Hand and forearm/elbow fx Flashcards
How do you describe finger dislocations (distal relative to proximal, or proximal relative to distal)?
Distal relative to proximal
What is the treatment for an unstable vs stable finger dislocation?
Stable = buddy tape Unstable = formal splinting
Volar PIP dislocations are concerning for what other injury? What, then, is the management for these?
- Dosal slip injury
- Splint and close f/u with hand
What is the treatment for a tuft fx?
- Since can be open under the nail bed, thorough cleaning and splint for comfort.
- Abx probably not
How many degrees of angulation are acceptable for each metacarpal neck fx? (note cannot be midshaft or proximally)
5th = 40 degrees 4th = 30 degrees 3rd = 20 degrees 2nd = 10 degrees
How do you determine the angle of a metacarpal neck fx?
Intersection of the lines through the metacarpal bone and the line through the fx part
What must always be assessed with metacarpal fractures? How?
- Rotation
- have patient make fist and assess if fingers are at all rotated. Must splint in anatomic position
What is a Bennett’s/rolando fx?
Fx and dislocation of the base of the first metacarpal
What is a skier’s/gamekeeper’s thumb?
Hyperabduction injury of the ulnar collateral ligament of the thumb. Skier’s is acute, gamekeeper’s is chronic
What are the four Kanavel’s signs?
- Fusiform digit
- Pain with passive extension
- Pain with palpation of over the flexor tendon
- Finger is held in slight flexion
How do you incise a felon vertically or horizontally?
Vertically (proximal to distal)
What causes a mallet finger?
Hyperflexion injury, break at the extensor tendon
How do you splint a mallet finger?
In hyperextension
Can a person with a mallet finger take the splint off?
No–will have to start all over again, and it takes 8 weeks to heal due to poor blood supply to tendon
What are the tendons that are inflamed with de Quervain’s tenosynovitis?
- Extensor pollicis brevis
- Abductor pollicis longus
What is a nightstick fx?
midshaft ulnar fx
A line drawn through the radius should always intersect with what part of the elbow?
Capitellum
What are the components of the FUME mnemonic for galeazzi or monteggia fractures?
- Fx of
- Ulna is called
- Monteggia when at the
- elbow joint
What is a Monteggia fx?
Fracture of the ulna at the elbow, with radial head dislocation
What is the Galeazzi fracture?
Fractures of the radius at the wrist with ulnar dislocation
What is an Essex-Lopresti fracture?
A fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint and disruption of the interosseous membrane.
What are the two radiographic signs of an elbow injury?
- Anterior sail signs
- Posterior fat pad
True or false: a posterior fat pad on an elbow radiograph is always abnormal
True
What lines should pass through the capitellum on a lateral elbow radiograph?
- Anterior humeral (should be at the middle third)
- Radial
What is the most likely fracture of an elbow in a child if there is/are anterior sail sign, posterior fat pad, but no obvious fracture? Adult? How do you splint these?
- Child = Supracondylar fx, posterior splint
- Adult = radial head/neck, sling
With severe fractures, how should you splint them?
In the position they’re in, to avoid possible neurovascular injury. And call ortho.
True or false: the x-ray of a nursemaid’s elbow is typically normal
True
What is the treatment for a nursemaid’s elbow that you are unable to reduce (and are sure there is no occult fracture)?
Sling and attempt again tomorrow
What is the management for non-septic bursitis?
Compression dressing and NSAIDs
What are the indications for surgery for clavicle fractures?
-More than 2 cm displaced (from bone to bone)
-More than 2 cm shortened
-Skin tenting
-
What should you do to the skin for a tenting clavicle fx?
Sterilize it and place sterile dressing to prevent infx if does break through
What defines “distal” clavicle fractures?
Distal to the coracoid process
What is the treatment for a displaced vs nondisplaced clavicle fx? Why?
- Nondisplaced = sling
- Displaced = Surgical due to torn coracoclavicular ligaments
How do AC joint injuries typically occur?
Falling directly onto a shoulder tip
What are types I-III AC joint separations?
I = stretched II= partial tear III = complete tear (operative)
When are scapular fractures surgical?
