4- Upper Extremity Flashcards
What is the SALTR Harris classification system for fractures?
S- separation of physis (growth plate)
A- above physis, through metaphysis
L- lower than physis, through epiphysis
T- through physis, metaphysis, and epiphysis
R- rammed/ crushed physis
What should be considered in the proximity of an open fracture until proven otherwise?
Soft tissue wound, risk of osteomyelitis
What surgical/ provider related interventions affect the risk of osteomyelitis?
Quality of surgical debridement
Prophylactic abx
What bone is most commonly involved with an open fracture?
Tibia
What should be checked as part of the neurovascular exam for an open fracture?
Pulses, sensation, passive stretching (r/o compartment syndrome)
What abx are prescribed for an open fracture?
IV cephazolin
+ gentamicin (aminoglycoside), if contaminated
What is included in the management of an open fx aside from abx?
IM tetanus prophylaxis
MSK tx after initial trauma survery (+/- OR)
What complications are a/w an open fracture? (4)
Compartment syndrome (risk NOT decreased)
NV compromise
Limb salvage
Osteomyelitis
What is the typical MOI for a scapula fx?
High energy injury
(typically a/w other trauma- UE, torso, spine)
What xray views should be ordered for a scapula fx?
AP
Trans-scapular “Y”
What is the typical healing time for a scapula fx?
6 months- 1 yr
What are the conservative txs for scapula fx?
Sling/ shoulder immobilizer
Rehab/ PT
When is surgery indicated for a scapula fx? (3)
Articular surface displacement (goes into glenohumeral joint)
Impingement syndrome
Associated injuries
Pt presents with severe pain and swelling to upper arm +/- limited ROM and guarding. What fx do you suspect and what is the typical MOI?
Proximal humerus fx
MOI- high energy trauma if younger, simple fall if elderly
What classification is used for a humerus fx?
Neer classification
What xray views should be ordered for suspected proximal humerus or humeral shaft fx?
AP
AP w/ external rotation
Pt presents w/ localized pain, swelling, +/- displacement. What should you evaluate for if you suspect a humerus fx?
NV eval- wrist drop if radial nerve involvement
Associated forearm fx- “floating elbow” (fx above + below elbow)
If you note a pathologic fx on xray of a peds pt, what is it most commonly a/w?
Benign unicameral bone cyst (UBC)
What is the tx for a humeral shaft fx?
Shoulder immobilizer, humeral cuff, early motion to prevent frozen shoulder
+/- surgery
Pt presents w/ hx of blow to shoulder in abduction, extension, and external rotation (often overhead). On PE you note the arm is held in position of protection. What UE injury do you suspect?
Anterior glenohumeral dislocation
(most common than posterior)
What specialized PE tests should you perform if suspicion of glenohumeral dislocation? (2)
Sulcus sign
Apprehension + relocation
What imaging should be ordered for glenohumeral dislocation?
AP xray +/- MRI
Axillary view if posterior dislocation
What is included in the tx for glenohumeral dislocation? (4)
Immediate reduction
+/- shoulder immobilizer 2-4 wks
PT
Surgery if repeat dislocations
What further injuries should you consider if ROM does not return following reduction of glenohumeral dislocation?
Axillary nerve injury and rotator cuff tear
Detachment of anterior labrum from glenoid rim is defined as what and a/w what UE injury?
Bankart lesion
A/w glenohumeral dislocation
Depression of the humeral head is defined as what and a/w what UE injury?
Hills Sachs lesion
A/w glenohumeral dislocation
Decreased sensation to the lateral aspect of the shoulder (acute) and decreased deltoid function (chronic) is a/w what UE injury?
Axillary nerve injury/ glenohumeral dislocation
What concerning signs on x-ray should warrant referral even if a fx is not evident?
Fat pad sign
Sail sign
How can you differentiate between subluxation and dislocation?
Subluxation- may spontaneously reduce, can become recurrent
Dislocation- clinically deformed, painful, decreased ROM, requires surgical reduction
What imaging is ordered for a subluxation or dislocation?
Plain xrays = diagnostic
CT to eval alignment, fractures, avulsions
MRI to eval ligament integrity
What is included in the tx for a subluxation/ dislocation?
Immediate reduction
Casting vs sling/ early mobilization +/- PT
Surgery if complex/ NV involvement
Pt presents w/ localized pain, swelling +/- wrist/ elbow pain and hx of direct impact. What should you eval for?
