Common Fractures Flashcards
1
Q
What are the common non-traumatic causes of shoulder pain?
A
Common non-traumatic causes-
- Subacromial pain syndrome (SAPS, AKA shoulder impingement syndrome)*
- Umbrella term for non-traumatic, usually unilateral shoulder pain due to pathology in the subacromial space.
- Includes subacromial bursitis, supraspinatus tendinopathy (including calcific tendinopathy), rotator cuff degeneration or partial tear and biceps tendinopathy. NOTE- ‘tendinopathy’ is preferred to ‘tendinitis’ as there is rarely evidence of inflammation.
- Presents with pain on lifting or overhead movements.
- On examiination- painful arc in 60-120 of abduction, Neer’s sign.
- Frozen shoulder (aka adhesive capsulitis)*
- Stiffness and/or pain and global reduction in active and passive movement, especially external rotation.
- Risk factors- diabetes, prolonged immobilisation.
- Osteoarthritis*
- Acromioclavicular joint OA- tenderness over the ACJ
- Glenohumeral OA- results from overuse eg. manual labour, walking with stick. Presents with pain (especially on external rotation) and reduced range of movement.
2
Q
What are traumatic or complex causes of shoulder pain?
A
- Traumatic full thickness rotator cuff tear- acute trauma (eg. dislocation, traction) followed by reduced active movement, especially abduction, but normal range of passive movement. Remember, the rotator cuff muscle group SITS around the joint- Supraspinatus, Infraspinatus, Teres minor and Subscapularis.
- Fracture, dislocation or infection.
- Cancer, usually metastatic
- Referred pain from cervical spine, sensory nerve (shingles), myocardium (MI), lung apices (cancer), muscles (polymyalgia rheumatica), diaphragm.
3
Q
What imaging should be performed in a patient presenting with shoulder pain?
A
IMAGING
- X-ray (AP and lateral) if suspecting fracture, dislocation, or cancer, or initial management has failed and are considering steroid injection.
- US or MRI if suspecting rotator cuff tear.
4
Q
How are the various causes for shoulder pain managed?
A
- SAPS, frozen shoulder and OA*
- 1st line- analgesia, normal activities as tolerated (though may require period of limited duties at work) and physiotherapy.
- 2nd line- steroid injection (not for glenohumeral OA)
- 3rd line- surgery, such as joint replacement (glenohumeral OA), manipulation under anaesthesia or capsular release (frozen shoulder)
SAPS and frozen shoulder typically self-resolve, though may take several months, while OA may progress.
Traumatic full thickness rotator cuff tears require prompt surgical repair (note that this isn’t true for partial, non-traumatic tears which are part of SAPS)
5
Q
Define shoulder dislocation.
A
- dislocation is a loss of continuity between two joint surfaces.
- subluxation is a partial dislocation, with both parts still touching.
- can be combined with a fracture in a ‘fracture dislocation’ or ‘fracture subluxation’
6
Q
What are the clinical features of shoulder dislocation?
A
- 95% are anterior dislocations, which most commonly follow a blow to an abducted elbow extended, externally rotated arm, such as a fall on an outstretched hand.
- associated injuries- Bankart lesion (avulsion of glenoid labrum anteriorly), Hill-Sachs lesion (damage to the humeral head), greater tuberosity fracture, axillary nerve palsy (check sensation in the Sargeant’s patch. before reduction)
- posterior dislocation follows a blow to the anterior shoulder or extreme muscle contraction eg. seizure. On XR, humeral head appears to be sitting in the glenoid, or is rounded (light bulb sign)
- may go on to develop shoulder instability, in which shoulder is prone to recurrent subluxation/dislocation.
7
Q
Which imaging should be performed in shoulder dislocation?
A
XR (AP and lateral) before and after reduction.
8
Q
What is the management for shoulder dislocation?
A
REDUCTION-
- under sedation and analgesia
- use any one of various techniques eg. scapular manipulation, external rotation, traction countertraction.
POST-REDUCTION
- re-examine sensation, pulses and movement.
