CMC COMPENDIUM
  • Prospective Applicants
    • 2020 MATCH
    • About CMC
    • Our Curriculum
    • Our Residents
    • Our Fellowships
    • Program Leadership
    • Explore Charlotte
    • Official Site
  • ROTATING STUDENTS
    • Prospective Visiting Students
    • UNC Students
    • Healthcare Disparities Externship
    • Current Students
  • Current Residents
    • Airway Lecture!
    • PGY - 1
    • PGY - 2
    • PGY - 3
    • Simulation Reading
    • Blogs >
      • EM GuideWire
      • CMC ECG Masters
      • Core Concepts
      • #FOAMed
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
    • Board Review
    • Journal Club
    • Resident Wellness
    • Resident Research
  • Top 20
  • Chiefs Corner
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Individualized Interactive Instruction
    • Evaluations/Interview Season
    • Contact Info
    • Resume Builder

Ulnar Nerve Injury

2/8/2015

0 Comments

 
HPI:  Middle age male who presents after falling at work. His medial forearm stroke a metal bucket just distal to his elbow and resulted in a large laceration.

PE: Patient is unable to flex at the DIP of digit 4 and 5. He is unable to cross the second and third fingers or adduct his fingers. He has decreased sensation over the medial aspect of the 4th and 5th digit.  Suspected ulnar nerve laceration. 

Picture
Anatomy: Derives from the medial portion of the brachial plexus (C8-T1). It lies posteromedial to the brachial artery in the upper arm and traverses behind the medial epicondyle.  The ulnar nerve runs along on the ulnar aspect of the wrist along with the ulnar artery. It passes through Guyon’s canal where it bifurcates into sensory and deep motor branches.  
Picture
Innervation:
-   Motor:
  • Flexor carpi ulnaris and Flexor digitorum profundus for the 4th and 5th digits.
  • Adductor pollicis and deep head of flexor pollicis brevis
  • Interossei and 3rd and 4th lumbricals. 
  • Abductor digiti minimi, opponens digiti minimi, flexor digiti minimi. 

-    Sensory:
  •  Dorsal and palmar cutaneous branches as well as Superficial terminal branches. 

Clinical conditions:
  •  Distal humerus fracture
  •  External compression at the medial epicondyle
  •  Prolonged elbow flexion. 
  •  Medial epicondylitis (Golfer’s elbow)
  •  Compression in Guyon’s canal (spares 4th and 5th digit flexion)
  •  Propulsion of a wheelchair
  •  Fractures of the hook of the hamate

Treatment: Forearm exploration with transected nerve repair.

Pearls:
  •  Evaluate flexion at the DIP of the 4th and 5th digits. 
  •  Inablity to adduct the fingers. Crossing the 2nd and 3rd digit is maximum adduction. If unable to do this secondary to pain, can adduct 2nd and 3rd digit in “scissoring” motion against examiners fingers between the medial aspect of 2nd digit and lateral aspect of 3rd digit.  
  •  Decreased sensation at the lateral 4th and entire 5th digit. 
  •  Compression in Guyon’s canal will exhibit decreased sensation and inability to adduct the fingers. Flexion of 4th and 5th digit is spared.


 


0 Comments

Supracondylar Humerus Fractures:

12/12/2014

0 Comments

 
HPI: 7 y/o fall from monkey bars. Landed on extended shoulder + outstretched arm.

Physical exam: Obvious arm deformity. Ecchymosis over distal/medial arm. Inability to flex thumb IP joint and DIP of index finger (AIN neuropraxia). Palpable pulses. Warm extremity.
Picture
AP showing mild varus angulation    

Picture
Lateral film showing significant posterior displacement of distal portion of fracture
Picture
 Normal lateral film
Picture
Normal AP flim showing Baumann's angle: angle btw humerus and capitellar physis. This measures amount of varus/valgus deformity
Supracondylar Humerus Fractures:
Two categories:
·       Extension: Distal fragment displaced anteriorly (95% of cases).
·       Flexion: Distal fragment displaced posteriorly (5% of cases).

Four Types:
·       I: Nondisplaced: look for posterior fat pad
·       II: Displaced. Posterior cortex intact
·       III: Completely displaced
·       IV: Complete periosteal disruption with instability on flexion and extension.

