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Plain radiography remains the imaging study of choice for most applications in the upper extremity. The upper extremity is divided into three sections: the shoulder, the elbow and forearm, and the wrist and hand. Similar to the shoulder, the most common use of elbow and forearm plain radiography is in the setting of acute trauma. As with the rest of the upper extremity, the major indication for imaging of the wrist and hand is in the setting of acute trauma. It is one of the most difficult areas to differentiate between soft tissue and skeletal injury on history and physical examination alone. Imaging is necessary even with obvious fractures because the extent of the fracture, displacement, angulation, and articular involvement are important to determine if the patient needs closed reduction in the ED or immediate orthopedic referral for possible open reduction and surgical fixation.
Trauma to an extremity is a common reason for a patient to present to the emergency department (ED). According to the Centers for Disease Control and Prevention, there were nearly 15 million visits to the ED in the year 2000 for injuries involving the extremity. The most common sites of injury were the wrist and hand, followed by the ankle and shoulder. It is important to perform a thorough but efficient history and physical examination in order to accurately diagnose and provide initial treatment for these injuries. When improperly treated, extremity injuries may lead to long-term pain and disability for the patient.
Each extremity can be viewed as a group of individual bones held together by a musculo-ligamentous apparatus. Careful attention must be paid to the vascular and nerve supply to each extremity; injury to these structures may be over-looked when fractures are present. Each extremity is encased in soft tissue that is often subdivided into fascial compartments. The clinician should become familiar with the normal anatomy and pathology of an extremity in this context: bones and ligaments, muscles and tendons, nerves and vessels, and soft tissue (compartments). The examination is complete only when all of these structures in the relevant area have been assessed (Tables 20.1 and 20.2).
Sensory and motor innervation of the extremities can be rapidly assessed.
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