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
