MIEMBRO SUPERIOR

Ortopedia y traumatología CIB. USMLE

IMPORTANTE MUY IMPORTANTE USMLE

Nerves Injuries

Lesión del nervio radial: Por encima del codo da mano caída, por debajo del codo puede hacer
extensión de muñeca pero no extensión de los dedos.
Lesión del nervio mediano: Mano de predicador.
Lesión del nervio cubital: Mano en garra.

Cambios radiológicos de la osteoartrosis: Disminución del espacio articular, esclerosis, osteofitos,

quistes.
Pathological fractures occur under physiological burdens.

In penetrating injuries of the extremities, the main issue is whether a vascular injury has occurred
or not. Anatomic location provides the first clue. If no major vessels in the tract or close to the
injury ONLY use tetanus prophylaxis and cleaning. If the injury is close to a vessel and the patient
is asymptomatic use Doppler studies or arteriogram. If there is a vascular injury ascertain by:
absent distal pulses, expanding hematoma) surgical exploration and repair is required.

Combined injuries to arteries, nerves and bones need repair. The usual is to repair the bone first,
the do the delicate vascular repair that could be damaged by putting together the bones and last
the nerve. Fasciotomy should be adde because the prolonged ischemia could lead to
compartment syndrome.

High velocity gunshot wounds produce a large cone of disruption that usually lead to amputation
or extensive debridements.

Crushing injuries of the extremities → HYPERKALEMIA, MYOGLOBINEMIA, MYOGLOBINURIA, AND

RENAL FAILURE, COMPARTMENT SYNDROME. Use Fluids, osmotic diuretics and alkalinization of
the urine to prevent or use fasciotomy for the compartment syndrome.

Clavicular Fractures

More common between the middle and distal thirds. Treated with a figure-of-eigth device for 4 –
6 w. The S form predisposes to fractures. To see the distal third take ZANCKA Projections (AP with
10° of cephalic inclination).

Direct force= Posterior dislocation. May compress the trachea or the venous system. > painful.

Indirect force > common = Anterior dislocation. Sport and car accidents.

It presents with pain to move the upper body, edema. The DX is clinical, but X rays may be used.
The most common is the “Serendepity view” 40 looking to the sternum. The ACT is the best
option.

Treated with a figure-of-eigth device for 4 – 6 w. Speak to the surgeon before reducing a posterior
dislocation to rule out vascular lesions. Surgical repair is done only in open fractures, septic non
union, vascular lesion, severe movement, multiple injuries, floating shoulder (Humerus + scapula
Fx).

80% of the fractures occur in the middle third. The patient presents with a history of trauma, pain,
edema, deformity, crepitation and ecchymosis.

Complications: Non union, bad union, neurovascular injuries, posttraumatic arthritis (Lidocaine
helps).

Indicaciones quirúrgicas para fractura de clavícula: Fractura abierta, eminente ruptura de piel,
compromiso del tercio distal, desplazada o acortada más de 2.5 cm, lesión neurovascular.

Dislocation of the Shoulder

Anterior is more common. Patients have the arm close to the body in EXTERNAL ROTATION. There
can be numbness in the deltoid, from stretching the axillary nerve. DX with AP and lateral X rays.
Some patients have recurrent dislocation with minimal trauma.

Posterior dislocation is rare and needs a massive trauma or uncoordinated contraction as in

epileptic seizure or electrical burn. The arm is in “protected position” INTERNALLY ROTATED.
Needs axillary and scapular views.

Proximal Humerus Fracture

5% of all fractures. More common in women (Osteoporosis). Is divided in 4 parts: 2 tuberosities,

anatomical neck, surgical neck. Surgical neck: > common and less severe, does not compromise
irrigation. Anatomical neck: More complications because irrigation is compromised.

Usually after a fall with the extended hand following mild or moderate trauma (osteoporosis). 80%
are non or minimally displaced. They present with pain edema and functional impotence with
crepitus. Check for neurovascular injuries specially in the axillary nerve, ↓ of strength in deltoids.

80% are treated with a sling and rehabilitation.

Complications: Frozen shoulder, avascular necrosis, non union, bad union, neurologic injury.

Deltoid atrophy= Radial nerve injury.

Diaphisis Fracture of the Humerus

Common fracture > 90% orthopedic treatment. Presents with shortened arm, pain, edema,
deformity. Brachial cast in U shape like sugar tong. Is the only fracture of a long bone treated
orthopedically.

CX: Open fracture, vascular injury, floating elbow, segmentary fracture, bilateral, multiple trauma,
radial nerve injury, > 3cm of shortening.

Complications: Radial injury, vascular injury, non union.

