1. Assessment and Management of Shoulder and Elbow Fractures and Dislocations Yingda Li HMO Surgery May 2010

2. 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

3. 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

4. Is there a life-threatening injury 1. Airway 2. Breathing 3. Circulation 4. Disability 5. Exposure

5. Is there a limb-threatening injury 1. Vascular compromise 2. Compartment syndrome 3. Open fracture 4. Overlying skin integrity 5. Neurological compromise

7. Is there an indication for surgery Threat to limb not abated by non-operative measures Significant fracture displacement Significant intra-articular component

8. History Mechanism of injury Age Allergies Medications Previous medical history Influence of drugs, alcohol Immunisation status Handedness Occupation Premorbid function Last meal Collateral history

9. Examination 1. Look 2. Feel 3. Move

10. Investigations Plain film Computed tomography Magnetic resonance Angiography Blood tests

11. Management 1. Short-term Operative, non-operative, communication 2. Medium-term Follow-up, rehabilitation, delayed surgery 3. Long-term Secondary prevention, vigilance for complications

13. Shoulder

16. 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

18. 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

22. 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

23. Elbow

25. Supracondylar fractures Mechanisms of injury Patterns of injury Clinical findings Potential life-threatening or limb-threatening injuries Indications for surgery Long-term consequences

28. Fractures of radial head Mechanisms of injury Patterns of injury Clinical findings Potential life-threatening or limb-threatening injuries Indications for surgery Long-term complications

30. 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

32. Elbow dislocations Mechanisms of injury Patterns of injury Clinical findings Potential life-threatening or limb-threatening injuries Indications for surgery Long-term complications

33. Topics not covered today Fractures of proximal humerus Acromioclavicular joint disruption Pulled elbow Epiphyseal injuries

34. Which of the following fractures is most commonly associated with a significant vascular complication: A. Fracture of mid-shaft of femur B. Fracture of distal radius C. Fracture of lower end of tibia D. Supracondylar fracture of the humerus E. Subcapital fracture of humerus

35. 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 10 o 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. Frozen shoulder (adhesive capsulitis) B. C5 nerve root injury C. Axillary nerve injury D. Musculocutaneous nerve injury E. Upper brachial plexus (C5-6) injury

36. 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. Full length arm plaster for 8 weeks. B. Insertion of a nail into the shaft of the humerus. C. Excision of the head of the humerus. D. Collar and cuff for pain relief followed by early mobilisation E. Open reduction and stabilisation by plate and pins

37. 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

38. Questions