Forearm fx
ALWAYS consider 2 fxs (radius + ulna) OR fx + dislocation
Pt with forearm fx will display restricted ROM with what movements?
Supination and pronation
What imaging should be ordered for suspected forearm fx?
AP/ lateral xray
*if only 1 fx seen, look for another and assess joints*
What should be ruled out w/ “isolated” ulnar shaft fractures and how is it dx?
Ulnar shaft fracture w/ dislocation of radial head (Monteggia fx)
Dx w/ xray (include elbow)
What is included in the management for a nondisplaced forearm fx?
Splint + refer for casting (6-8 wks)
NSAIDs, elevation, sling, ice
Pt with nondisplaced forearm fx should refrain from sports activity for how long?
4-6 mos
(high risk of re-fx)
What is included in the management for a displaced forearm fx?
Emergent reduction
ORIF: IM rods
What does ORIF stand for?
Open reduction internal fixation
What does CRPPF stand for?
Closed reduction percutaneous pin fixation
What does DRUJ stand for?
Distal radioulnar joint
What is a Colles and Smiths wrist fx?
Colles- dorsal displacement (dinner fork deformity)
Smiths- volar displacement
What xrays should be ordered for a wrist fx?
AP, lateral, oblique
+/- scaphoid
What is included in the tx for wrist fx?
Splinting +/- reduction
Casting 4-6 wks
Surgery- ORIF vs CRPPF
What is defined as a distal radius fx w/ disruption of DRUJ/ TFCC and what is the management?
Galeazzi fracture
Refer w/i 2-3 days w/ wrist fx protocol
Casting in slight pronation
What is the most common carpal bone fractured in the wrist and how is it dx?
Scaphoid
Clinical dx- “anatomic snuffbox” TTP
What xrays are ordered for scaphoid fx?
AP, lateral, scaphoid
(scaphoid = AP w/ 30 deg ulnar deviation)
What is the protocol if initial imaging is negative but suspicion for scaphoid fx?
Repeat imaging in 10-14 days
MRI if elite athlete
What is the tx for a scaphoid fx?
Thumb spica cast
Surgery if displaced
What complication is a/w a scaphoid fx?
Avascular necrosis (AVN)
Proximal aspect at highest risk
Pt presents w/ pain, swelling and ecchymosis and you suspect fracture of the hand. What needs to be determined?
Dislocation vs fx
Eval of rotational/ angular deformity (curl fingers down)
What xrays are ordered for a finger fx?
AP, lateral, oblique
What is included in the tx for a finger fx?
Conservative (splinting, casting, buddy tape)
Surgical
+/- reduction
What injury should you be concerned about if hx of ball contact injury or “jamming” finger?
IP dislocation
(dorsal > volar)
What is the tx for IP dislocation?
Conservative- reduction, splinting, buddy tape
Surgical- CRPPF vs ORIF (depending on fx involvement/ superimposed tissue)
Crush injury may result in accumulation of blood under the nail causing increasing pressure/ pain, aka?
Subungal hematoma
(nail matrix trauma can lead to nail loss/ permanent deformity)
What is the management for subungal hematoma?
+/- nail trephination
Abx if a/w distal phalanx fx
Pt presents w/ inability to flex DIP joint with pain over volar aspect on ring finger. What type of injury are you concerned for?
Jersey finger injury (flexor tendon rupture (FDP))
+/- avulsion fx in children
What is a mallet finger injury?
Rupture of extensor tendon (DIP)
= inability to extend DIP
What is the tx for mallet finger (rupture of extendor tendon- DIP)?
STAX extension splint x 6-8 wks
Surgery if large fx fragment or subluxation at joint
What is injured if Boxer’s fx?
Neck of 5th IMC
What is the tx for Boxer’s fx (neck of 5th IMC)?
Ulnar gutter splint then cast x 3-6 wks
Surgery- CRPPF or ORIF
(closed allows up to 30 deg angulation but no rotational deformity)
What is a Bennett’s fx and what is the tx?
Fx to base of 1st IMC w/ extension into joint
Tx w/ splinting then casting
(CRPPF or ORIF)
What is a game keepers thumb (skiers thumb)?
Injury to MCP joint resulting in ulnar collateral ligament tear and instability of the MCP joint
What is the tx for game keepers thumb (skiers thumb)?
(injury to MCP joint resulting in ulnar collateral ligament tear and instability of the MCP joint)
Thumb spica splint/ cast
Surgery (soft tissue involvement)