Presentation:

·       Usually from fall on outstretched hand.
·       Frequently will have neurologic findings:
·       Anterior Interosseus Neuropraxia:
·       Most common neurologic finding. Particularly with extension-type fractures.
·       AIN is a branch of Median nerve.
·       Patient's cannot flex thumb IP joint or index DIP joint (Can't make an “OK” sign).
        Almost all will resolve with conservative management.

       Also have vascular compromise in approximately 1%
       Usually brachial artery compromise
       High collateral flow, so patient may have a pink, but pulseless extremity. Still requires emergent reduction.

Treatment:
       Type I: Immobilization at 90 degrees and ortho follow-up.
       Type II: Closed reduction unless displacement is minimal.
       Adequate reduction: Baumann's angle wnl, anterior humeral line transects capitellum
       Type III: High-risk for neurovascular complications. Get ortho involved. Almost always require closed reduction + pinning vs. open reduction
     Type IV: Open surgical reduction and fixation

       Indications for open reduction:
       1.) Inadequate reduction with closed techniques
       2.) Vascular injury
       3.) open fracture
       4.) Type iv fracture

0 Comments

radial nerve palsy

11/13/2014

1 Comment

 
HPI:  Patient presents with a grossly deformed right upper extremity.

PE:  Gross deformity of humerus, no open fracture.  Unable to extend wrist. Unable to hyper-extend MP joints of fingers and unable to flex IP joint of thumb.  Radial and ulnar pulses intact.

IMAGING:  Multi-factorial fracture along the mid third of humerus along the expected course of the radial nerve.

DISPO (if at free standing ED):  Transfer patient to ED with on-call orthopedics for definitive fixation.  Reduce and splint prior to transfer.

TREATMENT:  Nonoperative managment.  Splinted and cast at bedside.  Follow radial nerve palsy clinically for improvement.
Picture
1 Comment

    Orthopedics Blog

    Picture

    Author 

    CMC ER Residents 
    (for learning purposes, imagine all cases present to a free standing ED for dispo and treatment options)

    Subscribe To Blog

    Archives

    June 2018
    April 2018
    March 2018
    October 2017
    September 2017
    February 2016
    January 2016
    December 2015
    November 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014

    Categories

    All
    Lower Extremity
    Nerve Injury
    Spine
    Sports Medicine
    Upper Extremity
    Vascular Injury

    RSS Feed

    Disclaimer: All images and x-rays included on this blog are the sole property of CMC EM Residency and cannot be used or reproduced without written permission.  Patient identifiers have been redacted/changed or patient consent has been obtained.  Information contained in this blog is the opinion of the author and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.
Disclaimer: All original material and images included on this website are the sole property of CMC EM Residency and cannot be used or reproduced without written permission.  Information contained on this website is the opinion of the authors and does not necessarily represent the official opinion of Atrium Health or Carolinas Emergency Medicine Residency. 


For Health Care Providers:  Every effort is made to provide the most up to date evidence based medicine.  However, this content may not necessarily reflect the standard of care and application of material contained on this website is at the discretion of the practitioner to verify for accuracy.


For the Public:  This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Relying on information contained on this website is done at your own risk.  Do not disregard professional medical advice or delay seeking care secondary to content on this website.  Call 911 or seek a medical professional immediately for any medical emergencies.
Like us on Facebook or
follow us on Twitter/Instagram

Contact Us:

Department of Emergency Medicine
Medical Education Building., Third floor
1000 Blythe Blvd.
Charlotte, NC 28203

Telephone: 704-355-3658 
Fax: 704-355-7047
​
  • Prospective Applicants
    • 2020 MATCH
    • About CMC
    • Our Curriculum
    • Our Residents
    • Our Fellowships
    • Program Leadership
    • Explore Charlotte
    • Official Site
  • ROTATING STUDENTS
    • Prospective Visiting Students
    • UNC Students
    • Healthcare Disparities Externship
    • Current Students
  • Current Residents
    • Airway Lecture!
    • PGY - 1
    • PGY - 2
    • PGY - 3
    • Simulation Reading
    • Blogs >
      • EM GuideWire
      • CMC ECG Masters
      • Core Concepts
      • #FOAMed
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
    • Board Review
    • Journal Club
    • Resident Wellness
    • Resident Research
  • Top 20
  • Chiefs Corner
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Individualized Interactive Instruction
    • Evaluations/Interview Season
    • Contact Info
    • Resume Builder