11a. Upper limb fracture Flashcards
first ling investigations of a upper limb fracture
x-ray in 2 views
eg shoulder AP and Lateral/scapula Y view (named due to the “Y” shape of the scapula in this view)
eg elbow AP and lateral views
bloods
routine blood tests, including a clotting screen and a Group and Save.
joints in the shoulder
AC joint - acromioclavicualr
glenohumeral joint
when may a shoulder xray be useful
anterior dislocation
posterior dislocation
acromioclavilar joint dislocation
clavicualr fracture
humeral head fracture
most common type of shoulder dislocation
Anterior shoulder dislocations account for > 95% of cases.
management shoulder dislocation
If the dislocation is recent then reduction may be attempted without any analgesia/sedation.
However, other patients may require analgesia +/- sedation to ensure the rotator cuff muscles are relaxed.
What causes winging of the scapula
damage of the long thoracic nerve (innervates the serratus anterior)
The long thoracic nerve can be damaged by trauma to the shoulder, repetitive movements and by structures becoming inflamed.
what portion of the clavicle do most clavicualr fractures occur in?
80% of clavicular fractures occur in the middle third.
classification of clavicualr fractures
Clavicular fractures can be classified by the Allman classification system, determined by the anatomical location of the fracture along the clavicle:
Type I – fracture of the middle third of the clavicle, constituting 75% clavicular fractures (as the middle third is the weakest segment)
They are generally stable, although significant deformity is usually present
Type II – fractures involving the lateral third of the clavicle and constituting around 20% of all clavicular fractures
When displaced, this type are often unstable
Type III – remaining 5% occur in the medial third of the clavicle, commonly associated with multi-system polytrauma
As the mediastinum sits directly behind the medial aspect of the clavicle, they can be associated with neurovascular compromise, pneumothorax, or haemothorax
complications of clavicualr fractures? in which type of clavicualr fractures
type 2 (distal) - non-union is a particualr issue
type 3 (medial) - neurovascular compromise, pneumothorax, or haemothorax
features of proximal humeral fracture?
proximal - FOOSH elderly or young high trauma, axillary nerve damage (difficulty abducting and sensation over deltoid impaired)
features of shaft humeral fracture
shaft - fall directly onto the outstretched limb or falling laterally onto an adducted limb. Risk of damage to the radial nerve and profunda brachii artery.
The radial nerve innervates the extensors of the wrist. Extensors become paralysed → unopposed flexion of the wrist ‘wrist drop’
types of distal humeral fracture? what enrve may be damaged?
distal humeral fractures comprise of:
- supracondylar
- intra-articualr
supracondylar are particualrly common in chidlren and rare in adults
ulnar nerve can be damaged in distal humeral frcatures
features of supracondylar fractures?
supracondylar
paediatric
Moi: FOOSH with elbow in extension
neurovascualr injury is common
signs of gross deformity, swelling, limited range of elbow movement (secondary to pain), and ecchymosis of the anterior cubital fossa. Ensure to look closely for evidence of an open injury.
Urgent orthopaedic review is required for all supracondylar fractures, especially those with neurovascular compromise or evidence of an open fracture.
important complications of supracondyalr fractures
- compartment syndrome
- volkmanns contracture
Brachial artery can be damaged → ischemic → uncontrolled flexion of the hand. (volkmann’s ischaemic contracture) - Anterior interosseous nerve damage - okay sign - weakness of flexor pollicis longus
- ulnar nerve damage
- malunion
what type of scan is useful for intra-articualr extension in distal huemral fractures
CT imaging may be useful for comminuted fractures or where intra-articular extension is suspected, which aides with surgical planning.
signs on xray supracondyalr fracture
Posterior fat pad sign (lucency visible on the lateral view)
Displacement of the anterior humeral line (in children >5yrs, this should intersect the middle third of the capitellum)
invetsigation ?spracondyalr fractyre
The mainstay of investigation for suspected supracondylar fractures is via plain film radiographs in both antero-posterior (AP) and lateral views of the elbow.
nerve damage supracondyalr fractures
The anterior interosseous nerve is most commonly affected by the initial injury, however ulnar nerve palsy is the most common post-operative complication. The ulnar nerve is at risk during insertion of the medial K-wire.
