I.

BIOMECHANICS

A. Different Mechanisms of Injury

Shoulder (Glenohumeral Joint)

Type Mechanism of Injury
Anterior Indirect blow with arm in
abduction, extension, and
external rotation.
Posterior Indirect force that produces
forceful internal rotation and
adduction.
Inferior Neck of the humerus is
levered against the acromion
and inferior capsule tears.
Humeral head is forced out
inferiorly.
Examination
Arm is held in abduction and slight external
rotation with shoulder appearing “squared
off.”
Subacromial- Arm is adducted and internally
rotated.
Subglenoid Anterior shoulder is flat and the
posterior aspect full.
Subspinou-s Coracoid process is prominent;
Patient will not allow external rotation or
abduction because of severe pain.
Patient is in severe pain. Humerus is fully
abductedThe elbow is flexed.
Patient’s hand is on or behind the head.
Humeral head can be palpated on the lateral
chest wall.

Elbow
Type Mechanism of Injury Examination
SUPRACONDYLAR
FRACTURES
Extension Type fall on an outstretched hand The patient will have
Supracondylar Fractures with the elbow significant edema and
in full extension tenderness
at the elbow, a prominent
olecranon, and a depression
proximal to the
elbow
Flexion Type
Supracondylar Fractures The mechanism of injury is a anterior displacement of the
-rare direct anterior force against a distal fragment. Because the
flexed elbow mechanism is direct force,
these fractures are often open
INTERCONDYLAR force directed against the
FRACTURES posterior elbow

EPICONDYLE FRACTURE a posterior elbow dislocation,

repeated valgus stress, such
as
 throwing a baseball (Little
League elbow), or a direct
blow.
CONDYLE FRACTURES transmitted force from Pain and swelling medially
the ulna, such as a fall on an are prominent findings.
outstretched hand, or
excessive valgus stress
OLECRANON by direct trauma or by a fall Pain is present over the
FRACTURES with posterior elbow, and
forced hyperextension of the examination reveals swelling,
elbow tenderness, and occasionally
crepitus

Wrist
Carpal Bone Mechanism of Injury
Scaphoid Fall on outstretched hand
Snuffbox tenderness.
Triquetrum Avulsion fracture—twisting
of hand against resistance
or hyperextension; Body
fracture—direct trauma
Lunate Fall on outstretched hand
Trapezium Direct blow to thumb; force
to wrist while dorsiflexed
and radially deviated
Pisiform Fall directed on the
hypothenar eminence
Hamate Interrupted swing of a golf
club, bat, or racquet
Capitate Forceful dorsiflexion of the
hand with radial
Impact
Trapezoid Axial load onto the index
metacarpal
Examination
Pain with radial deviation and
flexion
Tenderness at the dorsum of the wrist, distal
to the
ulnar styloid.
Tenderness at shallow indentation of the
mid-dorsum
of the wrist, ulnar and distal to Lister
tubercle
Painful thumb movement and weak pinch
strength;
Snuffbox tenderness
Tender pisiform, prominent at the base of the
hypothenar eminence
Tenderness at the hook of the hamate, just
distal
and radial to the pisiform
Tenderness over the capitate just proximal to
the
third metacarpal
Tenderness over the radial aspect of the base
of the
index metacarpal

B. Evaluation of Injury
 Prehospital Care
 Prehospital Splinting
- It reduces pain
- It reduces damage to nerves and vessels by preventing them from being compressed
between the fracture fragments or being stretched by angulation at the fracture site
- It reduces thechance of inadvertently converting a closed fracture to an open one if a
sharp bone fragment pokes its way through the skin
- It reduces the pain associated with patient transport by minimizing movement of
the fracture fragments.

 Emergency Department Management

 Control pain and swelling
- Application of cold and elevation to keep swelling to a minimum or at least halting its
progression.
- Jewelry, watches, or rings that may cause compression or constriction as an extremity
swells should be removed.
- Analgesics should be administered as necessary. If the patient is relatively comfortable at
rest, medication may not be required.

 Withhold oral intake

- For any patient who might be a candidate for prompt surgical fixation, manipulation,
or any other procedure under general anesthesia or procedural sedation.

 Reducing fracture deformity

- The long-term purpose is restoration of normal appearance and function of the extremity.
- Short-term benefits are:
Alleviating pain, relieving the tension on nerves or vessels thatmay be stretched as they
pass along the deformity, eliminating or significantlyminimizing the possibility of inadvertently
converting a closed fracture to an open one when the skin is tented by a sharp bony fragment and
restoring circulation to a pulseless distal extremity.

 Reducing dislocations
- Prereduction
Following a reduction maneuver, postreduction radiographs are valuable
for confirming the success of the procedure, as well as for providing
documentation, in the event the joint redislocates after the patient is discharged
from the ED.

