Arm Fractures Flashcards
proximal humerus fractures
- who is it common in
- displacement
- which structures are often injured
common low energy in osteoperotic bone due to fall onto outstretched hand/directly onto shoulder
most commonly fracture of surgical neck (rather than anatomic neck) with medial displacement of the shaft due to the pull of the pec major muscle
brachial plexus and axillary artery are at risk of injury
where is the anatomical and surgical neck of the humerus
treatment of proximal humerus fractures
minimally displaced - conservatively in a sling
displaced - wait for muscle spasm to resolve, position might improve
persistently displaced - internal fixation, but stiffness, chronic pain and failure of fixation are common
humeral shaft fractures
caused by direct trauma resulting in transverse/comminuted fractures
or by fall with/out twisting injury - obique/spiral fractures
high union rates and due to mobility of joint significant (up to 30º) angulation can be tolerated without loss of function
what nerve is often damaged in humeral shaft fractures
- how does this manifest
radial nerve that runs in radial groove
manifests as wrist drop ( supplies posterior extensor muscles) and loss of sensation in first dorsal web space
treatment of humeral shaft fracture
most non-operative with a brace that compresses the fragments into alignment
internal fixation with IM nail or screw may afford quicker recovery
distal humeral fractures
usually intra articular and so require ORIF
olecranon fracture
- treatment
usually avulsion - fall onto elbow with triceps contraction
treat with ORIF
what are the attachments of the triceps muscle
proximal:
long head - infraglenoid tubercule of scapula
superior (lateral head) and inferior (medial head) to radial groove of humerus
distal:
all 3 heads combine to form triceps tendon, which attaches to olecranon process of the ulna
who are supracondylar fractures common in
most common type of elbow fracture in children
what are the two structures commonly injured in supracondylar fractures
median nerve and brachial artery
what is often damaged in a medial epicondyle fracture
ulnar nerve
radial head fractures
- fall onto outstretched arm
- OE; marked local tenderness over head of radius, impaired elbow movements and sharp pain at lateral side of elbow at extremes of rotation
- undisplaced/minimally displaced treated conservatively with sling
- often patients lose 10-15º extension
- ORIF if fragment large enough or block to extension
x ray signs of radial head fracture
- pathological posterior fat pad sign
why is the forearm unlikely to only break in one place
acts as a ring
nightstick fracture
- manage
- rule out?
isolated ulnar fracture occurs after direct blow
manage conservatively
rule out Monteggia
nightstick fracture
fracture of both bone of forearm
ORIF - highly unstable and anatomic reduction to maximise function and prevent deformity
in children, minimally angulated fractures can be treated with plaster only
Monteggia fracture
fracture ulnar and dislocation of radial head
ORIF even in children
monteggia
Galeazzi fracture
fracture radius and dislocate ulnar at distal radioulnar joint
ORIF required
Galeazzi fracture
colles fracture
occurs doing FOOSH with wrist extended
distal radius dorsally displaced/angulated
treatment :
- minimal and stable - POP
- displaced - MUA
- comminution - add K wiring
colles fracture
complications of colles fracture
median nerve compression, EPL rupture, loss of grip strength and CRPS
smiths fracture
volarly (palmar) displaced distal radius - falling back onto flexed wrist
v unstable - ORIF
grip strength and extension greatly reduced if there is malunion with excessive volar angulation
barton’s fracture
intra articular fracture of distal radius involving dorsal/volar rim, where the carpal bones of the wrist sublux into the displaced rim fragment
can be vorsal Bartons (intra-articular Smiths) or dorsal Barton’s (intra-articular Colles)
ORIF
smiths fracture
comminuted intra articular distal radius fracture
so comminuted stable fixation isnt possible
external fixator sited across joint, or wires to pin larger fragments
scaphoid fracture
- clinical signs
- imaging
- treatment
- usually occurs after FOOSH
- clinical signs are tenderness in anatomical snuffbox and pain on compressing thumb metacarpal
- difficult to visualise on x ray - take 4 views if have suspicion. around 5% are only detected when callus forms
- treatment: undisplaced - plaster cast for 6-12 weeks . displaced - compression screw
clinical scaphoid fracture
fracture suspected but doesnt show up on x ray
reviews x rays 2 weeks later
complications of scaphoid fracture
non union due to synovial fluid inhibiting healing
- CT useful to determine if union has occurred
AVN of proximal pole due to retrograde blood supply from distal branch of radial artery
- partial/total wrist fusion required
penetrating hand injury
thorough examination, low threshold for surgical exploration
tendon injuries - surgical repair
digits can function with one digital artery, however, damage to both requires surgical repair
extensor tendon injuries
divison of more than 50% requires surgical repair with splintage in extension for 6 weeks
mallet finger
forced flexion of extended DIPJ causes avulsion of extensor tendon from insertion into terminal phalanx
patient presents with pain, dropped DIPJ and inability to extend
treat with mallet splint holding DIPJ in extension for >4 weeks
flexor tendon injuries
problematic due to tendon sheaths and pulleys - bow stringing
fingers splinted in flexed position, often with elastic traction
metacarpal fractures
- boxers injury
- fight bite
3, 4, 5 treated conservatively
5th - punching injury (boxer’s fracture)/ strap digit to adjacent finger and check rotational alignment
fight bite - laceration on hand from punchee’s tooth. risk of septic arthritis - explore and wash out, dont suture up in A and E
Bennett fracture
intra articular fracture of base of CMC joint on thumb
phalangeal fractures
neighbour strapping/splintage
significantly dispalced/angulated - MUA/digital nerve block
unstable - K wiring or fixation with small screws
fat pad sign
The fat pad sign suggests displacement of one or more bones at the elbow, caused by displacement of the fat pad around the elbow joint.
Anterior fat pad is often normal, posterior is always pathological
posterior fat pad sign in adults
suggests radial head fracture
posterior fat pad sign in children
suggest supracondylar fracture
clavicle fracture
- incidence
- management
- occurs after a fall onto the point of the shoulder eg mountain bike or horse rider
- managed in a broad arm sling