If they involve the glenoid
What bones, if fractured, should you suspect other injuries? (4)
- Scapula
- First rib
- Sternum
- Chance fx
What is a Bankart lesion?
an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.
How do you determine if a lateral view of the shoulder is adequate?
If the body of the scapula is narrow
What is a Hill-sachs fracture?
a cortical depression in the posterolateral head of the humerus. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly.
What movement of the shoulder can patients with a posterior dislocation not do?
External rotation
What are the three Es that posterior shoulder dislocations are associated with?
- EtOH
- Epilepsy
- Electricity
What is the “light bulb” sign associated with shoulder injuries?
Loss of the greater tuberosity of the shoulder on AP view with a posterior dislocation
What is the primary movement of the each of the SITS muscles?
- Supraspinatus = abduction
- Infraspinatus = external rotation
- Subscapularis = internal rotation
- Teres Minor = Lateral rotation
How far must a patient be able to abduct the shoulder in order to say the supraspinatus is intact?
Past 60 degrees
What is the treatment for a complete rotator cuff tear?
MRI, and surgical referral
What sign on x-ray may be seen with acute onset of adhesive capsulitis?
Calcification of the supraspinatus tendon-responds well to cortisone shots
What causes thoracic outlet syndrome?
Compression of the neurovascular bundle beneath the 1st rib and clavicle
What movement worsens s/sx of thoracic outlet syndrome?
Overhead activity
What is the Adson’s test for thoracic outlet syndrome?
- Hold shoulder in slight abduction and flexion, extend and rotate neck toward arm, and take a deep breath
- If s/sx are reproduced or pulse lost, confirms
What joints must be involved in the splint for a midshaft fractures?
Joints above and below
What is the treatment for a humeral head fx (that is not extremely displaced)?
Sling and close f/u
What is the treatment for a proximal vs distal biceps tears?
- Proximal tears = close f/u with ortho
- Distal = surgical
Speed’s tests diagnoses what?
Bicep tendonitis
What is the classic mechanism for an ACL tear? Meniscal tear? LCL/MCL?
- ACL = planting, change direction
- Meniscal = twisting
- LCL/MCL = varus/valgus
What movement tests should be performed in patients with a patellar injury?
Straight leg raise to assess for extensor mechanism disruption
What is the treatment for a patellar fx?
Knee immobilizer
Why should you be hesitant to diagnose an LCL injury?
May have a posterolateral corner injury, and mean something more significant
What are the four pieces of an ACL history?
- Sudden deceleration
- Felt/heard a pop
- Swelling within an hour
- Did not continue playing
What is a Segond fracture?
Vertically oriented avulsion fx over the lateral knee, specific for LCL tear
What is a “locked knee”? What pathology is it seen in, and what does it indicate?
- Knee lacks full extension
- Seen in ACL tears
- Indicates may get contracture
If you suspect a tibial plateau fracture, what testing is indicated?
CT of the knee
What are proximal tibia fractures prone to compartment syndrome?
Very good blood supply to this area
Tenderness and swelling over the joint lines of the knee indicated what possible pathology?
LCL/MCL sprain/tear, or tibial plateau fx
What is the difference between a subluxation and a dislocation?
Subluxation = still contact between articular surfaces
Why are patients with patellar dislocations sore on the medial side of the patella?
Medial patellofemoral ligament inserts there
What is the significance of a loose bone fragment on a knee x-ray? (2)
- May get in joint and cause knee locking
- If cartilage attached is from weight bearing surface, can cause OA on that joint later
Lipohemarthrosis on x-ray (knee)= ?
Fx somewhere
Why are popliteal injuries such a concern with knee dislocations?
It is tethered proximally and distally, without and “slack in the line”
Why do all patients with a knee dislocation need to be admitted to a hospital?
-If there is an intimal tear in the popliteal artery, can form a thrombus and embolize
What defines a knee dislocation in terms of number of ligaments with laxity?
2+
Foot drop after knee injury =?
Peroneal nerve injury, and likely dislocation of the knee
What is the Insall-Salvati index to determine if a patella is high riding or not?
