Ski injuries to the upper

extremities

Eugene Bailey, MD
Department of Family Medicine
SUNY Upstate Medical University

Toggenberg MA Presentation
January 03, 2010
Objectives
 General Comments  Wrist
 Shoulder Injurties  Scaphoid fracture
 ShoulderDislocation  Colles fracture
 Clavicular fracture
 Scapular fracture
 Hand/Fingers
 Acromioclavicular joint (ACJ) injury  Skier’s thumb
 Humerus fractures (Gamekeeper’s thumb)
 Head
 Shaft
 Suprachondylar
 Elbow
 Anterior/Posterior dislocation
 Olecrenon fracture
 Radial head fracture
Not going to cover
 Bicipital tendonitis
 Medial and Lateral epichondylitis
 Nursemaid’s elbow
 Carpel tunnel syndrome
 Bursitis
 Finger fractures
General Comments
Zone of Injury
General Comments
In the field
 ABCs
 Airway
 Breathing
 Circulation
 Always assess neurovascular status
(CMS = circulation, motor and sensory)
 Control any bleeding
 Do not move victim until stabilized
General Comments
 If possible, always ask the patient to
“point with one finger to the area that
hurts the most.”
 Remove jewelry, etc before splinting
 Patient will self-splint the upper
extremity (internal rotation, elbow
flexed and adducted to body)
Remember
 "Ability and experience are probably the
most important factors in determining
an individual's likelihood of injury when
pursuing an outdoor sport."
“ARMS”
 Appearance and alignment
 Radial pulse
 Motor function and mechanism of injury
 Sensation
Self-splinting
Prevention
Case Scenario
 A call comes to you
over your radio that
a skier is down and
appears to have an
injury.
 You grab a
toboggan and
respond to the
scene quickly
 Upper extremity injuries
Snowboarding

www.ski-injury.com
 Upper extremity injuries
Snowboarding – Val, Colorado (10 year survey)
 7430 injuries
 Most 30 yrs or younger
 74% men, 26% women
 39% beginners, 61% intermediate or experts
 Men rode more advanced levels than women
 Results
 Injured were more likely to be beginners than non-injured
 49.06% upper extremities (56.43% fractures, 26.78% sprains and
9.66% dislocations)
 Wrist fx (x scaphoid) more common in beginners, women and
younger age groups
 Intermediate and expert were more likely to sustain hand, elbow
and shoulder injuries as well as more severe injuries
 Snowboarders who wear protective wrist guards are ½ as likely to
sustain wrist injury
Idzikowski, et al. AJSM 2000;28:825-832.
 Upper extremity injury
Skiing

www.ski-injury.com
 Upper extremity injury
Skiboard

www.ski-injury.com
Shoulder Injuries
 Shoulder dislocation
 MOI:
 Fall onto an outstretched
hand c the momentum of
the fall twisting the body
around wretching the
shoulder out of joint
 Posterior blow to
shoulder
 Majority are anterior
dislocation (97%)
Shoulder dislocation
 The diagnosis of a
dislocated shoulder is
usually clinical
 Walk slowly holding
affected arm, careful not to
move it. Usually arm is
away from body.
 Loss of smooth contour of
the shoulder anatomy
Radiograph of Anterior shoulder dislocation
Shoulder dislocation
 X-rays do not have
to be obtained
before treatment
 There are numerous
techniques for
reduction
 Traction
 Leverage

Kocher’s technique
Shoulder dislocation
 Immobilize the
injured joint
 Blanket roll
 Sling
 Sling and swath
 Ice
Clavicular fracture
 Most commonly
fractured bone in
the entire body!
 MOI:
 Transmission of
force up the arm
 Fall onto shoulder
 Direct blow to the
clavicle
 Clavicular fracture
 presents with:
 pain to direct palpation
over the clavicle or with
movement of the arm or
neck
 may be deformity of the
bone with swelling and
ecchymosis. (“tenting”
over fracture site)
 Arm held to the side
 Palpate for crepitus
 Clavicular Fracture
Distal third classification

•Middle third - 80%

•Proximal third - 5%
•Distal third - 15%
Clavicular Fracture
 Simple sling
 Figure-of-eight
 Do not apply if
causes patient
discomfort
 Do not apply for
distal fractures
 Ice
Anderson, et.al., Acta Orthop Scand 1987;58:71-74

Stanley, et. al., Injury 1988;19:162-164

Scapular Fracture
 MOI: Forceful, direct
blow to the back
 Very rare because
well protected by
muscles
 Always assess for
spinal injury or
breathing difficulty
 Sling and swathe
Acromio-clavicular joint (ACJ) injury
ACJ Injury
 MOI:
 Falling directly onto
the adducted
shoulder
 Injury to the
ligament causes
 Tear (subluxation)
 Dislocation
 ACJ Injury

