Common upper and lower limb fractures Flashcards
Classifications of clavicular fractures
Allman classifications
Group I; fractures of middle 1/3 (70%)
Group II: distal third (less than 30%)
Group III: proximal third (3%)
Mechanism of injury of clavicle fracture
Fall onto shoulder
- traffic accidents
- sports
Less commonly, direct blow from an object
Presentation of clavicle fracture
Middle third:
- Pain (well localised, exac. by arm movement)
- cracking or snapping sensation at time of injury
- local swelling around clavicle
- point tenderness +/- crepitus
+/- visible bulge
+/- bone angulation
tenting of skin suggests significant angulation or displacement
Distal third:
- pain and tenderness around AC joint
- Cross arm tests (pain inc. if adduct arm across chest)
- little or no deformity seen on examination
Radiological diagnosis of clavicular fraacture
30 DEGREE UPTILT VIEW (so can see clavicle “above horizon”)
Types of distal 3rd (group 2) clavicle fractures
Type I (most common): no displacement Type II: proximal fragment loses ligamentous attachment (sup. displacement) Type III: intra-articular - extending into AC joint diff. to diagnose on x-ray
Management of clavicle fracture
Referral to orthoif: - open - "floating shoulder" - displaced - comminuted - shortened - distal type II or III Conservative manageemt: - pain relief (e.g. endone) - intermittent icing first 72h - sling for 6-12w adult, 3-6w child
Management of scapula fracture
operative if glenoid cavity fractured
Otherwise sling and swathe bandage short term immobilisation
most heal completely within 6 weeks
Mechanism of injury of proximal humeral fracture
Fall from standing
Direct blow, violent muscle contraction (e.g. seizure)
Clinical features of proximal humeral fracture
Mod-sev pain inc with shoulder movement Arm held adducted at side Swelling and ecchymosis \+/- gross shoulder deformities focal tenderness at proximal humerus neurovascular injury (most commonly axillary or subscapular)
Radiology for proximal humerus fracture
Shoulder series:
- AP
- axillary
- Scapular Y view
Indications for ortho referral of proximal humeral fracture
Fracture of anatomic neck
All displaced or open fractures
Complications of proximal humeral fractures
Red. shoulder mobility (range from insignificant to adhesive capsulitis)
Neurovasc, inj (circumflex artery, axillary or supscapular n.)
Non-union
Osteonecrosis of humeral head
Impingement from avulsed fragments
Midshaft humerus fracture mechanism of injury
Trauma (direct blow or bending force to humerus)
Less commonly: FOOSH or fall on elbow
Clinical presentation of midshaft humeral fracture
Severe mid-arm pain
+/- referred pain to shoulder/elbow
Swelling and ecchymosis
+/- abrasions or lacerations
Significant localised tenderness to palpation
+/- crepitus
Shortening of upper arm (sig. displacement)
Classification of supracondylar fractures
Gartland Classification:
I: non-displaced
II: Displaced fracture with intact posterior periosteum, anterior displacement of anterior humeral line
III: displaced fracture with disruption of both anterior and posterior periosteum (no continuity between proximal and distal fracture fragments, S-shaped configuration or pucker sign)
Radiological diagnosis of supracondylar fractures
Provide appropriate analgesia should be provided BEFORE x-rays
Splinting advised prior to radiology if severe fracture (e.g. S-shaped)
- anterior humeral line should usually dissect the capitulum
Anterior and posterior fat pads
indications for referral of supracondylar fractures to ortho
Open
Neurovascular compromise
Type II or III
Acute compartment syndrome
Complications of supracondylar fractures
Vascular injury (common with type I and II) Volkmann ischaemic contracture (fixed flexion of elbow, pronation of forearm, flexion at wrist, extension of MCPs) Neurological deficit (medial, radial or ulnar) Cubitus varus deformity - function preserved
Classification of radial head and neck fractures
Mason classification