- immobilisation for 1 week (if age>30 as there is increased risk of stiffness) or 3 weeks (if age <30 due to increased risk of re-dislocation)
- rehabilitation with home exercises
- MRI or US if ongoing symptoms at 2 weeks for possible rotator cuff injury. Some recommend routinely for all age 40-60 due to the increased risk.
9
Q
What are the causes of elbow pain?
A
EPICONDYLITIS
- pathology of the forearm muscles and tendons due to overuse, often work-related.
- presents with elbow and forearm pain, with limitation of forearm/wrist movement (eg. with gripping) but not elbow movement.
- lateral epicondylitis (aka tennis elbow) is the commonest and involves the extensors. Presents with lateral elbow pain and tenderness and pain on wrist and middle finger extension (especially if resisted)
- medial epicondylitis (aka golfer’s elbow) involves the flexors. Presents with medial elbow paina nd tenderness, pain on wrist flexion and pronation, and. may feature ulnar nephropathy (parasthesia of ring and little fingers).
OTHERS
- Olecranon bursitis (aka student’s elbow)- boggy swelling of elbow with/without pain, due to trauma or overuse, or less commonly, gout or RA. A minority of cases are due to infection (septic bursitis), typically staph. aureus, following break in the overlying skin.
- elbow osteoarthritis- pain, limited elbow flexion/extension.
- radial tunnel syndrome- posterior interosseous nerve compression causing dorsoradial forearm pain, but no motor or sensory deficits.
- inflammatory or septic arthritis, most commonly rheumatoid arthritis or gout.
- fractures
- cancer
- referred pain from cervical spine, shoulder (eg. SAPS) or wrist (eg. carpal tunnel syndrome)
10
Q
Which imaging should be performed if fracture or other bony joint disease is suspected?
A
XR
11
Q
What is the management of epicondylitis?
A
- physiotherapy to guide strengthening exercises and cessation/modification of aggravating sport/work activities. No clear evidence for splints/orthotics, but still widely used.
- analgesia, preferably paracetamol.
- steroid injections provide up to 6 weeks of relief but do not alter long-term outcomes.
- most self-resolve within 1 year. Persistence beyond this may necessitate interventions such as botulinum toxin or surgery
12
Q
What is the management of other causes of elbow pain?
A
- radial tunnel syndrome- as for epicondylitis, with radial tunnel release surgery for refractory cases.
- olecranon bursitis- rest, ice, analgesia, consider aspirationif very large or symptomatic and reassure that it will likely self-resolve. If septic bursitis suspected (systemic or local signs of infection), aspirate and treat empirically with antibiotics (eg. flucloxacillin)
- elbow OA - as for all OA, analgesia and physiotherapy, with arthroscopy or joint replacement in refractory cases.
13
Q
Describe proximal humerus fracture.
A
- fracture proximal to surgical neck ie. in the shoulder
- common in elderly following fall on outstretched hand (FOOSH)
- usually stable and can be managed with sling and early mobilisation.
- complications- axillary nerve injury.
14
Q
Describe distal humerus (supracondylar) fracture.
A
PRESENTATION-
- common in children following FOOSH
- complications- anterior interosseous (median) nerve injury (can’t make OK sign), brachial artery injury, compartment syndrome.
XR-
- usually reveals fracture line, though it may be obscured by anterior/posterior fat pad sign reflecting joint effusion.
- GARTLAND classification-
- –undisplaced (type 1)
- –posterior angulation with intact cortex (type 2)
- –complete posterior displacement (type 3)
MANAGEMENT
Initial management is with posterior splint. Followed by-
-type 1- cast immobilisation with elbow at 90 degrees for 2-4 weeks- may be followed by removable posterior splint.
-type 3 and (most) type 2- reduce via MUA (manipulation under anaesthetic) and immobilise with K-wires (pins).
15
Q
Describe elbow fractures.
A
- mechanism- radial head fracture (adults) or radial neck fracture (kids) from FOOSH or olecranon fracture from direct blow to flexed elbow
- olecranon fractures are usually intra-articular. May have significant swelling.
- undisplaced fractures are managed with 7 days posterior splint, with elbow at 90 degrees, then a sling.