Grade 1 Grade 2 Grade 3………

ACJ Injury
 Presentation:
 Type 1/Grade 1 –
local tenderness
without deformity
 Type 2,3,4,5,6/
Grade 2,3 – local
tenderness with
deformity
ACJ Injury
 Simple sling!
 Collar and cuff
 Ice
Humerus Injuries
Bony Anatomy: Humerus
 Distally – 2 condyles
forming articular
surfaces of trochlea
and capitellum
 Proximally – neck
and head articulate
with glenoid fossa of
scapula
Humeral Fractures
MOI

 Head - Direct trauma to

the humerus from
collision with an object
or fall directly onto the
bone
 Shaft – bent forces like
breaking a stick (shear
or torsion)
 Supraconylar – upper
transmission of force on
outstretched hand
Humeral Head fracture
Diagnosis

 Upper humeral fractures

usually involve the
surgical neck of the
bone
 extracapsular
 low incidence of
avascular necrosis (AVN)
 Anatomical Neck
 intracapsular
 higher incidence of AVN
Humeral Head Fractures
NEER Classification

*Velpeau view if cannot abduct arm

Humeral Head Fractures
Treatment
 One part fractures (no
fracture fragments
displaced < 1cm or 45 deg)
 Non-operative immobilization
in sling1-2 weeks
 Early motion started
immediately
 75% good to excellent results;
10% poor
 Any other fracture
 Closed reduction with
percutaneous pinning
 ORIF
 2-6 weeks to allow pain free
movement
Humeral Fractures
Complications

 Avascular Necrosis of Humeral Head

 Especially at risk with 4 part fractures
 Non-union
 3-6 mos after injury
 Shoulder stiffness with prolonged
immobilization
 Humeral Shaft Fracture
Diagnosis

 Fractures of the
shaft of the humerus
1-3% of all fractures
Up to 18% have

radial nn palsey
Humeral Shaft Fracture
Humeral Fractures
Treatment

 Non-operative
 Acceptable alignment
 AP anglulation - 20 deg
 Varus – 30 deg
 <30mm shortening
 70-80% with 90-100%
union rates
 Time-consuming and
requires cooperative patient
 Collar and cuff; coaptation
splint; hanging cast;
functional bracing
 Weight of forearm provides
traction
Humeral Fractures
Treatment
 Operative
 Absolute Indications
 Failure of closed treatment
 Associated articular involvement
 Vascular injuries
 Ipsilateral forearm fractures
 Pathological fractures
 Open fractures
 Polytrauma
 Relative Indications
 Short oblique or transverse fracture in an active individual
 Body habitus
 Patient compliance
 Staff considerations
Humeral Fractures
Complications
 Radial nerve palsy
 Most at risk – distal 1/3
fractures
 Occurs up to 18% of
fractures
 90% neurapraxias and
heal in 3-4 mos
 Exploration indicated
 No recovery in 3-4 mos
(clinical or EMG)
 Loss of function with
closed reduction
 Open fractures
 Holstein-Lewis distal 1/3
spiral fractures
Supracondylar fracture
Diagnosis

 Supracondylar
fractures
 Most common
pediatric elbow
fracture (65% of
fractures and
dislocations of the
elbow)
 Commonly
associated with
neurovascular injury
Supracondylar fractures
Diagnosis

 Classification
 Type I - non-displaced
 Type II - angulated but not translated in
the sagittal plane with hinging of the
posterior cortex of the humerus
 Type III - posteriorly displaced with IIIA
being posteromedial and type IIIB being
posterolateral
 Supracondylar Fractures
Diagnosis

 Radiology
 AP view
 Baumann’s angle
 Medial epichondylar
epiphyseal angle
(MEE)
 Lateral view
 Humero-
trochlear angle
 Oblique
Supracondylar Fracture
Treatment

 Non-displaced fxs –
cast immobilization
 Displaced fxs – close
reduction with
percutaneous
pinning
Suprachondylar fracture
Complications

 Vascular injury –
brachial aa
 Neurologic deficits –
median nerve;
possible radial nerve
 Volkmann’s
contracture
 Cubitus varus
Humerus Injuries
Emergency Care

 Sling
 Ladder splint
Elbow Injuries
Radial Anatomy

 Radial head
articulates with
capitellum
 Radial neck tapers
to radial tuberosity
which is insertion for
biceps brachii
tendon
 Ulnar Anatomy
 Sigmoid/semilunar/
trochlear notch
 Anteriorly composed
of coronoid process
 Posteriorly composed
of olecranon process
 Articulates with
trochlea of humerus
 Elbow Joint Articulation
- Elbow consists of
articulations:
 Ulnohumeral (elbow
flexion/extension)
 Radiohumeral (forearm
pronation/supination)
 Radioulnar (forearm
pronation/supination)
Elbow Injuries
MOI

 Fall onto
outstretched hand
(FOOSH) with elbow
extended or direct
trauma
Elbow dislocation
Diagnosis

 Second to shoulder
dislocations
 Posterior dislocation
account for 80-90%
 Most occur without
fracture
Elbow dislocation
Treatment
 Immediate reduction vs
splint and refer
 Children should be
splinted; increase
incidence of fractures
 Need for radiographs