I: non-displaced (displacement less than 2mm)
II: displaced fractures over 2mm
III: comminuted fractures
IV: radial head fracture + elbow dislocation
radiology of radial head or neck fracture
Does not always show fracture line
Raised anterior and posterior fat pads “sail sign”
what is a Monteggia fracture/dislocation
Proximal ULNAR fracture with displacement and shortening and dislocation of radial head
Mechanism of injury leading to Monteggia fracture
Direct blows to ulnar aspect of arm
Fall with hyperpronation or hyperextension
Radiology in monteggia fracture/dislocation
Radiocapitellar line should usually bisect the capitulum, doesn’t if radial head is dislocated
Management of Monteggia fracture/dislocation
Reduction of radial head will reduce pain
Always refer to ortho for open reduction and internal fixation
Galeazzi fracture-dislocation
Distal 1/3 radius fracture + dislocation of distal radio-ulnar joint
Classification of galeazzi fracture/dislocation
Based on position of distal radius
I: Dorsal displacement
II: Volar displacement
Essex-lopretsi fracture/dislocation
Proximal radius fracture with dislocation of distal radioulnar joint
What is a colles fracture
Fracture of distal radial metaphysis with DORSAL angulation and impaction (dinner fork deformity)
Epidemiology of Colles fracture
most common type of distal radial fracture
most commonly in elderly women with OP
Management of Colles fracture
Most can be treated with closed reduction and cast immobilisation
Cast from elbow-metacarpal heads
Wrist flexed in ulnar deviation (as if holding a footy about to kick)
What is a Smiths fracture
Fracture of distal radius with VOLAR angulation and displacement
Normal lines in pelvic or hip x-rays
Shenton’s line: curve from inferior line of femoral neck to acetebulum
Iliopectineal line
Ilioischial line
Sacral arcuate lines
Pelvic ring fracture radiology
disruption of any of the pelvic rings (pelvic inlet or rami)
Signs of instability of pelvic ring fracture
Over 5mm displacement of posterior Sacroiliac complex
posterior sacral fracture gap
Avulsion fractures
management of pelvic ring fracture
Immediate:
- Resuscitation, massive transfusion guidelines
- Pelvic binder/sheet - placed over greater trochanters (not iliac crest/abdo)
- External fixation
Definitive:
- +/- ORIF
Acetabular fracture mechanism of injury
Impaction of femoral head, lateral compression or axial loading
Letournel’s lines
Iliopectineal line - disruption = anterior column fracture
Ilioischial line - disruption = posterior column fracture
Acetabular roof, anterior rim and tear drop
Teardrop displacement = sacral fracture
Angulated sacral arcuate lines = sacral fracture
Classifications of femoral neck fracture
Anatomical:
- intracapsular (Subcapital, transcervical, basicervical)
- extracapsular (intertrochanteric and subtrochanteric)
GARDEN CLASSIFICATION - predicts development of AVN
I: undisplaced, incomplete
II: undisplaced, complete
III: Complete fracture, imcompletely displaced
IV: complete fracture, completely displaced
Management of fractured NOF
Undisplaced: internal fixation Displaced: - Under 60y - urgent ORIF - 60-80y - usually hemiarthroplasty - 80y+ arthroplasty
Ankle fracture classification
Weber Classification
A: below the level of the ankle joint (tibiofibular syndesmosis intact) Stable = manage conservativel
B: at level of ankle joint extending superiorly and laterally up fibula - no widening of distal tiobiofibular articulation
C: above level of ankle joint, tibiofibular syndesmosis disrupted (widening of distal tibiofibular articulation) +/- medial malleolus fracture UNSTABLE - REQUIRES ORIF
Ottawa ankle rules for x-rays
Ankle x-ray indicated if:
- Bone tenderness at posterior edge of lateral malleolus OR medial mallolus
OR
- inability to bear weight either immediately after injury or in ED
Foot x-ray series indicated if: - Bone tenderness at base of 5th MT OR - bone tenderness at navicular OR - inability to bear weight either immediately after injury or in ED
