Common Upper Limb Fractures and Dislocations Flashcards
Definition of surgical neck of humerus fracture
- Anatomic neck represents the old epiphyseal plate whilst the surgical neck represents the weakened area below head
- Caused by low energy falls in the elderly with osteoporosis and high energy trauma in young individuals
Management of surgical neck humerus fracture
- Classified using AO/OTA or Neer classification
- X-ray and CT for pre-op/position uncertain
- Non-operative (most treated this way if minimally displaced and those who are not surgical candidates)
- Sling immobilisation with progressive rehab
- Operative
- CRPP (closed reduction percutaneous pinning)
- ORIF
- Intramedullary nailing
- Arthroplasty
Required X-ray views for anterior and posterior shoulder dislocations
- Anterior
- AP view
- Y- view
- Posterior
- Axillary view for diagnosis
Clinical assessment of shoulder dislocations
- Hx
- Examination - remember to check for neurovascular compromise
- X-rays
- Direction of dislocations
- Associated features/fractures (Hill-Sachs lesion, Bankart lesion, humeral fractrures, AC disruption, clavicular fractures, acromial fracture)
Management of shoulder dislocation
- Anterior
- Closed reduction and immobilisation to allow capsular healing
- Physiotherapy to aid mobility and muscle strength
- Surgical repair only if complications (i.e. instability, injury to brachial plexus/axillary nerve)
- Posterior
- In most cases spontaneously reduce prior to imaging
- Closed reduction only in consultation with orthopedics as very difficult
- If dislocated for more than 3 weeks or if articular injury closed reduction contraindicated
Humeral shaft fracture management
- Treated with supporting/hanging cast followed by supportive splint and infrequently require open reduction
- ORIF required if:
- Adequate alignment cannot be maintained
- Open fractures
- Presence of vascular injury
- Segmental fracture
- Floating elbow
- Presence of significant other injuties (i.e. nerve)
- Non-union
- Pathological fracture
NB - Remember risk of radial nerve injury in diaphyseal fractures
Elbow dislocation assessment and management
- Most elbow dislocations are posterior
- Hx, examination (include wrist and shoulder) and X-ray - AP and lateral views (can use anterior humeral line to assess), look for direction and associated features
- Closed reduction iand immobilisation at 90 degrees if simple dislocation
- ORIF if complex (associated fracture)
Management of forearm fractures and fracture-dislocations
- Examination (include wrist and elbow)
- AP and lateral views
- Treatment depends on degree of displacement
- Often significant displacement and so reduction required
- If associated radial head or distal ulnar dislocation then manipulation with reduction of the fracture and dislocation is required
Management of distal radial fractures
- Often caused by FOOSH
- Management depends on the type
- Many can be managedas an outpatient with cast - if unstable must be reviewed regularly
- Significant displacement required manipulation
- A small number require internal fixation
NB - Risk of median nerve compression in these fractures
Clinical assessment of scaphoid fractures
- 70-80% of all carpal bone fractures
- Classically pain in anatomical snuffbox
- Often caused by FOOSH
- Require dedicated scaphoid views to evaluate fracture + displacement - in AVN first sign will be slight sclerosis
- CT can be used if plain films are normal but high clinical suspicion
- MRI for assessing AVN
NB - Look out for associated dislocation of the carpus
Management of scaphoid fractures
- Management can be divided into:
- Immobilisation with cast application
- Internal fixation
- Non-union can be managed with internal fixation and bone grafting
- Factors affecting prognosis
- Distal pole - excellent liklihood of union (nearly 100%)
- Waist 10-20% change of non-union
- Proximal pole - 30-40% change of non-union
- Vertically orientated fractures, displacement of >1mm and ligamentous instability also affect prognosis
- Complications
- Non-union or malunion
- AVN (30% of cases) - most commonly involves the proximal portion as a result of arterial supply entering distally
Types of metacarpal fracture
- Bennett fracture is a fracture of the base of the first metacarpal bone which extends into the carpometacarpal (CMC) joint.
- A boxer’s fracture is the break of the 5th metacarpal bones of the hand near the knuckle.
Management of metacarpal fractures and dislocations
- External immobilisation followed by early motion in most cases
- Fractures where stable positions are difficult to maintain (i.e. CMC injuries) require internal fixation
NB - Minor rotational deformities can cause the fingers to overlap when the hand is made into a fist. Rotational abnormalities are best judged clinically by comparing the injured and uninjured digits through a full range of motion (ROM). With flexion, each digit should point toward the scaphoid tuberosity. The plane of the nail should be similar between the injured digit and the contralateral corresponding finger when evaluated in an intrinsic plus position.
What is the position of safety in the hand?
- DIPs in full extenions
- PIPs in full extension
- MCPs flexed 60-90o
- Wrist extended 10-45o
Management of phalanx fractures
- Non-operative treatment is generally choice of treatment using splints for immobilising non-displaced fractures of the IPJs or tape for the MCPs
- Reduction can be used if there is displacement
- Kirchner wires or open reduction required if significant displacement if unstable or rotational issues
- Open fractures require tetanus and antibiotic therapy