 After relocation
 Assess neurovascular
status
 Assess joint stability
 Rehab early
Elbow fracture

 Radial head – 30%

 Olecrenon – 20%
 Coronoid fractures –
10 to 15% of elbow
dislocations
Elbow fat pads
Elbow Fat Pads
 Elbow Fractures
Treatment

 Radial Head
 Non-displaced (type I)
 sling and or splint until no pain
 Displaced (type II)
 Longer immobilization (1-2
weeks)
 removal of bone fragments if
necessary
 Comminuted (Type III)
 Surgery to remove bone
fragments
 Repair ligament damage
 Elbow Fractures
Treatment

 Olecrenon Fracture
 Non-displaced (type I)
 Sling, splint and or cast for
3-4 weeks
 Follow by x-ray for
dislocation of fracture
 Displaced (type II)
 ORIF
 Comminuted (Type III)
 ORIF
 Elbow Fractures
Treatment

 Coronoid Fracture
 Type 1
 Immobilization for 2 weeks
 Type 2
 Immobilization for 2 weeks
 Displaced or humeroulnar
joint instability may
consider ORIF
 Type 3
 ORIF
Elbow dislocation or fracture
Emergency Care

 Immobilize
 Sling
 Posterior elbow
splint using ladder
splint or SAM splint
 ice
Wrist Injuries
Anatomy of the wrist
Wrist fracture
 Incidence of fracture
is 2x for
snowboarding vs.
skiing
 With loss of balance,
the natural tendency
is to break fall with
outstretched hand
(FOOSH)
Wrist fracture (distal radial)
 Most common -
Distal radius or
Colles fracture
 Silver fork deformity
Wrist Fracture (distal radial)
Median nerve assessment (ant interosseous)

normal abnormal
Wrist fracture
Colles Fracture
Treatment
Colles Fracture
Treatment
Colles Fracture
Treatment
Colles Fracture
Treatment

 Closed reduction and immobilization in cast

 Stable fractures
 Examine for carpal tunnel syndrome before and
after application
 Avoid palmar flexion and ulnar deviation (Cotton-
Loder position)
 Percutaneous pinning
 External Fixators
 ORIF
Scaphoid fracture
Diagnosis
Scaphoid fracture
Scaphoid Fracture
 Acute non-displaced,
distal and horizontal
 Thumb spica cast
 Displaced or prox,
vertical fractures
 ORIF
 Increased incidence
of avascular necrosis
 Prevention of Wrist Injury

www.ski-injury.com
 Wrist fracture
Emergency Care
 Padded splint
 Including the elbow is
not essential in distal
injuries
 Splint in the “position of
function”, ie., fingers
cupped around a gauze
roll held in the palm
 Sling can be used to
steady extremity to aid
in patient comfort
Hand/Finger Injuries
Gamekeeper’s or skier’s
thumb
 thumb forced away
like from a ski pole
 Disruption or sprain
to the ulnar
collateral ligament
(MCP joint)
 Splint including
thumb (thumb
spica)
Gamekeeper’s thumb
with fracture
Gamekeeper’s thumb
Treatment
 Short arm immobilizer
with thumb splica
 Main complication is
inability to heal
 Surgery (<2-3 weeks
old)
 Gross radiologic
instability
 Palpable torn ligament
ends (Stener lesion)
 Reassessment reveal
unstable joint
Conclusion
 Falls, collisions and direct blows cause injury
to the upper extremities
 Humerus
 Elbow
 Wrist
 Hand/fingers
 Remember general comments
 “Zone of injury”
 Life-threatening injuries first (ABCs)
Conclusion
 Patients will self-splint the extremity
 Internal rotation, elbow flexed, adducted to body
 Injuries close to joints can involve
neurovascular bundle
 Assess CMS
 ARMS
 Appearance and alignment, radial pulse, motor
and MOI, sensation
Conclusion
 Accurate assessment and rapid transport
critical (60” rule)
 Immobilize in the position found
 Sling and swathe is good immobilizer for
upper extremity injuries
 Every patient should be advised to seek the
care of a physician regardless of injury,
especially if symptoms persist > 24 hrs.
Thank -You
Distal Humerus Anatomy
 Medial epicondyle
proximal to trochlea –
attachment site for UCL and
flexor/pronator ms.
 Lateral epicondyle
proximal to capitellum –
attachment site for RCL,
extensor/supinator ms.
 Radial fossa – accommodates
margin of radial head during
flexion
 Coronoid fossa – accepts
coronoid process of ulna during
flexion
Distal Humerus – Posterior

 Olecranon fossa
accepts olecranon
process of ulna
during extension
Bony Alignment
 With elbow extended,
straight line between
medial/lateral
epicondyles and tip of
olecranon process’
 With elbow flexed,
isosceles triangle
connects these points
Carrying Angle/Cubitus Valgus
 Formed by long axis
of humerus and
midline of forearm
 Male norms – 11-14
degrees
 Female norms – 13-
16 degrees
 Larger angles are
considered abnormal