Malunion is an important complication to assess for following a supracondylar fracture, more common in those fractures managed suboptimally. In some cases, patients may even develop a cubitus varus deformity (often termed “gunstock deformity”), whereby the extended forearm deviates towards the midline.
what is the olecranon
The olecranon is the part of the ulna that cups the lower end of the humerus, creating a hinge for elbow movement.
features olecranon fracture
FOOSH followed by elbow pain, swelling and lack of mobility
olecranon is pulled up by triceps muscle leading to displacement
what guides management in olecranon frcature
degree of dispalcement with >2mm often warranting surgical fixation
signs on imaging radial head fracture
Sail sign: An elevated, sharply demarcated anterior fat pad. It is often the only radiographic signs for a radial head injury.
what is the most common fracture of the elbow
radial head fracture
features radial head fracture
FOOSH
The radial head is forced into the capitulum of humerus, causing it to fracture.
There are complex ligament structures that can also be damaged in these injuries, which may need further clinical/imaging assessment.
most common wrist frcature
colles distal radius fracture
what does volar mean?
relating to the palm of the hand or the sole of the foot.
colles vs smith in terms of angulation
colles has dorsal/posterior angulation/displacement on lateral view = points towards the dorsum
smith has volar/vental/anterior angulation/displacement as it points towards the palm
think of it as what you see when you fall
features of colles fracture
A Colles’ fracture* describes an extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface.
FOOSH with arm pronated - palm hits the floor
Distal structures (hand and wrist) are displaced posteriorly resulting in ‘dinner fork deformity
features of smith fracture?
Smith’s Fracture: What Is It, Difference from Colles, and …
A Smith’s fracture is a volar displacement fracture where the fragment of the radius that has broken off projects towards the palm side of the hand,
FOOSH but fall onto dorsal surface of the hand
Distal structures (wrist and hand) are displaced anteriorly
what is a bartons fracture
This is an intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint.
what is the anterior interosseas nerve? how to test it?
The anterior interosseous nerve (AIN) is the terminal motor branch of the median nerve. It branches from the median nerve in the proximal forearm just below to the elbow joint. It is about 5–8 cm distal to the lateral epicondyle and 4 cm distal to the medial epicondyle.
*Ask for an ‘okay’ sign, if the DIPJ of the 2nd digit and IPJ of thumb extend, this signifies AIN nerve involvement
complications of distal radius fractures
malunion
median nerve compression especially if malunion
osteoarthritis especially with intra-articualr involvement
Axillary nerve normal function
Motor: Shoulder abduction (deltoid muscle)
Sensory to inferior region of the deltoid muscle
How may the axilliary nerve become damaged?
Humerus surgical neck fracture: usually by direct blow or falling on an outstretched hand
anterior dislocation
Examination axillary nerve damage
flattened deltoid, loss of sensation over deltoid
weakness of shoulder abduction
which are the distal radius fractures
colles
smith
bartons
which are the radius/ulnar co-injuries
MUGR
MU = MonteggiA = ulnar
A - a is proximal = bones affected proxiamally
= ulnar fracture with dislocation of radial head
GR = Galeazzi = radius
radial fracture with dislocation of the ulnar at the distal radioulnar joint
pathophysiology ulnar/radius co-injury
Interosseous membrane. The ulna and radius are attached by the interosseous membrane. The force of a trauma to one bone can be transmitted to the other
Mechanism of injury monteggi and galeazzi
M - Fall on outstretched hand with forced pronation
G - Occur after a fall on the hand with a rotational force superimposed on it.
Features scaphoid fracture
FOOSH
clinical features
- pain in anatomical snuff box
- pain on telescoping the thumb
- pain on ulnar deviation of the wrist
important to pick up!!!!
initial management ?scaphoid fracture
Initial plain radiographs should be taken. A “scaphoid series” should be requested, including anteroposterior, lateral, oblique views.
