Stinger/Burner Nerve Injury

A “stinger” or “burner” is a common transient injury that occurs in contact sports such as football. The injury occurs from stretching the upper trunk of the brachial plexus or compression of the C5-C6 nerve root.

contactStretching of the brachial plexus is the mechanism of injury typically seen in high school aged athletes suffering from this condition. This injury occurs from a direct blow, causing the shoulder to be depressed and forcing the neck into lateral flexion, causing the neck to bend toward the opposite side.

stretchingCompression of the nerve root is the basis of injury most often associated with older athletes. It is not a cervical cord injury and it is not a transient quadriplegia.

compressionThe patient will complain of burning pain, numbness, and weakness with painful symptoms starting above the shoulder, going down to the arm. Symptoms will begin immediately after the trauma occurs and can last from several minutes up to several weeks after the accident, but they will usually resolve themselves. A stinger or burner is a transient, intensely painful nerve injury that may result in time loss from competition.

burner pain

When the injury occurs, the athlete should stop participating in sports until full recovery of strength, sensation, and pain-free range of motion is reestablished to the cervical spine. Treatment consists of alternating between ice and heat, anti-inflammatory medications, and rehabilitation exercises. An MRI may be necessary to rule out a herniated disc. Surgery is usually not necessary for a Stinger/Burner injury.


Carrying Angle of the Elbow

The carrying angle of the elbow is the clinical measurement of the varus-valgus angulation of the arm with the elbow fully extended and the forearm fully supinated. With the arms extended at the sides and the palms facing forward, the forearm and hands are normally slightly away from the body.

axis The intersection of the axis of the upper arm and axis of the forearm defines the carrying angle. The carrying angle is greater in shorter persons compared to taller persons. The shorter the forearm bone length is, the greater the carrying angle will be. The normal carrying angle of the elbow is between 5-15°. The carrying angle is greater in women and in throwing athletes. It is difficult to assess if there is a flexion contracture of the elbow. This angle permits the forearms to clear the hips in swinging movements during walking, and is important when carrying objects.

carrying angleCubitus varus is the opposite of cubitus valgus, causing the elbow to have inward angulation towards the midline of the body. Cubitus valgus is a deformity which causes the forearm when it is fully extended to be angled away from the body in a greater degree than normal. Supracondylar fractures usually occur in children.

If the fracture is malaligned and if it heals in a malaligned position, the fracture may develop into a severe varus deformity of the elbow which decreases the carrying angle of the elbow. This decrease of the carrying angle causes the elbow to have more of an inward angulation towards the midline of the body. This creates what is called a “gunstock deformity”. The deformity is caused by fracture malunion. This is usually a cosmetic deformity with little functional limitation.leading

A fracture of the lateral condyle of the humerus can lead to:

  1. Cubitus Valgus
  2. Stretching of the ulnar nerve

If the fracture did not heal or the fracture is malaligned, the medial part of the humerus will grow and the lateral part will not grow. The forearm will drift into valgus malalignment. The carrying angle will increase (cubitus valgus) and the ulnar nerve will be stretched and may need transposition. The nonunion of the lateral condyle of the humerus may need fixation in order to stop progression of the valgus deformity. 30° of varus or valgus angulation is tolerated in fractures of the humerus without any clinical functional significance.thirty


Intrinsic Plus Hand Contracture

Contractures of the intrinsic muscles of the fingers disrupts the delicate and complex balance of the intrinsic and extrinsic muscles. Sometimes, it is called Intrinsic Plus Hand. The hand assumes a posture with a hyper flexed metacarpophalangeal (MCP) joint and a hyperextended proximal interphalangeal (PIP) joint. Contracted interossei and lumbrical muscles deform the natural cascade of the fingers. Severe disability may result because of weakness in grip and pinch strength as well as difficulty in grasping large objects.


Intrinsic Contracture of the hand is caused by trauma, spasticity, ischemia, rheumatological disorders, vascular injuries, and compartment syndrome.

bunnellWhen testing the digit for intrinsic muscle or capsular tightness, you will perform the Bunnell Test. When the MCP joint is in extension, the intrinsic contracture (interosseous and lumbrical muscle contracture) impedes the flexion of the PIP joint. When the MCP joint is flexed, the PIP joint flexion increases.

Bunnel IITo treat intrinsic tightness, physical therapy is usually recommended first—passive stretching and orthotics in mild cases. Surgery is performed if the condition is severe or if noticed too late. Surgery will consist of a distal intrinsic release of the oblique fibers and preserving the proximal transverse fibers. Options for surgical management are diverse and decided by the cause and severity of the contracture.

When testing for extrinsic tightness, you will place the MCP join in flexion and try to passively flex the PIP joint. The PIP motion is less with the MCP joint flexed than when it is extended (opposite of intrinsic contracture). Treatment consists of aggressive therapy and tenolysis. PIPjoint contracture

A PIP joint contracture is determined when the loss of motion of the PIP joint is the same with the MCP joint extended or flexed. Intrinsic minus hand, or Claw Hand, is a condition usually secondary to a crush injury caused by contracture of the intrinsic muscles of the hand. Intrinsic minus hand is characterized by the flexion of the PIP and DIP joints as well as the extension of the MCP joint.


Monteggia Fracture Dislocation

Monteggia fracture is the fracture of the proximal third of the ulna with dislocation of the radial head. The fracture is more common in children and rare in adults. Treatment will depend on the age of the patient.The normal position of the radial head and shaft should line up with the capitellum in any position. Dislocation of the radial head may be missed.

normal position

Type I Monteggia fractures occur in the middle or proximal third of the ulna with anterior dislocation of the radial head and characteristic apex anterior angulation of the ulna. This is the most common type and occurs in about 60% of cases. In children, you will immobilize the fracture in flexion and supination. Flex the elbow more than 90 degrees to relax the biceps.

Only 15% of Monteggia fractures are Type II. This fracture occurs in the middle or proximal third of the ulna with posterior dislocation of the radial head and characteristic apex posterior angulation of the ulna. You will need to immobilize this fracture in extension.

type ii

20% of Monteggia fractures are type III. These fractures occur at the ulna just distal of the coronoid process with lateral dislocation of the radial head.

Type IV only occur 5% of the time and is classified as the fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head, and a fracture of the proximal third of the radius below the bicipital tuberosity. This fracture will require surgery, even in children.

TypeIVWith Monteggia Fracture Dislocations, it is important to perform a neurovascular exam. Nerve injury, especially involving the posterior interosseous nerve, is not uncommon. Additionally, you will want to watch the patient for compartment syndrome.

Treatment in adults consists of ORIF of the ulna—when the ulna is properly aligned and fixed, the radial head will reduce by itself. Radial head instability may usually be caused by nonanatomic reduction of the ulna or by interposition of the annular ligament. Fracture of the ulna may need a bone graft for healing.

platingWhen treating pediatric patients, it is important to note that the radial head ossifies around age 4. For Type I-III fractures, you will perform a closed reduction of the ulna to restore the length of the ulna and reduce the radial head. Remember to immobilize in flexion and supination. Type IV fractures or cases where you are unable to reduce the radial head or the length of the ulna in pediatrics will require surgery. Fixation will be done with an IM rod or a plate.

When treating old cases, you will perform an osteotomy of the ulna and an open reduction of the radial head, followed by plating of the ulna.