 Initial management for open fractures

- Tetanus prophylaxis
- Irrigation
- Debridement
- Antibiotics

 Splinting
Indicated for fractures and dislocations
With plaster of fiber glass
II. KINEMATICS

Range of Motion and Mobility Examination

Shoulder
Movement Patient Instruction Muscle
Flexion “Raise your arms in front of Pectoralis major (clavicular
you and overhead.” head); deltoid (clavicular and
anterior acromial parts)
Extension “Raise your arms behind you.” Deltoid (spinal part), Latissimus dorsi, teres
major, triceps brachii (long
head)
Abduction “Raise your arms out to the Deltoid (as a whole, but
side and overhead.” especially acromial part),
Supraspinatus,serratus anterior
(via upward rotation of
the scapula)
Adduction Cross your arm in front of Pectoralis major; latissimus
your body.” dorsi, coracobrachialis, teres
major, subscapularis
Internal Rotation “Place one hand behind your Subscapularis, anterior deltoid,
back and touch your shoulder pectoralis major,
blade.” teres major, latissimus
dorsi
External Rotation “Raise your arm to shoulder Infraspinatus teres minor,
level; bend your elbow and posterior deltoid
rotate your forearm toward
the ceiling.” or “Place one hand behind your
neck or head as if you are
brushing your hair.”
 Maneuver Structure Technique
Crossover test Acromioclavicular Palpate and compare both
Tenderness Joint joints for swelling or
Sensitivity- 95% tenderness. Adduct the
Specificity- 10% patient’s arm across
the chest.
Pain with adduction
Sensitivity- 80%
Specificity- 50%
Apley scratch Overall Shoulder Ask the patient to touch the
Rotation opposite scapula using the two
Motions:
abduction and
external rotation & adduction
and internal rotation.
Neer’s impingement Rotator Cuff Press on the scapula
sign. to prevent scapular
motion with one hand,
and raise the patient’s
arm with the other. This
compresses the greater
tuberosity of the
humerus against the
acromion.
Hawkin’s impingement Flex the patient’s
sign. shoulder and elbow to
90 degrees with the palm
facing down. Then, with
one hand on the forearm
and one on the arm, rotate
the arm internally. This
compresses the greater
Notes
Localized tenderness
or pain with adduction
suggests
inflammation or arthritis of
the
acromioclavicular joint.
Difficulty with these
motions
suggests
a rotator cuff disorder or
adhesive capsulitis.
Pain during this maneuver
is a
positive
test, indicating possible
inflammation or rotator
cuff tear.
Pain during this maneuver
is a
positive
test, indicating possible
inflammation or rotator
cuff tear.
 tuberosity against the
coracoacromial
ligament.

Supraspinatus strength Elevate the arms to Weakness during this

or“empty can test” 90 degrees and internally maneuver is
rotate the arms a positive test, indicating
with the thumbs pointing possible
down, as if emptying rotator cuff tear.
a can. Ask the
patient to resist as you
place downward pressure
on the arms.
Infraspinatus strength
Ask the patient to Weakness during this
place arms at the side maneuver is
and flex the elbows to a positive test, indicating
90 degrees with the possible
thumbs turned up. Provide rotator
resistance as the cuff tear or bicipital
patient presses the tendinitis.
forearms outward.

Forearm supination Flex the patient’s forearm Pain during this maneuver
to 90 degrees at is a
the elbow and pronate positive
the patient’s wrist. test, indicating
Provide inflammation
resistance of the long head of the
when the patient supinates biceps tendon
the forearm. and possible rotator cuff
tear.
 “Drop-arm” sign Ask the patient to fully If the patient cannot hold
abduct the arm to the arm
shoulder level (or up to fully abducted at shoulder
90 degrees) and lower level or
it slowly. Note that cannot control lowering the
abduction above shoulder arm,
level, from 90 the test is positive,
degrees to 120 degrees, indicating a
reflects action of the rotator
deltoid muscle. cuff tear.

Elbow
Movement Patient Instruction Muscle
Flexion “Bend your elbow.” Biceps brachii, brachialis,
brachioradialis
Extension “Straighten your elbow.” Triceps brachii, anconeus
Supination “Turn your palms up, as if Biceps brachii, supinator
carrying a bowl of soup.”
Pronation “Turn your palms down.” Pronator teres, pronator
quadratus

Wrist
Movement Patient Instruction Muscle
Flexion “With palms down, point Flexor carpi radialis,
your fingers toward flexor carpi ulnaris
the floor.”
Extension “With palms down, point Extensor carpi ulnaris,
your your fingers extensor carpi radialis
toward the ceiling.” longus, extensor carpi
radialis brevis

Abduction (ulnar deviation) “With palms down, bring your fingers away from Flexor carpi radialis
 the midline.”
Adduction (radial deviation) “With palms down, bring your fingers toward the Flexor carpi ulnaris
midline.”