NICE guidance from 2016 suggested the MRI should be considered the first-line imaging following clinical examination. However, this is still not common practice in the UK
Initial management of suspected or confirmed scaphoid fracture
1. immobilisation with a Futuro splint or standard below-elbow backslab
+ referral to orthopaedics
clinical review with further imaging (eg MRI) should be arranged for7-10 days later when initial radiographs are inconclusive
how do orthopaedics manage scaphoid fracture
undisplaced fractures of the scaphoid waist
cast for 6-8 weeks
union is achieved in > 95%
certain groups e.g. professional sports people may benefit from early surgical intervention
surgical fixation for:
displaced fractures
proximal scaphoid pole fractures
complications scaphoid fractures
non-union → pain and early osteoarthritis
avascular necrosis
what is the common complication of scaphoid fractures? why?
Avascular necrosis is common complication of a scaphoid fracture (in around 30% of cases), with its risk increasing the more proximal the fracture.
retrograde blood supply
blood supply scaphoid ?
The dorsal branch of the radial artery, which supplies 80% of the blood, enters in the distal pole and travels in a retrograde fashion towards the proximal pole.
Consequently, fractures can compromise the blood supply, leading to avascular necrosis (AVN) and subsequent degenerative wrist disease. The more proximal the scaphoid fracture, the higher the risk of AVN.
numbering the digits
1 = thumb coz only 1 of them
Metacarpal I – Thumb.
Metacarpal II – Index finger.
Metacarpal III – Middle finger.
Metacarpal IV – Ring finger.
Metacarpal V – Little finger
what are the two common fractures of the metacarpals
Boxer’s fracture (tip to remember : pinky finger can make a box shape but thumb cant) –
A fracture of the 5th metacarpal neck. It is usually caused by a clenched fist striking a hard object. The distal part of the fracture is displaced anteriorly, producing shortening of the affected finger.
Bennett’s fracture – A fracture of the 1st metacarpal base, caused by forced hyperabduction of the thumb. This fracture extends into the first carpometacarpal joint leading to instability and subluxation of the joint. As a result, it often needs surgical repair.
bones of the hand
Fingers
(Phalanges)
distal phalange
DIP
medial phalange
PIP
Proximal phalange
MCP
Metacarpals
Thumb
(phalanges)
distal phalanx
IPJ
Proximal phalanx
MCP
metacarpal
joints of fingers from top to bottom
distal interpharangeal joint (DIP)
proximal interpharyngeal joint (PIP)
metacaropharyngeal joint (MCP)
thumb just has an interpharyngeal joint (IPJ) and an MCP
Normal function of radial nerve
Motor: “stop”
Extension of wrist, fingers, forearm, thumb
Sensory: area between the dorsal aspect of the 1st and 2nd metacarpals
How may the radial nerve become damaged?
humeral midshaft fracture
How would a damaged radial nerve present?
wrist drop
due to unopposed flexion of the wrist
weakness of thumb extension
Normal function of median nerve
“power to the people”
Motor: LOAF muscles
Lateral lumbicals
Opponens pollicis
Abductor policis
Flexor policis brevis
wrist flexion, finger flexion, thumb opposition, pronation, thumb abduction
Sensation : Palmar aspect of lateral 3½ fingers
How does the median nerve become damaged
compression at the wrist (carpal tunnel syndrome)
how would a damaged median nerve present?
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
sign of benediction
Anterior interosseous nerve: opposition of the thumb and index finger* ‘okay sign’
Normal function of ulnar nerve?
“peace sign”
motor: abduction of fingers
Sensory: medial 1 1/2 fingers
adduction of thumb (adductor policis)
How would the ulnar nerve become damaged?
fractures at the elbow:
medial epicondyle fracture
supracondylar fracture (+ is a comp of surgery)
compression at the elbow
cubital tunnel
How would a damaged ulnar nerve present?
frommets sign (cant adduct thumb properly)
inability to abduct/adduct fingers and adduct thumb
sensory loss over medial 1 1/2 fingers
cubital tunnel syndrome
Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
Over time patients may also develop weakness and muscle wasting
Pain worse on leaning on the affected elbow
Medial epicondyle fracture -
Damage may result in a ‘claw hand’