Length of the patella on lateral x-ray should be about the same -ish compared to the length from the inferior pole of the patella to the tibial tuberosity
How can US be used to differentiate between bursitis vs septic arthritis?
joint effusion = concern for septic arthritis
What is the management for septic bursitis?
Admission with ortho consult and IV Abx
What is the major clinical difference between prepatellar and infrapatellar bursitis?
Suprapatellar bursa connects with the knee joint itself, whereas the inferior bursa does not
What are the three (four) major compartments of the lower leg?
- Anterior
- Lateral
- Posterior (deep and superficial)
If you see a fibular fracture, what other area needs to be assessed?
Medial malleolus
What direction of fracture is concerning for a fibula fx?
Oblique–may indicate spiral fx
What is a pilon fracture?
a fracture of the distal part of the tibia, involving its articular surface at the ankle joint. Pilon fractures are caused by rotational or axial forces, mostly as a result of falls from a height or motor vehicle accidents.
What is a tongue fracture, and what is the significance of it?
Break of the calcaneus where the achilles tendon inserts (rips off)
-Sharp end may erode through the skin and convert it to an open fx–call ortho
What are the three ligaments that comprise the lateral ankle?
ATFL
PTFL
Calcaneofibular
What are the two ligaments that are involved in a high ankle sprain?
Anterior and posterior inferior tibiofibular ligaments
What is the purpose of the mortise view of the ankle?
To ensure that the space between the distal tibia and the talus is equal (1 mm of change or more is significant)
What is the posterior malleolus?
Posterior aspect of the tibia
Is the navicular bone on the medial or lateral aspect of the foot? What imaging should you get if there is tenderness here?
- Medial
- Foot series
How many steps must a person weight bear to pass the ottawa ankle rules? Does it matter if it is an antalgic gait?
- two on each foot
- does not matter if antalgic
What is the treatment for a syndesmosis injury to the tib/fib?
Foam walker, WBAT
What is a Telo fracture? Why does this occur?
Fracture of the distal tibial growth plate at the lateral aspect.
-Growth place begins fusion medially, and extends laterally
What is a Weber A fracture of the ankle? Stable or unstable?
- fx of the fibula below the level of the joint
- Stable if not tender over deltoid
What is a Weber B fracture of the ankle? Stable or unstable? Treatment?
- fx is at the level of the joint
- unstable especially if tender on the medial side. Posterior slab, NWB
What is a Weber C fracture of the ankle? Stable or unstable? Treatment?
- Above the level of the syndesmosis
- unstable
- Surgical treatment
Leaving a talus subluxed relative to the distal tibia may cause what concerning issue?
Ischemic necrosis of the talus
What is a Maisonneuve fracture?
a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of the deep deltoid ligament.
What is the mechanism by which a LisFranc fracture occurs?
Plantarflex and external rotation (falling off a horse)
What is a Lisfranc fx?
Where one or more of the metatarsals are displaced from the tarsus due to ligamentous disruption
What additional x-ray view can be obtained for a Lisfranc fracture?
Weight bearing compared to non-weight bearing
Where are patient’s tender with a lisfranc injury? How do you determine on x-ray if there is a ligamentous disruption?
- Medial Midfoot
- Metatarsals should line up with the cuneiforms
What is the treatment for a lisfranc injury?
- Mild/suspected = NWB and close f/u
- Mildly displace = call
- Dislocated = reduce and call
What is a Dancer’s fracture?
Fx at the base of the fifth metatarsal
What is a Jone’s fracture?
Fracture of the 5th metatarsal, distal to the metatarsal ligaments
What is the treatment for a dancer’s fracture?
Stable and can WB so need foam walker or still soled shoe
What is the treatment for a Jones fracture?
NWB
What is the treatment for a 5th metatarsal fracture that goes through the the whole metatarsal?
Boot and f/u if have intact sensation
What is Bohler’s angle found in calcaneal fractures?
-Line connecting the anterior and posterior processes of the calcaneus, should be 20-40 degrees
How do you examine the calcaneus for fractures?
Lift foot off of bed with patient in supine position, and squeeze the calcaneus. If painful, or bruising present, then concerning