Distal Humerus. Fracturas supracondileas

Its hard to tell apart from posterior dislocation. But if the olecranon triangle is fine de Dx is made.
The triangle is lost in posterior dislocation. Use Rx and ACT.

Triada desgraciada de codo: Luxación de Codo, fractura de coronoides, fractura de cabeza del
radio.

Elbow dislocation

High incidence between 5 and 25 years consisting 25% of fractures.

Colles Fracture: Outstreched hand in old osteoporotic women. The wrist looks like a dinner fork.
The lesion is dorsally displaced, dorsally angulated fracture of the distal radius. Close reduction
and arm cast. Criterios de cx en fx de radio distal: 1. Conminuta 2. Intraarticular 3. Desplazamiento
>1mm (acortamiento) 4. Daño severo tejidos blandos 5. Lesión nervio mediano.

Ulnar and radial Diaphisis

Lesión de Essex-Lopresti: Se caracteriza por la fractura de la cabeza del radio y la luxación de la

articulación radiocubital distal con lesión de la membrana interósea.

Monteggia Fracture: Diaphyseal fracture of the proximal ulna and anterior dislocation of the radial
head. Direct blow to the ulna.

Galeazzi Fracture: Fracture of the distal third of the radius, and dorsal dislocation of the distal
radioulnar joint.

In both Monteggia and Galeazzi the broken one needs open reduction and fixation and the other
close reduction.

Criterios quirúrgicos para fracturas distales de radio: Conminuta, muy desplazada, acortamiento
más de 3mm, lesiones neurovasculares.

Fracture of the Scaphoid (Carpal Navicular), affects a young adult who falls on an outstretched
hand. Wrist pain, tenderness in the snuff box. If Initially the fracture is not seen, a thumb spica
cast is used, fracture is seen 3 weeks later, if is easily seen use open reduction and fixation. VERY
HIGH RATE OF NONUNION . Avascular necrosis. Use a cast for 12 weeks. CX if >1mm.

Metacarpal neck fractures: > fourth or fifth when closed fist hits a wall. Swollen tender hand, X
rays are diagnostic. Depending on the severity use closed reduction or Kirshcner wire or plate for
the bad ones.

Músculos del Manguito Rotador: > 40 años, dolor nocturno, irradiado, debilidad, función limitada,
síntomas progresivos.
Tratamiento: Infiltracion.
Prueba para Evaluar
Supraespinoso: Elevación 90° Jobe
Infraespinoso: Principal rotador externo 60% Rotación externa
Redondo menor: Rotador externo 40% Rotación externa, lag test
Subscapular: Rotación interna Gerber, belly press
Signo de Neer: Dolor al levantar entre 60-120. Pinzamiento.
Hawkins: Con brazo extendido hacer rotación interna. Pinzamiento.
Gerber: Rotación interna hacia espalda.
Belly press: Rotacion interna hacia barriga.

ZONAS:

C5: S. cara externa brazo. R. bicipital. M. Deltoides. Flexores codo.

C6: S. cara externa antebrazo. R. braquioradial. M. biceps. Extensores muñeca.

C7: S. dedos. R. tricipital. M. triceps. Extensores codo.

C8 C7 T1: S. antebrazo medial. M. dedos.

T1 T2: S. cara interna codo.

T1: Abductores dedos.

Carpal tunnel Syndrome

> in women who do repetitive hand work. Numbness and tingling in their hands, > in night and the
area of the median nerve. The symptoms can be reproduced by Tinnel, Phallen, Durkan. The
diagnosis is clinical, but X rays should be taken to rule out other things. Treated with splints,
NSAIDS, surgery preceded by electromyography.

Trigger finger
> In women. They woke up with an acutely flexed finger. When they pull it with the other hand the
result is a painful snap. Steroid injection, surgery. Polea A1.

De Quervain tenosynovitis
Young mothers who force the thumb extension. The pain is reproduced by pulling the finger in
ulnar deviation=Finklestein. Splint, NSAIDS, but steroid injection is the best, surgery is rare.

Pruebas para tendinitis bicipital: Speed, Yergason.

Pruebas de inestabilidad de Hombro: Sulcus, cajón, aprehensión.
-Signo del hachazo y charretera: Luxación anterior de Hombro.
- Signo de la tecla: Luxación Acromioclavicular.
Epicondilitis medial (golfista): Positivo si dolor a la flexión de muñeca.
Epicondilitis lateral (tenista): Positivo si dolor a la extensión del tercer dedo.
Da por actividades repetitivas, daño unión tendón hueso.
Pruebas para Síndrome Túnel de Carpo: Tinnel, Phallen, Durkan.