings, testing, treatment |
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Definition
4 muscles that insert tendons into the greater and lesser tuberosity – SITS MUSCLES = Subscapularis, Supraspinatous, Infraspinatous, Teres minor
• Mechanisms of Injury
– Acute tear = Forceful abduction of the arm against resistance (e.g. fall on outstretched arm)
– Chronic teat = 90% = Results from subacromial impingement and decreased blood supply to the tendons (worsens as patient ages)
• Clinical Picture
– Typically affects males at 40 y/o or later
– Pain over anterior aspect of shoulder, tearing quality to pain, typically worse at night
– PE with weak and painful abduction or inability to initiate abduction (if complete tear)
– Tenderness on palpation of supraspinatous over greater tuberosity
• Imaging
– In ED, plain film x-rays indicated to exclude fracture and may show degenerative changes and superior displacement of humeral head
– MRI is diagnostic (not typically done in ED setting)
• Treatment
– Sling Immobilization, Analgesia, Ortho Referral
– Complete tears require early surgical repair (< 3 weeks)
– Chronic tears are managed with immobilization, analgesia and orthopedic follow-up for rehabilitation exercises and possible steroid injection |
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Term
| Proximal Humerus Fractures MOA, findings, treatment |
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Definition
– Common in elderly patients with osteoporosis
– Mechanism of Injury = Fall on outstretched hand with elbow extended
– Clinical Presentation
• Pain, swelling and tenderness around the shoulder
• Brachial plexus and axillary arteries injuries – Higher incidence (>50%) in displaced fractures
– Neer Classification guides treatment
• Fractures separate humerus into 4 fragments by epiphyseal lines
• Displacement > 1 cm or angulation > 45 degrees defines a fragment as a “separate part” when fractures occur
• If none of fragments are displaced > 1cm, fracture is termed 1 part
– Treatment
• One part fractures (85%) = immobilization in sling/swathe, ice, analgesics, orthopedic referral
• Two/Three/Four part fractures = Orthopedic Consultation
[image] |
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Term
| Mid-shaft Humerus Fractures MOA, findings |
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Definition
• Typically involve middle 1/3 of the humeral shaft
• Mechanism of Injury
– Direct Blow (Most common)
– Fall on outstretched arm or elbow
– Pathologic Fracture (e.g. breast cancer)
• Clinical Presentation
– Pain and deformity over affected region
– Associated Injuries
• Radial Nerve injury = Wrist Drop (10-20%) – Neuropraxia will often resolve spontaneously – Nerve palsy after manipulation or splinting is due to nerve entrapment and must be immediately explored by orthopedic surgery
• Ulnar and Median nerve injury (less common) • BrachialArteryInjury |
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Term
| Mid-shaft Humerus Fractures findings, treatment, complications |
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Definition
• Imaging = Standard x-ray imaging
• Treatment
– Non-operative Management (most common)
• Simple Sling and Swath adequate for ED patients
• Closed treatment options
– Coaptation splint (sugar tong) – Hanging cast
– External fixation
– Operative management
• Neurovascular compromise, pathologic fractures
• Complications
– Neurovascular injury – Delayed union
– Adhesive capsulitis |
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Term
| Biceps Rupture MOA, findings, treatment |
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Definition
• Proximal or distal biceps tendon rupture
• Mechanism of Injury = Sudden or prolonged contraction against resistance in middle aged or elderly patients
• Clinical Presentation
– “Snap” or “Pop” typically described
– Pain, swelling, tenderness over site of tendon rupture
– Flexion of elbow = Mid-arm ball
– Loss of strength sometimes minimal
– X-rays to exclude avulsion fracture
• ED Treatment
– Sling, Ice, Analgesia, Orthopedic referral
– Surgical repair for young, active patients |
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Term
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Definition
| acromioclavicular type III |
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Term
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Definition
Modified Hippocratic or Traction- Countertraction Technique
shoulder reduction |
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Term
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Definition
Stimpson or Hanging Weight Technique
shoulder reduction |
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